FAIR CITY HEALTH AND REHAB
For profit - Individual
121 Beds
Independent
Data: November 2025
5 Immediate Jeopardy citations
Trust Grade
0/100
#198 of 264 in LA
Photo by Fair City Health and Rehab
Photo by Kory Rhoden
Photo by Fair City Health and Rehab
1 / 5 photos
Last Inspection: April 2025
Within standard 12-15 month inspection cycle. Federal law requires annual inspections.
Overview
Fair City Health and Rehab has received an F trust grade, indicating significant concerns about the quality of care provided. They rank #198 out of 264 facilities in Louisiana, placing them in the bottom half, and #2 of 3 in Washington County, meaning only one local option is better. The facility has shown some improvement, with a reduction in reported issues from 13 in 2024 to 6 in 2025. However, they face serious staffing challenges with a 55% turnover rate, which is near the state average, and they have accumulated a concerning $248,719 in fines, higher than 95% of Louisiana facilities. Specific incidents included staff failing to report COVID-19 symptoms before providing care, a staff member caring for residents while positive for COVID-19, and inadequate infection control measures, all raising serious concerns about resident safety. While there is some RN coverage, the overall staffing rating is below average, indicating a need for better management and care practices.
- Trust Score
- F
- In Louisiana
- #198/264
- Safety Record
- High Risk
- Inspections
- Getting Better
- Staff Stability ⚠ Watch
- 55% turnover. Above average. Higher turnover means staff may not know residents' routines.
- Penalties ✓ Good
- $248,719 in fines. Lower than most Louisiana facilities. Relatively clean record.
- Skilled Nurses ⚠ Watch
- Each resident gets only 13 minutes of Registered Nurse (RN) attention daily — below average for Louisiana. Fewer RN minutes means fewer trained eyes watching for problems.
- Violations ⚠ Watch
- 43 deficiencies on record. Higher than average. Multiple issues found across inspections.
0/100
Bottom 25%
Review needed
13 → 6 violations
★☆☆☆☆
1.0
Overall Rating
★★☆☆☆
2.0
Staff Levels
★☆☆☆☆
1.0
Care Quality
★☆☆☆☆
1.0
Inspection Score
↔
Stable
2024: 13 issues
2025: 6 issues
The Good
-
Full Sprinkler Coverage · Fire safety systems throughout facility
-
No fines on record
Facility shows strength in fire safety.
The Bad
1-Star Overall Rating
Below Louisiana average (2.4)
Significant quality concerns identified by CMS
Staff Turnover: 55%
Near Louisiana avg (46%)
Frequent staff changes - ask about care continuity
Federal Fines: $248,719
Well above median ($33,413)
Significant penalties indicating serious issues
Staff turnover is elevated (55%)
7 points above Louisiana average of 48%
The Ugly 43 deficiencies on record
5 life-threatening 1 actual harm
Apr 2025
6 deficiencies
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Assessment Accuracy
(Tag F0641)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to ensure resident's MDS assessments accurately reflected the residen...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to ensure resident's MDS assessments accurately reflected the resident's status for 5 (#19, #27, #46, #73, and #91) out of 19 residents reviewed in the final sample. The facility failed to ensure:
1. Resident #19 was coded accurately for urinary tract infections within the last 30 days;
2. Resident #27 and Resident #46 were accurately coded for PASRR (Pre-admission Screening and Resident Review);
3. Resident #73 was coded accurately for use of Physical Restraints; and
4. Resident #91 was coded accurately for discharge.
Findings:
1.
Resident #19
Review of Resident #19's Clinical Record revealed she was admitted to the facility on [DATE], with diagnoses which included Urinary Tract Infections.
Review of Resident #19's Annual MDS with an ARD of 02/06/2025 revealed she was coded as no for having a urinary tract infection (UTI) within the past 30 days.
Review of the Infection Log dated January 2025 revealed Resident #19 was diagnosed with a UTI on 01/24/2025.
On 04/02/2025 at 9:04 a.m., an interview was conducted with S9MDS. S9MDS stated she was responsible for completing Resident #19's MDS assessment. S9MDS reviewed the Annual MDS with an ARD of 02/06/2025 and the Infection Log dated January 2025. She verified resident #19 had a urinary tract infection on 01/24/2025. S9MDS confirmed resident #19 should have been coded for having a UTI within the last 30 days and was not.
On 04/02/2025 at 09:09 a.m., an interview was conducted with S2DON. S2DON reviewed resident #19's Annual MDS with an ARD of 02/06/2025. She confirmed resident #19 was not coded accurately for urinary tract infections within the last 30 days.
2.
Resident #27
Review of Resident #27's Clinical Record revealed he was admitted to the facility on [DATE], with diagnoses which included Major Depressive Disorder and Unspecified Psychosis not due to a substance or known physiological condition.
Review of Resident #27's 142 Form titled Louisiana Department of Health and Hospitals Medicaid Program Notice of Medical Certification dated 05/06/2024, revealed an approval for admission by the State Level II Authority for a temporary period effective 05/06/2024 through 05/05/2025.
Review of Resident #27's Annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 06/30/2024 revealed Section A1500: Resident evaluated by PASRR was coded 0. No. Further review revealed section A1510: Serious Mental Illness was blank.
Resident #46
Review of Resident #46's Clinical Record revealed she was admitted to the facility on [DATE] with diagnoses which included Major Depressive Disorder, Schizoaffective Disorder, and Panic Disorder.
Review of Resident #46's 142 Form titled Louisiana Department of Health and Hospitals Medicaid Program Notice of Medical Certification dated 10/04/2024, revealed an approval for admission by the State Level II Authority for a temporary period effective 10/04/2024 through 10/03/2025.
Review of Resident #46's Annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 07/07/2025 revealed Section A1500: Resident evaluated by PASRR was coded 0. No. Further review revealed section A1510: Serious Mental Illness was blank.
On 04/02/2025 at 9:00 a.m., an interview was conducted with S9MDS. She verified Resident #27 and Resident #46's Form 142 indicated approval for admission by the State Level II Authority for a temporary period. She reviewed Resident #27 and Resident #46's most recent Annual MDS assessments and confirmed Section A1500 should have been coded as 1-Yes, and was not.
On 04/02/2025 at 9:10 a.m., an interview was conducted with S2DON. She reviewed the aforementioned findings for Resident's #27 and #46. She confirmed the resident's most recent Annual MDS assessments should have been coded correctly and were not.
3.
Resident #73
Review of Resident #73's Clinical Record revealed he was admitted to the facility on [DATE].
Review of Resident #73's Quarterly MDS with an ARD of 03/11/2025 revealed Resident #73 was coded for use of Physical Restraints as followed: Section P- Restraints and Alarms- P0100- used in chair or out of bed- G. Chair prevent rising- 1.-used less than daily. Further review revealed Resident #73 had a BIMS score of 15 which indicated he was cognitively intact.
On 04/01/2025 at 10:06 a.m., an interview was conducted with Resident #73. He confirmed he had never been physically restrained.
On 04/01/2025 at 1:50 p.m., an interview was conducted with S9MDS. She reviewed Resident #73's Quarterly MDS dated [DATE]. She stated Section P- Restraints and Alarms-G-Chair prevents rising was inaccurately coded as 1. Used less than daily. She confirmed it should have been coded as 0.-Not Used.
On 04/02/2025 at 9:10 a.m., an interview was conducted with S2DON. She confirmed Resident #73 had never required use of physical restraints. She reviewed Resident #73's Quarterly MDS dated [DATE]. She stated Section P- Restraints and Alarms-G-Chair prevents rising was inaccurately coded as 1.-Used less than daily. She confirmed it should have been coded as 0.-Not Used.
4.
Resident #91
Review of Resident #91's Clinical Record revealed he was admitted to the facility on [DATE] and was discharged on 01/20/2025.
Review of Resident #91's Discharge MDS with an ARD of 01/20/2025 revealed Section A2105 Discharge Status: Short Term General Hospital.
Review of Resident #91's Progress Notes dated 01/20/2025 revealed Resident #91 was released to local law enforcement custody.
On 04/02/2025 at 11:35 a.m., an interview was conducted with S10MDS. She confirmed Resident #91 was released into local law enforcement custody. She reviewed Resident #91's Discharge MDS and confirmed Section A2105 indicated the resident was discharged to Short Term General Hospital, and should have been coded for 99. Not Listed.
On 04/02/2025 at 11:55 a.m., an interview was conducted with S2DON. She confirmed Resident #91 was released into local law enforcement custody. She reviewed Resident #91's Discharge MDS and confirmed Section A2105 indicated the resident was discharged to Short Term General Hospital, and should have been coded for 99. Not Listed.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0697
(Tag F0697)
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 pain management was provided to residents who require such...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews and interviews, 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 1 (#2) out of 3 (#2, #25, and #88) residents reviewed for pressure ulcers. The facility failed to
1. Administer scheduled narcotics to Resident #2; and
2. Document narcotic administration for Resident #2.
Findings:
A review of the facility's policy titled Administering Pain Medication, with a revision date of October 2022, revealed the following, in part:
Steps in the Procedure
6. Administer pain medications as ordered
Documentation
Document the following in the resident's medical record:
2. Medication
Review of Resident #2's Clinical Record revealed she was admitted to the facility on [DATE] with diagnoses which included Pressure Ulcer of Left Buttock and Pressure Ulcer of Sacral Region.
Review of Resident #2's current Care Plan revealed the following, in part:
Focus: Resident is at risk for pain.
Interventions: Administer medications as ordered.
Review of Resident #2's current Physician Orders revealed the following, in part:
Hydrocodone-Acetaminophen Oral Tablet 10-325mg: Give 10 mg via PEG-Tube every 6 hours with a start date 01/17/2025.
1.
Review of Resident #2's Medication Administration Records (MAR), dated February 2025 and March 2025, revealed the following, in part:
Hydrocodone-Acetaminophen Oral Tablet 10-325mg: Give 10 mg via PEG-Tube every 6 hours. Further review revealed the medication was not documented as administered on 02/11/2025 6:00 a.m., 02/15/2025 06:00 a.m., 03/01/2025 06:00 a.m., and 03/05/2025 6:00 p.m.
Review of Resident #2's Narcotics Log, dated February 2025 and March 2025, revealed Hydrocodone-Acetaminophen 10-325mg was not signed out on 02/11/2025 6:00 a.m., 02/15/2025 6:00 a.m., 03/01/2025 6:00 a.m., and 03/05/2025 6:00 p.m.
On 04/02/2025 at 3:52 p.m., an interview was conducted with S12LPN. She confirmed she worked on 02/11/2025 at 6:00 a.m. and 03/05/2025 at 6:00 p.m. She was notified Hydrocodone-Acetaminophen 10-325mg was not documented on the MAR as administered nor was it signed out on Resident #2's Narcotic Log on the above mentioned dates. She confirmed if a medication was not signed out on the Narcotic Log or documented as administered on the MAR then it was not given. She confirmed she did not administer Resident #2's Hydrocodone-Acetaminophen 10-325mg per the physician order and should have.
2.
Review of Resident #2's Medication Administration Records, dated February 2025 and March 2025, revealed the following, in part:
Hydrocodone-Acetaminophen Oral Tablet 10-325mg: Give 10 mg via PEG-Tube every 6 hours. Further review revealed the medication was not documented as administered on 02/04/2025 6:00 a.m., 02/08/2025 6:00 a.m., 02/16/2025 6:00 a.m., 02/21/2025 6:00 a.m., and 03/18/2025 6:00 a.m.
Review of Resident #2's Narcotics Log for Hydrocodone-Acetaminophen 10-325mg, dated February 2025 and March 2025, revealed the medication was signed out on 02/04/2025 6:00 a.m., 02/08/2025 6:00 a.m., 02/16/2025 6:00 a.m., 02/21/2025 6:00 a.m., and 03/18/2025 6:00 a.m.
On 04/02/2025 at 3:48 p.m., an interview was conducted with S11LPN. She confirmed she worked on 02/21/2025 at 06:00 a.m. and 03/18/2025 at 06:00 p.m. She was notified Hydrocodone-Acetaminophen 10-325mg was signed out on Resident #2's Narcotic Log but was not documented on the MAR as administered on the above mentioned dates. She confirmed if she signed a medication out on the Narcotic Log, then she administered it. She confirmed she should have documented Hydrocodone-Acetaminophen 10-325mg on the MAR when she administered it and did not.
On 04/02/2025 at 9:20 a.m., an interview was conducted with S2DON. She reviewed Resident #2's MAR and Narcotic Log dated February 2025 and March 2025. She confirmed on 02/11/2025 at 6:00 a.m., 02/15/2025 at 6:00 a.m., 03/01/2025 at 6:00 a.m. and 03/05/2025 at 6:00 p.m. Resident #2's Hydrocodone-Acetaminophen 10-325 mg was not administered per the Physician order and should have been. S2DON also confirmed on 02/04/2025 at 6:00 a.m., 02/08/2025 at 6:00 a.m., 02/16/2025 at 6:00 a.m., 02/21/2025 at 6:00 a.m. and 03/18/2025 at 6:00 a.m., Hydrocodone-Acetaminophen 10-325 mg was not documented as administered on the MAR and should have been.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0809
(Tag F0809)
Could have caused harm · This affected multiple residents
Based on observations, interviews, and record review, the facility failed to ensure meals were served at regular times comparable to normal times in the community or in accordance with residents prefe...
Read full inspector narrative →
Based on observations, interviews, and record review, the facility failed to ensure meals were served at regular times comparable to normal times in the community or in accordance with residents preferences for 2 of 2 (Hall A and Hall B) halls observed for dining.
Findings:
Review of the facility's policy last revised July 2017 and titled, Frequency of Meals revealed the following, in part:
Policy: Each resident shall receive at least three meals daily, at times comparable to typical mealtimes in the community, or in accordance with resident needs, preferences, requests .
Policy interpretation and implementation:
3. A schedule of meal times and snacks shall be posted in resident area.
Review of the facility's posted meal times revealed lunch should be served at 11:00 a.m. on resident hallways.
On 04/01/2025 at 10:45 a.m., an interview was conducted with S6LPN. She stated she worked Hall B. She stated meals were consistently served late. She stated the residents complained and would start to look and ask for their food.
On 04/01/2025 at 10:50 a.m., an interview was conducted with S8CNA. She stated she worked Hall B. She stated meals were consistently served late and residents complained.
On 04/01/2025 at 10:59 a.m., an interview was conducted with S7LPN. She stated she worked Hall A. She stated meals were consistently served late and residents complained. She stated this had been an ongoing concern since she was hired a year ago.
On 04/01/2025 at 12:16 p.m., an observation was made of a Resident #11 sitting in the activity room between Hall A and Hall B asking staff for his lunch tray. Staff responded to him stating, Lunch is late, they did not forget about you, they are coming.
On 04/01/2025 at 12:20 p.m., an interview was conducted with Resident #11. He stated he resided on Hall B and meals were consistently served late. He stated he was hungry.
On 04/01/2025 at 12:46 p.m., an observation was made of staff serving lunch trays on Hall A.
On 04/01/2025 at 12:50 p.m., an observation was made of staff serving Resident #76's lunch tray on Hall A.
On 04/01/2025 at 12:51 p.m., an interview was conducted with Resident #76. She stated meals were often served late and she would prefer meals be served more consistent according to the posted meal times. She stated she was often hungry by the time the meals were served. She stated staff were aware of this issue but it had not improved.
On 04/01/2025 at 12:52 p.m., an observation was made of staff serving lunch trays on Hall B.
On 04/01/2025 at 1:00 p.m., an observation was made of staff serving Resident #11's lunch tray.
On 04/01/2025 at 1:10 p.m., an interview was conducted with S8CNA. She confirmed residents on Hall B were being passed their lunch tray and this was late.
On 04/01/2025 at 2:00 p.m., an interview was conducted with S4DM. She was made aware of the posted meal stating lunch was to be served at 11:00 a.m. to hallways and 11:30 a.m. in the dining area. She stated lunch was never served to the hallways first at 11:00 a.m. She stated lunch was served to the dining hall first and her goal was to start at 12:00 p.m. She confirmed lunch was served first at 12:11 p.m. to the dining hall today, which was late according to the posted meal times.
On 04/01/2025 at 2:05 p.m., an interview was conducted with S3DDM. She was made aware lunch was served first in the dining hall at 12:11 p.m., Hall A at 12:46 p.m. and then Hall B at 12:52 p.m. She stated meals should be served according to the posted meal times, and they were not. She confirmed lunch was served late.
On 04/01/2025 at 2:20 p.m., an interview was conducted with S1ADM. He stated he was aware residents were unhappy with meals served late. He stated he has had many conversations with the contracted dietary staff about the matter with no resolution. He stated the scheduled lunch time was 11:30 a.m. and he expected meals to be served at scheduled times. He was made aware lunch was first served today in the dining area at 12:11 p.m., Hall A at 12:46 p.m. and Hall B at 12:52 p.m. He confirmed lunch was not served at the posted scheduled time and should have been. He stated this was unacceptable.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Medical Records
(Tag F0842)
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 residents' Medication Administration Records (MAR) were ac...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews and interviews, the facility failed to ensure residents' Medication Administration Records (MAR) were accurately documented for 2 (#63 and #66) of 37 ( #2, #4, #7, #10, #11, #13, #18, #19, #20, #22, #25, #27, #29, #37, #38, #44, #46, #48, #49, #58, #61, #63, #66, #71, #73, #76, #83, #85, #88, #91, #92, #93, #244, #245, #344, #345 and #346) residents reviewed for pharmaceutical services. This deficient practice had the potential to affect any of the 89 residents residing in the facility.
Findings:
Review of the facility's policy Documentation of Medication Administration, with a revision date of November 2022 revealed in part:
Policy Statement: A medication administration record is used to document all medications administered.
Policy Interpretation and Implementation:
2. Administration of medication is documented immediately after it is given.
3. Documentation of medication administration includes, as a minimum:
f. reason(s) why a medication was withheld, not administered, or refused (as applicable);
g. initials, signature, and title of the person administering the medication;
Resident #63
Review of Resident #63's Clinical Record revealed an admission date of 05/17/2022, with diagnoses which included End Stage Renal Disease, Schizoaffective Disorder, Bipolar Type, Hypertension, Diabetes Mellitus-Type 2, Major Depressive Disorder, Heart Failure, Lack of Coordination, History of Falling, Repeated Falls, Unspecified Mood (affective) Disorder, and Dysphagia.
Review of Resident #63's January 2025-March 2025 Physician Orders revealed in part, the following:
Procardia XL oral tablet extended release 24 hour 30mg, give one tablet by mouth in the morning for Hypertension check Blood pressure prior. Start date 12/22/2024 at 6:00 a.m.
[NAME]-Vite oral tablet give tablet by mouth one time a day for mild malnutrition, weight loss related to weakness for appetite. Start date 02/02/2025 discontinue date 03/24/2025.
Sevelamer HCL oral tablet 800mg, give one tablet by mouth three times a day related to end stage renal disease. Start date 03/03/2025 at 2:00 p.m.
1 liter fluid restriction 240ml with each meal, 140ml with am and pm med-pass every shift. Start date 03/11/2025 at 7:00 p.m.
Assess resident for pain every shift: Non-pharmacological interventions. Start Date 01/06/2023 at 7:00 p.m.
Check AV shunt each shift assess for bruit and thrill every shift for monitoring. Start date 02/06/2025 at 7:00 p.m.
Review of Resident #63's January 2025-March 2025 MAR revealed in part, the following: Monitor for behaviors twice daily. No documentation noted on 03/20/2025 at 7:00 a.m.
Monitoring Anticoagulants-check for bleeding and bruising every shift. No documentation of monitoring noted on 03/20/2025 a.m. shift.
Hourly checks related to fall prevention every hour. No documentation of hourly checks noted on 03/20/2025 at 9:00 a.m., 10:00 a.m., 11:00 a.m., 12:00 p.m., 1:00 p.m., 2:00 p.m., 3:00 p.m., 4:00 p.m., 5:00 p.m., and 6:00 p.m.
Monitoring side effects: 1) Tardive dyskinesia, 2) Hypotension, 3) Sedation/drowsiness, 4) increased fall/dizziness 5) Appetite changes/weight change, 6) Headache, 7) Insomnia, 8) Weakness, 9) Visual Disturbances, 10) Gastrointestinal disturbances, 11) Other: see progress notes every shift for monitoring put in corresponding code, Start Date 01/06/2023. No documentation on 03/20/2025 a.m. shift.
Type of intervention attempted every shift put in corresponding code from above, Start Date 01/06/2023. No documentation of administration on 03/20/2025 at 7:00 a.m. shift.
Procardia XL oral tablet extended release 24 hour 30mg, give one tablet by mouth in the morning for Hypertension check Blood pressure prior-Start date 12/22/2024 at 6:00 a.m. No documentation of administration noted on 02/20/2025 and 03/20/2025.
[NAME]-Vite oral tablet give tablet by mouth one time a day for mild malnutrition, weight loss related to weakness for appetite. Start date 02/02/2025 D/C date 03/24/2025. No documentation of administration noted on 02/20/2025.
Sevelamer HCL oral tablet 800mg, give one tablet by mouth three times a day related to end stage renal disease-start date- 03/03/2025 at 2:00 p.m. No documentation of administration noted on 03/20/2025 at 2:00 p.m.
1 liter fluid restriction 240ml with each meal, 140ml with am and pm med-pass every shift-Start date-03/11/2025 at 7:00pm. No documentation of fluid restriction noted on 03/20/2025 at 7:00 a.m.
Assess resident for pain every shift: Non-pharmacological interventions. No documentation of pain assessment noted on 03/20/2025 at 7:00 a.m.
Check arteriovenous fistula shunt each shift assess for bruit and thrill every shift for monitoring. Start date 02/06/2025 at 7:00pm. No documentation of assessment noted on 03/20/2025 at 7:00 a.m.
Daily weights every day shift related to End Stage Renal Disease-Start date-03/13/2025 at 7:00 a.m. No documentation of weight noted on 03/20/2025.
Resident #66
Review of Resident #66's Clinical Record revealed an admission date of 05/19/2022, with diagnoses which included: unspecified Dementia, Psychotic Disturbance, Mood Disturbance, Anxiety, Bipolar Disorder, Mild and Major Depressive Disorder and unspecified Psychosis.
Review of Resident #66's January 2025-March 2025 Physician Orders revealed in part, the following:
Seroquel Oral Tablet (Quetiapine Fumarate), Give 75mg by mouth every night. Start date 07/11/2024 at 7:00 p.m.
Review of Resident #66's January 2025-March 2025 MAR revealed in part, the following:
On 02/24/2025 no documentation of the above medication being administered.
On 04/02/2025 3:46 p.m., a telephone interview was conducted with S14LPN. S14LPN stated she worked on 02/18/2025 and was assigned to Resident # 63. S14LPN was notified per Resident #63's MAR, the scheduled 6 a.m. dose Procardia XL 30 MG and [NAME]-Vite tablet
was blank. She could not recall why the medications were not documented. S14LPN stated Resident #63 frequently refuses his medications and treatments. S14LPN stated she should have documented medications and treatments as administered, or documented why they were not administered, and she did not.
On 04/02/2025 at 3:48 p.m., an interview was conducted with S11LPN. S11LPN confirmed she worked on 02/24/2025. S11LPN confirmed medications should have been documented as administered on the MAR. S11LPN stated her review of Resident #63's (date) MAR revealed the scheduled 6 a.m. administration of Seroquel 75mg was blank. S11LPN stated she had given the medication, but forgot to enter as administered.
On 04/02/2025 at 4:14 p.m., an interview was conducted with S13LPN. S13LPN stated LPNs are responsible for completing documentation on resident's MARs. S13LPN stated she worked on 02/20/2025 and 03/20/2025 and was assigned to Resident # 63. S13LPN reviewed Resident #63's MARs dated 02/01/2025 and 03/01/2025 and confirmed the following medication and treatment administrations were blank. S13LPN stated Resident # 63 received Procardia XL 30mg on 02/20/2025. S13LPN stated Resident #63 received Sevelamer HCL 800mg on 03/20/2025. S13LPN stated monitoring of behaviors, 1 liter fluid restrictions 240ml with each meal, 140 ml with morning med pass, assessments of resident for pain every shift, and AV shunt assessments each shift were completed. S13LPN confirmed the above dates on Resident #63's MAR were blank. S13LPN stated she should have documented medications and treatments immediately after administration, but did not.
On 04/02/2025 at 11:00 a.m., an interview was conducted with S2DON. S2DON reviewed the above mentioned MARs and confirmed the missing documentation of medications and treatments on Resident #63 and Resident #66's MARs. S2DON stated if medications/treatments are missed, refused, or resident is out of the facility it should be documented on the resident's MAR. S2DON confirmed all medications and treatments should be documented on the resident's MAR immediately after being administered, and were not.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Food Safety
(Tag F0812)
Could have caused harm · This affected most or all residents
Based on observations, interviews, and record review the facility failed to store and prepare food in accordance with professional standards for food service safety. The facility failed to ensure:
1. ...
Read full inspector narrative →
Based on observations, interviews, and record review the facility failed to store and prepare food in accordance with professional standards for food service safety. The facility failed to ensure:
1. Food was properly labeled in the refrigerators of the facility's kitchen;
2. Food products had not exceeded their expiration date;
3. Safe practices for thawing pork chops; and
4. Liquid pasteurized egg were maintained at a holding temperature of 41 degrees F or below.
This deficient practice had the potential to affect 87 residents who were served food and beverages from the kitchen.
Findings:
Review of the facility's policy last revised November 2022 and titled, Food Receiving and Storage revealed the following, in part:
Policy Statement: Foods shall be stored in a manner that complies with safe and handling practices.
Refrigerated/Frozen Storage
1. All foods stored in the refrigerator . are . labeled and dated.
2. Potentially Hazard Food and Time/Temperature Control for Safety foods are stored at or below 41degrees Fahrenheit.
On 03/31/2025 at 8:45 a.m., an initial tour was made of the kitchen with S5CK. The observations were made of the following items:
Refrigerator A:
4 red juices in 8oz plastic cups covered with no label or date.
Refrigerator B:
6 sandwiches wrapped in clear wrapping with no label or date; and
7 salads in covered plastic bowls with no label or date.
Dry Storage:
1 large can of pumpkin with a use by date of 10/05/2023.
1 large can of black beans with a use by date of 09/20/2024.
4 large cans of corned beef hash with a use by date of 06/02/2024.
Kitchen:
1 pack of 15 pork chops sitting in water in the sink with no running water.
6 32 ounce cartons of pasteurized liquid egg sitting on the counter.
On 03/31/2025 at 8:55 a.m., an interview was conducted with S5CK. She confirmed the above refrigerated items were not labeled or dated and should have been. She confirmed the above canned items were expired and should have been discarded. S5CK confirmed there was no running cold water on the pork chops. She confirmed the cartons of liquids eggs were on the counter.
On 03/21/2025 at 10:28 a.m., an interview and tour of the kitchen was conducted with S4DM. S4DM observed and confirmed the above food items in Refrigerator A and Refrigerator B were not labeled or dated and should have been. S4DM observed and confirmed the above named canned goods were expired and should have been discarded. S4DM observed 15 thawed pork chops in the kitchen sink sitting in water. S4DM confirmed the pork chops should have cold running water over them and they should have been discarded. S4DM further observed 6 32 ounce cartons of pasteurized eggs sitting out at room temperature on the counter. The temperature was taken of the liquid eggs and registered at 62.5 degrees Fahrenheit. S4DM confirmed eggs should be stored to keep a temperature of 41degrees or lower.
On 04/01/2025 at 2:20 p.m. an interview was conducted with S1ADM. He was made aware of the above findings in the kitchen. He confirmed these findings were unacceptable and staff should have used safe food handling practices.
MINOR
(C)
Minor Issue - procedural, no safety impact
Deficiency F0575
(Tag F0575)
Minor procedural issue · This affected most or all residents
Based on observations and interview, the facility failed to:
1. Post the names, addresses, and telephone numbers of pertinent state agencies and advocacy groups, such as the State Survey Agency, the ...
Read full inspector narrative →
Based on observations and interview, the facility failed to:
1. Post the names, addresses, and telephone numbers of pertinent state agencies and advocacy groups, such as the State Survey Agency, the State licensure office, the protection and advocacy network, home and community based service programs, and the Medicaid Fraud Control Unit; and
2. Post a statement for how a resident may file a complaint with the State Survey Agency concerning any suspected violation of state or federal nursing facility regulation for all required postings reviewed.
Findings:
On 04/01/2025 at 11:24 a.m., a tour of the facility was conducted. A list of names, addresses, and telephone numbers of all pertinent State agencies and advocacy groups, such as the State Survey Agency, the State licensure office, the protection and advocacy network, home and community based service programs, and the Medicaid Fraud Control Unit was not observed to be posted in the facility. Further observation revealed a statement for how a resident may file a complaint with the State Survey Agency concerning any suspected violation of a state or federal nursing facility regulation was not observed to be posted.
On 04/01/2025 at 12:22 p.m., a tour of the facility was conducted with S1ADM. He confirmed a list of names, addresses, and telephone numbers of all pertinent State agencies and advocacy groups, such as the State Survey Agency, the State licensure office, the protection and advocacy network, home and community based service programs, and the Medicaid Fraud Control Unit was not posted in the facility. He further confirmed a statement for how a resident may file a complaint with the State Survey Agency concerning any suspected violation of state or federal nursing facility regulation was not posted.
Dec 2024
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
Deficiency F0578
(Tag F0578)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to ensure all medical records regarding the resident's code status co...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to ensure all medical records regarding the resident's code status consistently reflected the resident's wishes for 1 (#3) of 3( #1, #R1 and #R2) residents reviewed for advanced directives.
Findings:
Review of Resident #3's clinical record revealed he was admitted to the facility on [DATE].
Review of Resident #3's Physician Orders in the electronic health record (EHR) revealed:
Date [DATE]- Full Code.
Review of Resident #3' Physician Orders in the physical chart revealed:
Date [DATE]- DNR.
On [DATE] at 10:40 a.m., an interview was conducted with S10LPN. She stated in the event of an emergency she would refer to the physical chart to determine a resident's code status.
On [DATE] at 10:50 a.m., an interview was conducted with S11LPN. She stated in the event of an emergency she would refer to the physical chart to determine a resident's code status.
On [DATE] at 10:52 a.m., an interview was conducted with S12LPN. She stated in the event of an emergency she would refer to the physical chart to determine a resident's code status.
On [DATE] at 11:10 a.m., an interview was conducted with S13LPN. She stated on [DATE], a CNA reported to her that Resident #3 looked pale. She stated she went and checked Resident #3 and found him with no pulse and no respirations. She stated she verified Resident #3's code status with the physical chart under the advanced directive tab. She stated Resident #3 was a DNR so she did not perform CPR.
On [DATE] at 11:45 a.m., an interview was conducted with S2DON. S2DON stated it was the nurse's responsibility to enter a physician's order into the EHR upon receiving the verbal/written order. S2DON reviewed Resident #3's hand written physician's order dated [DATE], and confirmed the order was never placed into the EHR and should have been. She reviewed the EHR and confirmed the Physician's Order dated [DATE] was for a Full Code. She confirmed the EHR did not reflect the most recent physician's order dated [DATE], DNR and 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
Assessment Accuracy
(Tag F0641)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews and interviews, the facility failed to ensure the Minimum Data Set (MDS) assessment accurately reflected...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews and interviews, the facility failed to ensure the Minimum Data Set (MDS) assessment accurately reflected the resident's status for 1 (#3) of 3 ( #1, #2, and #3) sampled residents. The facility failed to ensure Resident #3's status correctly reflected he had an Advanced Directive.
Findings:
Review of Resident #3's Clinical Record revealed he was admitted to the facility on [DATE].
Review of Resident #3's Significant Change Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 09/27/2024 revealed no Advanced Directive was selected in Section S.
Review of Resident #3's Care Plan dated 08/07/2023 revealed he had an Advanced Directive.
On 12/12/2024 at 11:15 a.m., an interview was conducted with S3SSD. She stated she was responsible for completing Section S in the MDS. S3SSD reviewed the Electronic Health Record and verified Resident #3 had an Advanced Directive. She confirmed the Significant Change MDS had not indicated he had one.
On 12/12/2024 at 11:45 a.m., an interview was conducted with S2DON. S2DON reviewed Resident #3's Advanced Directive dated 08/01/2023 and the Significant Change MDS with an ARD of 09/27/2024. S2DON confirmed the Significant Change MDS should have reflected Resident #3's Advanced Directive and did 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
Deficiency F0657
(Tag F0657)
Could have caused harm · This affected 1 resident
Based on record reviews and interviews, the facility failed to ensure a resident's Care Plan was revised to reflect a change in code status from Full Code to Do Not Resuscitate (DNR) for 1 (#3) of 3 (...
Read full inspector narrative →
Based on record reviews and interviews, the facility failed to ensure a resident's Care Plan was revised to reflect a change in code status from Full Code to Do Not Resuscitate (DNR) for 1 (#3) of 3 (#1, #2 and #3) sampled residents reviewed for care plans. This deficient practice had the potential to affect 84 Residents residing in the facility.
Findings:
Review of the facility's policy dated 03/2022, titled Care Plans, Comprehensive Person-Centered revealed, in part:
3. The care plan interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment.
11. Assessments of residents are ongoing and care plans are revised as information about the residents' condition change.
12. The interdisciplinary team reviews and updates the care plan.
Review of Resident #3's Clinical Record revealed an admit date of 08/01/2023.
Review of Resident # 3's most recent Care Plan revealed the following, in part:
08/07/23- Resident #3 wishes to be a Full Code.
Review of Resident #3's current Physician's Orders revealed the following, in part:
08/01/2023-Full Code
10/02/2024- Do Not Resuscitate (DNR)
On 12/12/2024 at 11:00 a.m., an interview was conducted with S4MDS. She stated she was responsible for updating resident's care plans. S4MDS reviewed and confirmed Resident #3 was care planned for a Full Code, dated 08/07/2023.
On 12/12/2024 at 11:45 a.m., an interview was conducted with S2DON. S2DON reviewed and confirmed Resident #3's Physician's order for code status, dated 10/02/2024, was Do Not Resuscitate (DNR). S2DON confirmed Resident #3's Care Plan was dated 08/07/2023 and reflected a code status of Full Code. S2DON confirmed the current Care Plan should have been updated to reflect Resident #3's current code status of DNR and 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
Deficiency F0658
(Tag F0658)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to ensure services were provided to meet quality professional standar...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to ensure services were provided to meet quality professional standards by failing to ensure physician's orders were accurately transcribed for 1 (#3) of 3 (#1, #2 and #3) residents reviewed for physician's orders.
Findings:
Review of Resident #3's Clinical Record revealed he was admitted to the facility on [DATE].
Review of Resident #3's Physician's Orders in the Electronic Health Record (EHR) revealed the following:
08/01/2023-Full Code
Review of Resident #3's hand written Physician's Orders in the physical hard chart revealed the following:
10/02/2024- Do Not Resuscitate (DNR)
On 12/12/2024 at 9:20 a.m., an interview was conducted with S5MR. S5MR confirmed when a nurse received a verbal or written physician's order, the nurse was responsible for the written/verbal order's entry into the EHR. S5MR confirmed it was her responsibility to upload written, paper orders into the EHR. S5MR confirmed she never received Resident #3's written DNR order dated 10/02/2024, and it was never uploaded into the EHR.
On 12/12/2024 at 11:45 a.m., an interview was conducted with S2DON. S2DON stated it was the nurse's responsibility to enter a physician's order into the EHR upon receiving the verbal/written order. S2DON reviewed Resident #3's hand written physician's order dated 10/02/2024 and Resident #3's EHR. S2DON confirmed Resident #3's ordered DNR status had not been entered or uploaded in the EHR 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
Menu Adequacy
(Tag F0803)
Could have caused harm · This affected 1 resident
Based on observations, interviews, and record review, the facility failed to ensure menus were followed to meet the nutritional needs of residents by failing to ensure the correct portion sizes ordere...
Read full inspector narrative →
Based on observations, interviews, and record review, the facility failed to ensure menus were followed to meet the nutritional needs of residents by failing to ensure the correct portion sizes ordered were provided for 1(#2) of 2(#1 and #2) residents reviewed for dining.
Findings:
Review of Resident #2's current Care Plan revealed the following:
08/13/2024-I am at risk for malnutrition, dehydration and weight fluctuations due to dialysis. I have a regular diet with double protein portions on each meal.
Review of Resident #2's Physician's Orders dated 12/09/2024 revealed the following:
08/13/2024- Regular diet, double protein with every meal.
On 12/09/2024 at 12:25 p.m., an observation was made of Resident #2's meal tray. One sausage link, one bun, French fries, green bell peppers, onions and cake.
On 12/09/2024 at 12:35 p.m., an interview was conducted with S8DC. She stated a meal slip was printed with the diet, including the portion size, for every resident. She stated today's lunch served was a sausage link, one bun, pepper, onions and French fries. She stated if a resident was ordered double protein they would have been served two sausage links.
On 12/09/2024 at 12:39 p.m., an interview was conducted with S9ST. She confirmed Resident #2 was served one sausage link for lunch.
On 12/10/2024 at 11:55 a.m., an observation was made of Resident #2's lunch tray served with 3 meatballs. An observation was made of Resident #2's meal ticket which read, double protein with all meals. Swedish meatballs- 6 each.
On 12/10/2024 at 11:56 a.m., an interview conducted with S7CNA. She confirmed Resident #2 was served 3 Swedish meatballs and should have been served 6.
On 12/10/2024 at 12:00 p.m., an interview was conducted with S2DON. She confirmed the meal ticket read double protein with all meals, Swedish Meatballs-6 each. She confirmed Resident #2 was served 3 meatballs and should have been served 6.
May 2024
4 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected 1 resident
Based on observations and interviews, the facility failed to ensure an infection prevention and control program was maintained by failing to ensure S9CNA appropriately discarded a soiled brief and wip...
Read full inspector narrative →
Based on observations and interviews, the facility failed to ensure an infection prevention and control program was maintained by failing to ensure S9CNA appropriately discarded a soiled brief and wipes with visible feces.
Findings:
On 05/20/2024 at 8:35 a.m., an observation and interview was conducted with S9CNA. S9CNA was observed walking down the hallway with soiled gloves, holding an exposed soiled diaper and soiled wipes with visible feces. S9CNA stated she should not have walked down a hallway with soiled gloves, a soiled brief and soiled wipes with visible feces and did.
On 05/22/2024 at 9:40 a.m., an interview was conducted with S8IP. She stated she would expect staff to bag soiled items in a resident's room, dispose of gloves and use hand hygiene prior to exiting a room. She confirmed S9CNA should not have walked down the hallway with soiled gloves, a soiled brief and soiled wipes with visible feces.
On 05/22/2024 at 4:05 p.m., an interview was conducted with S1ADM and S5DON. They confirmed S9CNA should not have walked down the hallway with soiled gloves, soiled brief and soiled wipes with visible feces.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Assessment Accuracy
(Tag F0641)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews, the facility failed to ensure the MDS assessment accurately reflected the resident's sta...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews, the facility failed to ensure the MDS assessment accurately reflected the resident's status for 3 (#20, #21, and #90) of 21 sampled residents by failing to ensure:
1. Resident #20 was coded correctly for hospice services,
2. Resident #21 was coded correctly for diagnosis; and
3. Resident #90 was coded correctly for Right Arm Splint.
Findings:
1.
Resident #20
Review of Resident #20's Clinical Record revealed he was admitted to the facility on [DATE].
Review of Resident #20's Quarterly MDS with an ARD of 04/15/2024 revealed a BIMS of 99, which indicated he was unable to complete the BIMs interview. Further review revealed the following:
Section O-Hospice: Blank
Review of Resident #20's Hospice admission Sheet revealed he was admitted to hospice on 02/15/2024.
On 05/22/2024 at 9:55 a.m., an interview was conducted with S6LPN. She stated Resident #20 had been receiving hospice services for a few months.
On 05/21/2024 at 1:25 p.m., an interview was conducted with S4MDS. She stated she was responsible for completing the resident's MDS assessments. She verified she was aware Resident #20 received hospice services. She reviewed Resident #20's Quarterly MDS assessment dated [DATE] and confirmed he was not coded for hospice and should have been.
On 05/21/2024 at 2:52 p.m., an interview was conducted with S5DON. He verified Resident #20 received hospice services. He reviewed Resident #20's last Quarterly MDS assessment and confirmed he was not coded for hospice.
2.
Resident #21
Review of Resident #21's Clinical Record revealed he was admitted to the facility on [DATE] with a diagnosis, which included Extended Spectrum Beta Lactamase ( ESBL)Resistance.
Review of Resident #21's Quarterly MDS with an ARD of 05/09/2024 revealed the following:
Section I- Active Diagnoses
-Multi Drug Resistant Organism
Review of Resident #21's Physician Orders revealed the following:
2/1/2024-2/12/2024- Contact Isolation precautions related to ESBL in urine
On 05/22/2024 at 9:05 a.m., an interview was conducted with S8IP. She stated Resident #21 did not have a current MDRO infection nor did she have a colonization of a MDRO.
On 05/22/2024 at 10:32 a.m. an interview was conducted with S4MDS. She confirmed Resident #21 did not have a current MDRO infection and the MDS should not reflect it.
On 05/22/2024 at 4:05 p.m. an interview was conducted with S5DON. He stated he was responsible for updating the Enhanced Barrier Precautions list weekly and as needed. He stated Resident #21 recently had a urinary tract infection which had resolved. He confirmed she did not have a current MDRO infection and the MDS should not reflect this diagnosis as being active.
3.
Resident #90
Review of Resident #90's Clinical Record revealed he was admitted to the facility on [DATE] with a diagnosis, which included Hemiplegia or Hemiparesis following Cerebral Infarction affecting Right Dominant Side.
Review of Resident #90's Quarterly MDS with an ARD of 03/26/2024 revealed the following:
Section O-Special Treatments, Procedures, and Programs
-No splint or brace assistance
Review of Resident #90's Physician Orders revealed the following:
01/20/2024 -Right resting hand splint to be worn during the day and off at night.
Review of Resident #90's MAR revealed the following:
02/01/2024-03/31/2024- Right Resting Hand Splint worn daily
On 05/22/2024 at 10:50 a.m., an interview was conducted with S8LPN. She stated Resident #90 wore his Right Hand Splint as ordered. She stated no one had ever reported Resident #90 refusing his splint. She stated if Resident #90 would refuse his splint it would reflect in the MAR.
On 05/21/2024 at 1:40 p.m., an interview was conducted with S4MDS. She confirmed Resident #90 had an order for a Right Hand Splint and the MDS was not coded for one.
On 05/22/2024 at 4:05 p.m., an interview was conducted with S5DON. He confirmed Resident #90 had an order for a Right Hand Splint. He stated the MDS should have been coded for a splint and was not.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Medication Errors
(Tag F0758)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to ensure PRN orders for psychotropic medications were limited to 14 ...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to ensure PRN orders for psychotropic medications were limited to 14 days and indicated the duration for 3 (#30, #58, and #62) of 6 (#2, #8, #13, #30, #58, and #62) residents reviewed for unnecessary psychotropic medications.
Findings:
Resident #30
Review of Resident #30's clinical record revealed the resident was admitted to the facility on [DATE] with diagnoses which included Unspecified Psychosis.
Review of Resident #30's May 2024 Physician's Orders revealed an order written on 03/07/2024 for Ativan 0.5 mg tablet, one tablet by mouth every 12 hours as needed (PRN) for anxiety. Further review revealed the PRN medication had no stop date.
Review of Resident #30's May 2024 Medication Administration Record (MAR)revealed Ativan 0.5 mg tablet, one tablet by mouth every 12 hours as needed (PRN) for anxiety was started on 03/07/2024. Further review revealed the PRN medication had no stop date.
Resident #58
Review of Resident #58's clinical record revealed the resident was admitted to the facility on [DATE] and admitted to a local hospice agency on 01/18/2024.
Review of Resident #58's May 2024 Physician's Orders revealed an order written on 01/18/2024 for Ativan 0.5 mg tablet, one tablet by mouth every 4 hours as needed (PRN) for anxiety/terminal restlessness. Further review revealed the PRN medication had no stop date.
Review of Resident #58's May 2024 Medication Administration Record (MAR) revealed Ativan 0.5 mg tablet by mouth every four hours as needed for anxiety/terminal restlessness was started on 01/18/2024. Further review revealed the PRN medication had no stop date.
Resident #62
Review of Resident #62's clinical record revealed the resident was admitted to the facility on [DATE] with diagnoses which included Insomnia.
Review of Resident #62's May 2024 Physician's Orders revealed an order written on 02/05/2024 for Belsomra 5mg tablet, one tablet by mouth every 24 hours as needed for sleep. Further review revealed the PRN medication had no stop date.
Review of Resident #62's May 2024 MAR revealed Belsomra 5mg tablet, one tablet by mouth every 24 hours as needed for sleep was started on 02/05/2024. Further review revealed the PRN medication had no stop date.
On 05/22/2024 at 9:00 a.m., an interview was conducted with S5DON. He reviewed the aforementioned findings and confirmed there was no duration or stop date documented for the resident's psychotropic PRN medications.
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 record review, observation, and interview the facility failed to ensure drugs and biologicals used in the facility were labeled in accordance with currently accepted professional principles f...
Read full inspector narrative →
Based on record review, observation, and interview the facility failed to ensure drugs and biologicals used in the facility were labeled in accordance with currently accepted professional principles for 1 (Cart A ) of 2 (Cart A and Cart B) medication carts observed. The facility failed to ensure:
1. Insulin pens were labeled with the date opened; and
2. Insulin pens were discarded 28 days after the date opened.
Findings:
Review of the updated 02/2023 facility policy titled Medication Labeling and Storage on 05/20/2024, revealed, in part:
Multidose vials that have been opened or accessed are dated and discarded within 28 days unless the manufacturer specifies a shorter or longer date for open vial.
An observation was made of Cart A on 05/20/2024 at 9:30 a.m. with S3LPN who confirmed the below observations:
Resident # 7's Humalog insulin pen was open, in use, and not dated to indicate when the insulin pen was opened.
Resident #47's Lantus insulin pen was open, in use, and not dated to indicate when the insulin pen was opened.
Resident #58's Humalog insulin pen was open, in use, and not dated to indicate when the insulin pen was opened.
An interview was conducted with S3LPN on 05/20/2024. S3LPN stated the above insulin pens should have been labeled with the open date to indicate when the pen was opened and discarded 28 days after opening and they were not.
An interview was conducted with S2ADON on 05/20/2024 at 10:00 a.m. She confirmed the facility uses the above noted Medication Labeling and Storage Policy. She stated insulin pens should be labeled with the open date and discarded per this guideline, and were not.
Mar 2024
3 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
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 interviews, the facility failed to ensure the physician was notified of a change in condition for 1 (...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to ensure the physician was notified of a change in condition for 1 (#1) of 4 (#1, #2, #3, and #R1) residents reviewed with urinary catheters. The nursing staff failed to ensure the physician was informed when Resident #1 had blood in his urine.
Findings:
Review of the Clinical Record for Resident #1 revealed a facility admission date of 01/05/2024.
Review of the Physician Orders for Resident #1 revealed the following, in part:
Start date: 01/06/2024 Eliquis oral tablet 2.5 mg give one tablet by mouth twice daily
02/20/2024 Send to emergency room for treatment and evaluation .
Review of the Emergency Department Records for Resident #1 revealed, in part, Resident #1 had an emergency room visit on 02/20/2024 and was diagnosed with a urinary tract infection.
Review of the Physician Note on 02/20/2024 at 6:46 p.m. revealed Review of Systems: Dysuria, No hematuria. Further review revealed Resident #1 was discharged from the emergency room on [DATE] with a urinary catheter in place.
Review of the emergency room Nurses' Notes for Resident #1 revealed the following, in part:
02/20/2024 at 9:59 p.m. Placed 16 French 10cc Foley catheter .500 ml of dark brown urine.
Review of the Medication Administration Record for Resident #1 dated February 2024 revealed the following, in part:
Eliquis 2.5 mg oral tablet give one tablet by mouth twice daily marked as administered from 02/01/2024 to 02/26/2024.
Review of the Nurses Daily Skilled Notes for Resident #1 dated February 2024 revealed the following, in part:
02/22/2024 1:13 p.m. Catheter status: indwelling; Describe urine color/clarity: Blank. Signed S7LPN
02/24/2024 12:52 p.m. Catheter status: indwelling; Describe urine color/clarity: Blood tinged, Cloudy with Sediments. Signed by S6LPN
02/25/2024 12:57 p.m. Catheter status: indwelling; Describe urine color/clarity: Blood tinged, Cloudy with Sediments. Signed by S6LPN
Review of the Nurses' Notes for Resident #1 dated February 2024 revealed no documentation the physician was notified Resident #1 had blood in his urine.
Review of the Physician Notes for Resident #1 dated February 2024 revealed no documentation Resident #1 had blood in his urine.
An interview was conducted with the dialysis nurse on 03/19/2024 at 10:38 a.m. She stated Resident #1 had a urinary catheter when he received his dialysis treatments on 02/21/2024, 02/23/2024, and 02/26/2024. She stated Resident #1 was not observed with blood in his urine until his dialysis treatment on 02/26/2024. She stated on 02/26/2024, the dialysis staff notified Resident #1's dialysis physician of blood in his urinary catheter, and he was transferred to the hospital. She stated no staff at the facility ever reported Resident #1 had blood in his urine.
An interview was conducted with S6LPN on 03/19/2024 at 11:10 a.m. She stated on 02/21/2024 Resident #1 returned from the hospital with a urinary catheter. She verified she was assigned to Resident #1 on 02/23/2024, 02/24/2024 and 02/25/2024. She stated on 02/24/2024 and 02/25/2024 Resident #1 had blood tinged urine. She stated she would not necessarily notify the physician of blood in Resident #1's urine since he was on antibiotics for a urinary tract infection. She stated she should have notified Resident #1's physician when she observed blood in his urine.
An interview was with S5NP on 03/20/2024 at 11:34 a.m. She stated she and S4MD were the primary care providers for Resident #1. She stated she was not aware Resident #1 had blood in his urine prior to his hospital transfer on 02/26/2024 from the dialysis center. She stated she would have expected staff to notify her or S4MD of blood in Resident #1's urine prior to 02/26/2024. She stated had she been notified by the facility's staff she would have ordered a urinalysis to be collected.
An interview was conducted with S4MD on 03/21/2024 at 2:25 p.m. He stated he was the primary care physician for Resident #1 at the facility. He stated on 02/22/2024 he saw Resident #1 at the facility for a follow up after an emergency room visit on 02/20/2024 where he was diagnosed with a urinary tract infection. He stated he was not made aware Resident #1 had blood in his urine. He stated he would have expected the facility's staff to notify him of blood in Resident #1's urine as the resident was on Eliquis. He stated had he known Resident #1 had blood in his urine he would have ordered a urinalysis, CT, and a Urology consult for Resident #1.
An interview was conducted with S3ADON on 03/20/2024 at 2:56 p.m. She reviewed Resident #1's electronic record and confirmed he returned to the facility from the hospital on [DATE] at 4:34 a.m. with a urinary catheter. She reviewed Resident #1's nurse assessments and nurse's notes dated 02/20/2024 to 02/25/2024 and verified S6LPN documented blood tinged urine, cloudy with sediment on 02/24/2024 and 02/25/2024, but there was no documentation she notified the physician. She confirmed when a resident had a change in condition, she would have expected the nurse to notify the resident's practitioner.
An interview was conducted with S2DON on 03/20/2024 at 3:00 p.m. He reviewed Resident #1's nurse assessments and nurse's notes dated 02/20/2024 to 02/25/2024 and verified S6LPN documented blood tinged urine, cloudy with sediment on 02/24/2024 and 02/25/2024, but there was no documentation she notified the physician. He confirmed there was no documentation Resident #1 had blood in his urine at the facility until 02/24/2024 and 02/25/2024.
An interview was conducted with S1ADM on 03/20/2024 at 3:05 p.m. He confirmed when a resident had a change in condition, he would have expected the nurse to notify the resident's practitioner.
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 F0658
(Tag F0658)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interviews, the facility failed to ensure services were provided to meet quality profes...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interviews, the facility failed to ensure services were provided to meet quality professional standards for 2 (#1, #R1) of 4 (#1, #2, #3, and #R1) residents reviewed with urinary catheters. The facility failed to ensure Resident #1 and Resident #R1 had a physician's order to maintain an indwelling urinary catheter.
Findings:
Resident #1
Review of the Clinical Record for Resident #1 revealed a facility admission date of on 01/05/2024.
Review of the Emergency Department Records for Resident #1 revealed, in part, Resident #1 had an emergency room visit on 02/20/2024 and was discharged from the emergency room on [DATE] with an indwelling urinary catheter in place.
Review of the Physician Orders for Resident #1 dated February 2024 to March 2024 revealed the following, in part:
02/20/2024 Send to emergency room for treatment and evaluation .
03/06/2024 Remove Foley catheter .
Further review revealed no physician's order for Resident #1's urinary catheter.
Review of the Nurses Daily Skilled Notes for Resident #1 dated February 2024 to March 2024 revealed, in part, he returned to the facility from the emergency room on [DATE] with a urinary catheter.
Review of the MAR/TAR for Resident #1 dated February 2024 to March 2024 revealed, in part, no documentation pertaining to his urinary catheter.
An interview was conducted with S6LPN on 03/19/2024 at 11:10 a.m. She stated on 02/21/2024 Resident #1 returned from the hospital with a urinary catheter. She reviewed Resident #1's physician orders, and confirmed there were no orders entered for the urinary catheter and there should have been.
An interview was conducted with S7LPN on 03/20/2024 at 10:30 a.m. She stated she was assigned to Resident #1 after he returned from the hospital on [DATE] with a urinary catheter, and she entered Resident #1's physician orders. She stated she did not request urinary catheter orders from the hospital or Resident #1's physician and should have.
An interview was conducted with S3ADON on 03/19/2024 at 12:50 p.m. She stated the nurses were responsible for entering physician orders for residents. She reviewed the clinical record for Resident #1, and confirmed when he returned from the hospital on [DATE] with a urinary catheter there were no physician orders entered for the catheter and there should have been.
An interview was conducted with S2DON on 03/19/2024 at 4:06 p.m. He stated the nurses were responsible for entering physician orders. He reviewed Resident #1's physician orders dated February 2024 to March 2024 and confirmed there were no orders for the urinary catheter. He stated the nurse who received Resident #1 from the hospital on [DATE], should have realized he had a urinary catheter and no orders for it. He stated he would have expected the nurses to contact the provider and request urinary catheter orders.
An interview was conducted with S1ADM on 03/20/2024 at 9:00 a.m. He verified Resident #1 had a urinary catheter placed in the emergency room on [DATE]. He stated Resident #1 was discharged to the facility with a urinary catheter and no orders were obtained and entered for the catheter and should have been.
Resident #R1
Review of the Clinical Record for Resident #R1 revealed a facility admission date of 03/15/2024 with diagnoses which included, Neuromuscular Dysfunction of the Bladder and Other Retention of Urine.
Review of the Hospital Discharge Records for Resident #R1 revealed, in part, Resident #R1 was discharged from the hospital on [DATE] with an indwelling urinary catheter in place due to urinary retention.
Review of the Physician Orders for Resident #R1 from 03/15/2024 to 03/18/2024 revealed no physician's order for Resident #R1's urinary catheter.
Review of the Nurses Notes for Resident #R1 dated March 2024 revealed the following, in part:
03/15/2024 at 11:41 p.m. Resident arrived at 9:41 p.m. Resident #R1 noted with indwelling urinary catheter.
An observation was made of Resident #R1 on 03/19/2024 at 10:30 a.m. He had a urinary catheter with a drainage bag on the right side of his wheelchair.
An interview was conducted with S10LPN on 03/21/2024 at 12:32 p.m. She stated on 03/15/2024 she admitted Resident #R1 from the hospital, and he had a urinary catheter. She stated at that time she was unaware the nurses were responsible for entering resident's physician orders. She confirmed she did not contact Resident #R1's provider for urinary catheter orders on 03/15/2024 and should have.
An interview was conducted with S6LPN on 03/21/2024 at 12:40 p.m. She verified she worked on 03/18/2024 and 03/19/2024 and was assigned to Resident #R1. She stated he had a urinary catheter. She stated on 03/19/2024, when she realized he did not have catheter orders she contacted the physician. She stated the admitting nurse should have contacted the physician and entered the urinary catheter orders in the computer.
An interview was conducted with S7LPN on 03/21/2024 at 1:05 p.m. She stated the admitting nurse was responsible for entering resident's physician orders. She stated Resident #R1 was admitted to the facility on [DATE] at 9:50 p.m. with a urinary catheter. She stated she entered physician orders on 03/16/2024 at 7:43 a.m. for Resident #R1. She reviewed Resident #R1's physician orders and confirmed urinary catheter orders were not entered until 03/19/2024. She stated she did not notice Resident #R1 did not have orders for the urinary catheter when she worked on 03/16/2024. She stated she should have contacted the physician and entered urinary catheter orders for Resident #R1.
An interview was conducted with S3ADON on 03/21/2024 at 1:14 p.m. She stated S6LPN notified S1ADM, S2DON and herself on 03/19/2024 that Resident #R1 did not have orders for the urinary catheter upon admit to the facility on [DATE]. She stated the admitting nurse should have contacted Resident #R1's physician for urinary catheter orders.
An interview was conducted with S2DON on 03/21/2024 at 1:16 p.m. He stated S6LPN notified S1ADM, S3ADON and himself on 03/19/2024 that Resident #R1 did not have orders for the urinary catheter upon admit to the facility on [DATE]. He stated the admitting nurse should have contacted Resident #R1's physician for urinary catheter orders.
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
Medical Records
(Tag F0842)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to maintain accurate records in accordance with accepted professional...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to maintain accurate records in accordance with accepted professional standards and practices for 2 (#1, #R1) of 4 (#1, #2, #3, and #R1) residents reviewed with indwelling urinary catheters. The facility failed to ensure nursing staff documented catheter care and monitoring of adverse signs and symptoms every shift for Resident #1 and Resident #R1.
Findings:
Review of the facility's policy titled, Catheter Care, Urinary revealed the following, in part:
Purpose: The purpose of this procedure is to prevent urinary catheter-associated complications, including urinary tract infections.
Documentation:
The following information should be recorded in the resident's medical record:
1.
The date and time the catheter care was given.
2.
The name and title of the individual(s) giving the catheter care.
4.
Character of urine such as color (straw-colored, dark, red), clarity (cloudy, solid particles, or blood), and odor.
Resident #1
Review of the Clinical Record for Resident #1 revealed a facility admission date of 01/05/2024.
Review of the Emergency Department Records for Resident #1 revealed, in part, Resident #1 had an emergency room visit on 02/20/2024 and was discharged from the emergency room on [DATE] with an indwelling urinary catheter in place.
Review of the Physician Orders for Resident #1 dated February 2024 to March 2024 revealed the following, in part:
02/20/2024 Send to emergency room for treatment and evaluation .
03/06/2024 Remove Foley catheter .
Further review revealed no physician's order for Resident #1's urinary catheter.
Review of the Nurses Daily Skilled Notes for Resident #1, dated February 2024 to March 2024 revealed, in part, he returned to the facility from the emergency room on [DATE] with a urinary catheter. Further review revealed no documentation of urinary catheter care or that the urinary catheter was monitored every shift for adverse signs and symptoms.
Review of the MAR/TAR for Resident #1, dated February 2024 to March 2024 revealed, in part, no documentation pertaining to his urinary catheter.
An interview was conducted with S6LPN on 03/19/2024 at 11:10 a.m. She stated on 02/21/2024 Resident #1 returned from the hospital with a urinary catheter. She stated catheter orders entered into the electronic record populated tasks for the nurses to monitor the catheter and provide care every shift. She stated the populated tasks and monitoring were to ensure catheter care was provided every shift by the nurse or CNAs, and the catheter was monitored for infection and blockages every shift. She stated these tasks and monitoring would be documented by the nurse on the MAR or TAR. She reviewed Resident #1's MAR and TAR and confirmed there was no documentation that catheter care and monitoring of the catheter had been provided every shift for Resident #1.
An interview was conducted with S8CNA on 03/19/2024 at 3:53 p.m. She stated Resident #1 returned from the hospital on [DATE] with a urinary catheter. She stated she provided catheter care for Resident #1 and the nurses documented the care provided.
An interview was conducted with S7LPN on 03/20/2024 at 10:30 a.m. She stated when a resident had a urinary catheter the process was to enter a batch order in the computer that included tasks assigned to the nurses for catheter care and monitoring for signs and symptoms of infection and patency every shift. She stated the nurses or the CNAs provided catheter care and the nurses documented the catheter care on the MAR or the TAR. She reviewed Resident #1's MAR and TAR, and confirmed there was no documentation that catheter care and monitoring had been done every shift for Resident #1.
An interview was conducted with S3ADON on 03/19/2024 at 12:50 p.m. She reviewed the clinical record for Resident #1, and confirmed when he returned from the hospital on [DATE], with a urinary catheter, there were no orders entered for catheter care and monitoring of the catheter for infection and patency and there should have been. She stated the nurses were responsible for documenting care provided on the MAR or TAR. She confirmed from 02/21/2024 until the urinary catheter was removed on 03/06/2024 there was no documentation that catheter care and monitoring of the catheter was done every shift for Resident #1.
An interview was conducted with S2DON on 03/19/2024 at 4:06 p.m. He stated urinary catheter care could be provided by the nurses or the CNAs and would be documented by the nurses on the MAR or TAR. He reviewed Resident #1's MAR and TAR dated February 2024 to March 2024 and confirmed there were no orders for the urinary catheter, catheter care and monitoring of the catheter. He confirmed from 02/21/2024 until the urinary catheter was removed on 03/06/2024 there was no documentation that catheter care and monitoring was provided every shift for Resident #1.
An interview was conducted with S1ADM on 03/20/2024 at 9:00 a.m. He verified Resident #1 had a urinary catheter placed in the emergency room on [DATE]. He stated Resident #1 was discharged to the facility with a urinary catheter and no orders were entered for the catheter, catheter care and monitoring the catheter for infection. He confirmed the nursing staff had not entered urinary catheter orders to trigger staff to document catheter care for Resident #1. He confirmed the nursing staff had not documented catheter care and monitoring of the catheter every shift from 02/21/2024 until the urinary catheter was removed on 03/06/2024. He stated the facility had not followed their catheter care policy.
Resident #R1
Review of the Clinical Record for Resident #R1 revealed a facility admission date of 03/15/2024 with diagnoses which included, Neuromuscular Dysfunction of the Bladder and Other Retention of Urine.
Review of the Hospital Discharge Records for Resident #R1 revealed, in part, Resident #R1 was discharged from the hospital on [DATE] with an indwelling urinary catheter in place due to urinary retention.
Review of the Physician Orders for Resident #R1 from 03/15/2024 to 03/18/2024 revealed no physician's order for Resident #R1's urinary catheter.
Review of the Nurses Notes for Resident #R1 for March 2024 revealed the following, in part:
03/15/2024 at 11:41 p.m., Resident arrived at 9:41 p.m. Resident #R1 noted with indwelling urinary catheter.
An observation was made of Resident #R1 on 03/19/2024 at 10:30 a.m. He had a urinary catheter with a drainage bag on the right side of his wheelchair.
An interview was conducted with S10LPN on 03/21/2024 at 12:32 p.m. She stated when urinary catheter orders were entered for a resident, tasks for catheter care and monitoring for infections and patency were assigned to and documented by the nurses on the TAR. She confirmed she did not contact Resident #R1's provider for urinary catheter orders on 03/15/2024.
An interview was conducted with S6LPN on 03/21/2024 at 12:40 p.m. She verified she worked on 03/18/2024 and 03/19/2024 and was assigned to Resident #R1. She stated he had a urinary catheter. She stated there were no tasks to trigger the nurses to provide catheter care or monitoring for infections. She confirmed she had not documented catheter care and monitoring of the catheter every shift for Resident #R1 and should have.
An interview was conducted with S7LPN on 03/21/2024 at 1:05 p.m. She stated Resident #R1 was admitted to the facility on [DATE] at 9:50 p.m. with a urinary catheter. She confirmed there was no documentation that catheter care and monitoring of the catheter had been provided every shift for Resident #R1.
An interview was conducted with S3ADON on 03/21/2024 at 1:14 p.m. She confirmed there was no documentation that catheter care and monitoring of the catheter had been provided every shift for Resident #R1 from 03/15/2024 to 03/18/2024.
An interview was conducted with S2DON on 03/21/2024 at 1:16 p.m. He confirmed there was no documentation that catheter care and monitoring of the catheter had been provided every shift for Resident #R1 from 03/15/2024 to 03/18/2024.
Feb 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
Free from Abuse/Neglect
(Tag F0600)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews and interviews, the facility failed to ensure each resident had the right to be free from physical abuse...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews and interviews, the facility failed to ensure each resident had the right to be free from physical abuse by another resident for 1 (#4) of 5 (#2, #3, #4, #5, and #6) residents reviewed for abuse. The facility failed to protect Resident #4 from physical abuse by Resident #5.
The facility implemented corrective actions which were completed prior to the State Agency's investigation, thus it was determined to be a Past Noncompliance citation.
Findings:
A review of the facility's policy titled, Abuse, Neglect, Exploitation & Misappropriation revealed the following, in part:
Policy: It is inherent in the nature and dignity of each resident at the center that he/she be afforded basic human right, including the right to be free from abuse .
Definitions:
Abuse:
Abuse is the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish.
-Physical Abuse includes but is not limited to: Hitting, Slapping, Punching .
Resident #4
A review of the Clinical Record for Resident #4 revealed he was admitted to the facility on [DATE], with diagnoses which included Altered Mental Status, Dementia, and Hearing Loss.
A review of the Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/01/2023 revealed Resident #4 had a Brief Interview for Mental Status (BIMS) of 0, which indicated he was severely cognitively impaired.
Resident #5
A review of the Clinical Record for Resident #5 revealed he was admitted to the facility on [DATE], with diagnoses which included Hemiplegia and Hemiparesis following Cerebral Infarction and Aphasia.
A review of the Quarterly MDS with an ARD of 01/12/2024 revealed Resident #5 had a BIMS of 0, which indicated he was severely cognitively impaired.
A review of the facility's Self-Reported Incident Report, dated 01/11/2024, revealed the following, in part:
Victim: Resident #4
Accused: Resident #5
Allegations: Physical abuse
Allegation Findings: Substantiated
Incident Description: On 01/11/2024 around 1:30 p.m., Resident #4 was coming out of his room and his roommate, Resident #5, was right behind him trying to come out of the room as well. Resident #5 told Resident #4 to move. Resident #4 responded he was trying, and Resident #5 struck Resident #4 in the face. The residents were separated immediately. The Resident's responsible party(s) and MD/NP were made aware of the incident. NP gave order to send Resident #5 out to behavioral for evaluation; his Responsible party was made aware.
Resident #5 was placed on one-on-one until he was sent to the behavioral hospital for evaluation.
On 01/12/2024 at 9:36 a.m., Resident #5 was transferred to the behavioral hospital via their transportation.
A review of the Nurse's Notes dated January 2023 for Resident #5 revealed the following, in part:
01/11/2024 at 1:30 p.m., staff member heard yelling from resident's room, resident was attempting to exit room while roommate was attempting to enter room. Resident got visibly agitated and struck roommate in the face with closed fist. Resident and roommate immediately separated; resident placed on one on one. S8ED, S1DON, and S3SW notified immediately. NP notified and gave order to send resident to behavioral, S3SW made aware. RP made aware of event and order and verbalizes understanding. Signed, S5LPN.
A review of the written statement by S6CNA dated 01/11/2024 revealed S6CNA heard yelling and turned to see Resident #5 hit Resident #4 in the face. The residents were then separated.
A review of the written statement by S7CS dated 01/11/2024 revealed S7CS saw Resident #4 walk out his room, Resident #5 shoved Resident #4, Resident #5 punched Resident #4 in the face, and the residents were separated.
On 02/12/2024 at 12:58 p.m., an interview was conducted with Resident #4's family member. She stated Resident #4 had dementia and was confused. She stated if Resident #4 did not have dementia, he would have been angry about getting punched.
On 02/12/2024 at 3:02, an interview was conducted with S5LPN. She verified she witnessed an altercation between Resident #4 and Resident #5 on 01/11/2024. She stated Resident #4 was in the doorway of their room and Resident #5 was attempting to get out. She stated Resident #5 told Resident #4 to move, but Resident #4 could not hear him. She stated Resident #5 hit Resident #4 in the face. She stated the two residents were separated at once, and Resident #5 was placed on 1:1 supervision, until he was transferred to the behavioral hospital. She stated after the altercation, she notified S1DON, S3SW, the NP, and each resident's responsible party. She stated she received an abuse in-service after the altercation occurred between Resident #4 and Resident #5
On 02/12/2024 at 2:18 p.m., an interview was conducted with S6CNA. She verified she witnessed an altercation between Resident #4 and Resident #5 on 01/11/2024. She stated Resident #4 was in the doorway of their room and Resident #5 was attempting to get out. She stated Resident #5 told Resident #4 to move, but Resident #4 could not hear him. She stated Resident #5 pushed Resident #4 in the chest then hit him in the face. She stated the two residents were separated at once. She stated no injuries were noted to Resident #4. She stated S5LPN notified S1DON and S3SW after the altercation occurred. She stated she received an abuse in-service after the altercation occurred between Resident #4 and Resident #5.
On 02/12/2024 at 2:52 p.m., an interview was conducted with S7CS. She verified she witnessed an altercation between Resident #4 and Resident #5 on 01/11/2024. She stated Resident #4 was in the doorway of their room and Resident #5 was attempting to get out. She stated Resident #5 pushed Resident #4 then hit him in the face. She stated there was a CNA and a nurse at the nurse's station and they helped her separate the two residents immediately. She stated Resident #5 punching Resident #4 was abuse. She stated she received an abuse in-service after the altercation occurred between Resident #4 and Resident #5.
On 02/14/2024 at 9:25 a.m., an interview was conducted with S4LPN. She stated she was aware of the altercation that occurred between Resident #4 and Resident #5. She confirmed the incident was abuse. She stated Resident #5 was moved to a different room on a different hall after the altercation. She stated she received an abuse in-service after the altercation occurred.
On 02/14/2024 at 10:16 a.m., an interview was conducted with S3SW. She verified she was working on 01/11/2024 and was aware of the altercation between Resident #4 and Resident #5. She stated she did not witness the event, but she was notified after it happened. She stated Resident #5 was sent out to the behavioral hospital after the altercation occurred. She stated Resident #4 was assessed and had no injuries from the altercation. She confirmed the incident was abuse because Resident #5 hit Resident #4. She stated since the incident, she started monitoring residents for abuse. She stated she began monitoring for 7 days daily, weekly for a month, then monthly for two months facility wide.
On 02/14/2024 at 1:45 p.m., an interview was conducted with S1DON. He verified he was aware of the altercation between Resident #4 and Resident #5 on 01/11/2024. He stated Resident #4 was standing in the doorway when Resident #5 was attempting to get out. He stated Resident #5 got frustrated that Resident #4 was not moving fast enough and hit him. He confirmed the incident was abuse. He stated Resident #4 was assessed after the altercation and had no injuries. He stated the two residents were separated immediately, and Resident #5 was placed on 1:1 supervision until he was transferred to the behavioral hospital. He stated after the incident, all staff, including administration, were in-serviced on abuse. He stated S3SW had been monitoring for abuse facility wide since the incident, and monitoring was ongoing.
The facility has implemented the following actions to correct the deficient practice:
On 01/11/2024 at 13:30 pm Resident #4 and Resident #5 had a Resident-to-Resident abuse incident. S5LPN separated Residents and Resident #3 was placed on one on one until 01/12/24 at 9:36 a.m. at which time he was transferred to inpatient behavioral health. Resident #5 returned 01/24/24 at 3:54 p.m. and was placed in a different room on a different hall. Resident #4 or Resident #5 has had no further incident of Resident to Resident.
On 01/13/24 Education with Executive Director, Director of Nursing and Assistant Director of Nursing was conducted by the Regional Director of Clinical Services on Mandatory Reporting and Abuse, Neglect Exploitation, & Misappropriation.
On 01/13/2024 Education was conducted by LPN and Regional Director of Clinical Services on Abuse, Neglect Exploitation, & Misappropriation with staff.
Quality Monitoring:
Quality Monitoring for Abuse and Neglect for six residents per review was began on 01/12/24 and is ongoing.
A Quality Assurance Performance Improvement Committee Meeting held on 01/12/24 to review incident of resident-to-resident abuse to conduct root cause analysis and review plan of correction. QAPI attendees were Executive Director, Director of Nursing. Assistant Director of Nursing, Regional Director of Clinical Services, Unit Manager, Senior Director of Sales and Marketing, Social Services Director, Dietary Manager, Maintenance Director, and MDS Nurse. Verbal conducted by Executive Director and Regional Director of Clinical Services.
Facility compliance date as of 01/13/2024.
Throughout the survey on 02/12/2024 and 02/14/2024, observations, record reviews, and staff interviews revealed staff received training on the facility's abuse policies and procedures, de-escalating aggressive behaviors, were knowledgeable of the types of abuse, and were aware abuse should be reported to administration immediately. Observations were made throughout the survey with no abuse identified. Observations, interviews, and record review, revealed monitoring had begun with no further issues identified.
Oct 2023
3 deficiencies
2 IJ (2 affecting multiple)
CRITICAL
(K)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Immediate Jeopardy (IJ) - the most serious Medicare violation
Free from Abuse/Neglect
(Tag F0600)
Someone could have died · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews, the facility failed to ensure residents were free from sexual abuse for 1...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews, the facility failed to ensure residents were free from sexual abuse for 1 (Resident #5) of 6 (Residents #1, #2, #3, #4, #5, and #6) sampled residents reviewed for sexual abuse.
The deficient practice resulted in an Immediate Jeopardy situation on 08/29/2023 when Resident #4, a moderately cognitively impaired resident, returned to the facility from a psychiatric hospital stay for sexually inappropriate behaviors. Upon Resident #4 returning to the facility on [DATE], he continued to exhibit sexually inappropriate behaviors with staff. On 09/13/2023 at 1:45 p.m., Resident #4 grabbed Resident #5's breast. After the incident, Resident #4 was placed on 1:1 supervision for 72 hours. After 72 hours, the 1:1 supervision was discontinued and no new interventions were implemented to ensure Resident #4 would not sexually abuse another resident. Staff interviews revealed Resident #4 continued to exhibit sexually inappropriate behaviors after the incident on 09/13/2023. Due to the lack of new interventions, there was a likelihood of Resident #4 sexually abusing other residents if not immediately corrected.
S1ADM, S2DON, and S3CVP were notified of the Immediate Jeopardy on 10/04/2023 at 6:55 p.m.
The Immediate Jeopardy was removed on 10/05/2023 at 2:50 p.m. when the facility submitted an acceptable Plan of Removal. Through observations, interviews and record reviews, the surveyors confirmed the following had been initiated and/or implemented prior to exit. The Immediate Jeopardy Plan of Removal included the following:
-On 10/04/2023 Resident #4's care plan was updated to include intervention of one on one observation and inpatient behavioral services.
-On 10/04/2023 at 7:30 p.m. Immediately Resident #4 was placed on one on one observation.
-On 10/04/2023 physician was notified and orders noted to send Resident #4 to inpatient behavioral health services. Resident discharged from building at 10:00 p.m. on 10/04/2023 to behavioral inpatient. Resident is not to return to the facility.
-On 10/04/2023 at 10:00 p.m. Resident #4 was transported to inpatient behavioral health services.
-On 10/05/2023 76 interviews with Residents with BIMS (Brief Interview for Mental Status) of 9 or greater were interviewed by IDT Team to ensure that they had not been abused and had not witnessed any abuse or neglect of a fellow resident as well as to inquire about their safety. Process initiated on 10/04/2023 8:00 p.m. Time of completion on assessments: 10/05/2023 8:30 a.m.
-On 10/05/2023 26 Residents were assessed by licensed nurses conducting skin sweeps for suspicious injuries. Process initiated on 10/04/2023 8:00 p.m. Time of completion on assessments: 10/05/2023 8:30 a.m.
-On 10/05/2023 Resident #5 to receive psychiatric consultation and ongoing weekly monitoring by psychiatric services and social worker.
-Quality Assurance Performance Committee (QAPI) met on 10/04/2023 at 9:30 p.m. to review 09/13/2023 incident of Resident #4's inappropriate sexual behavior and determine a Root Cause. Meeting was led by Assistant Regional [NAME] President of Operations and Executive Director. Attendees were Executive Director (ED), Regional [NAME] President of Operations (RVPO), Social Services Director (SSD), Housekeeping Supervisor (HKS), Business Office Manager (BOM), and Director of Nursing (DON), Activities Director (AD, Therapy Manager (TM), Maintenance Supervisor (MS), Licensed Nurse (LPN) and Medical Records Clerk (MRC) and Director of Sales and Marketing (DSM). The Root Cause was determined to be that the facility failed to ensure resources were effectively and efficiently used to put interventions in place to prevent sexual abuse.
-On 10/04/2023 at 8:00 p.m. education was conducted with the Executive Director (ED) and the Director of Nursing (DON) by the Regional [NAME] President of Operations (RVPO) on Abuse, Neglect, and Misappropriation and on ensuring resources are effectively and efficiently used to put interventions in place to prevent sexual abuse by Residents with inappropriate sexual behavior.
-Quality Monitoring on effectiveness of education to be reviewed by Assistant Regional [NAME] President of Operations by weekly visitation with the Regional Director of Clinical Services, Director of Nursing, and Executive Director weekly for 4 weeks and monthly for 3 months following. Monitoring will be held weekly by Administrator, Director of Nursing, Business Development Director, Admissions Coordinator, and Social Services Director or comparable designee. Monitoring team will review confirmed admission packets for potential hyper-sexual behaviors or tendencies. Any adverse findings will be rectified through care planning and appropriate interventions. Team will review baseline care plans of recent admissions. A random sample of 10 residents shall be interviewed for psychosocial well-being and reviewed with corporate leadership. To begin on 10/06/2023 and complete on 02/06/2024. All findings of reviews will be reported monthly to IDT through the QAPI meeting.
-On 10/05/2023 7:00 a.m. education was conducted on Abuse, Neglect, and Misappropriation with emphasis on sexual abuse and appropriate interventions for a Resident with sexually inappropriate behaviors to prevent sexual abuse. All present staff completed on 10/05/2023 at 10:00 a.m., including MDS staff. Expected completion time on Full-Time staff by 10/06/2023 6:00 p.m. PRN staff will be requiring education prior to working their next shift. No staff shall be allowed to work his or her assignment until training has been completed.
-Employees will receive training upon hire and prior to accepting assignment.
The deficient practice continued at a potential for more than minimal harm for the 97 residents currently residing in the facility.
Findings:
Review of the facility's policy titled, Employee Acknowledgment of Resident -Patient Rights revealed the following, in part:
Policy: These Resident Rights ensure that each resident admitted :
7. Is free from sexual abuse.
Review of the facility's policy titled, Abuse, Neglect, Exploitation and Misappropriation revealed the following, in part:
Policy: It is inherent in the nature and dignity of each resident at the center that he/she be afforded basic human rights, including the right to be free from abuse.
Definitions: Sexual Abuse is non- consensual sexual contact of any type with a resident. Sexual abuse include but is not limited to:
-Unwanted intimate touching of any kind especially of breast or perineal area
-All types of sexual assault or battery, such as rape, sodomy and coerced nudity
-Forced observation of masturbation and/or pornography
Generally, sexual contact is non-consensual if the resident either:
-Does not want the contact to occur.
Resident #4
Review of Resident #4's Pre-facility admission Hospital Records dated 08/03/2023, revealed in part, the following: Resident #4 was admitted to the hospital on [DATE] with hypersexual behaviors, verbally aggressive with staff, and masturbating in front of staff over the past few days. On 08/11/2023 Resident #4 was discharged and transferred to the nursing facility.
Review of Resident #4's clinical records revealed he was admitted to the facility on [DATE] with diagnosis, which included: Alzheimer's disease, Unspecified Dementia, and Delirium Due to Known Physiological Condition.
Review of the admission MDS with an ARD of 08/18/2023 revealed Resident #4 had a BIMS of 11, which indicated he was moderately cognitively impaired. Further review of Resident #4's functional status revealed he required setup help only during locomotion on unit per wheelchair.
Review of Resident #4's Baseline Care Plan revealed, in part, the following:
Date 08/11/2023
Resident Problem: Sexually inappropriate behaviors.
Resident Goal: Will have fewer episodes of sexually inappropriate behaviors.
Interventions: Monitor behaviors.
Review of Resident #4's Nurse's Notes dated August 2023 revealed the following:
08/17/2023 at 9:27 a.m., Resident grabbed staff member's breast and back saying Don't you want to ****? Staff redirected resident to cross his hands over his chest while performing care. During care resident continues to ask staff Why won't you let me **** you? Reminded resident that his language and actions are inappropriate. RP and NP notified of the above. No new orders at this time, states to continue care. Plan of care ongoing. S5LPN.
08/17/2023 at 11:00 a.m., Conducted BIMS assessment with resident. BIMS score is 11. During assessment resident was very verbally and sexually inappropriate. S15SW.
Review of the Facility's Transfer Log dated August 2023 revealed Resident #4 was transferred to a psychiatric hospital on [DATE] for behaviors and returned to the facility on [DATE].
Review of the Hospital Records revealed Resident #4 was sent to a psychiatric hospital on [DATE] for sexually inappropriate behaviors and discharged following treatment.
Review of the Hospital Discharge documents dated 08/18/2023 revealed no changes to Resident #4's medications and no new orders.
Review of Resident #4's most recent Physician Orders, dated August 2023 through October 2023, revealed in part, the following:
Monitor for behaviors each shift, start date 08/29/2023.
Further review revealed no Physician Orders changes related to Resident #4's sexually inappropriate behaviors.
Review of Resident #4's Physician's Progress Notes dated August 2023 through October 2023 revealed the following:
08/30/2023 at 9:41 a.m., Resident was seen today after discharge from the psychiatric hospital. Admit due to hypersexual behaviors, including exposing himself and inappropriate comments and behaviors. Administer medications as prescribed. No new consults at this time. S13NP.
09/08/2023 at 11:16 a.m., Resident continues to have inappropriate behaviors including grabbing at staff and inappropriate comments. Neurologic: Grossly intact. Assessment: Hypersexual Behaviors. Plan: Monitor behaviors. S13NP.
09/21/2023 at 11:16 a.m., Resident continues to have occasional inappropriate behaviors including grabbing at staff and inappropriate comments. Neurologic: Grossly intact. Assessment: Hypersexual Behaviors. Plan: Monitor behaviors. S14MD.
Review of Resident #4's Nurse's Notes dated August 2023 through October 2023 revealed the following:
09/13/2023 at 1:52 p.m., at approximately 1:45 p.m., it was reported that Resident #4 was rolling his wheelchair through the dayroom when he stopped by another resident grabbing Resident #5's whole breast and feeling on it. Resident #5 stated she was pushing his hand away and telling him don't touch me. The aide that was walking through the room got the resident away from victim and redirected to resident's room and reported it to the nurse. RP aware. S6LPN.
09/20/2023 at 10:41 a.m., Resident #4 presents with sexually inappropriate behavior during routine wound care treatment with CNA present. Resident grabbing at staff private parts and stating suck my d**k, suck it good, suck it all the way off. Resident redirected throughout treatment without success. MD and RP aware. S4WC.
Resident #5
Review of the clinical record revealed Resident #5 was admitted to the facility on [DATE] with diagnosis, which included Hemiplegia, Major Depressive Disorder, Generalized Anxiety, and Lack of Coordination.
Review of the quarterly MDS with an ARD of 07/27/2023 revealed Resident #5 had a BIMS of 14 which indicated she was cognitively intact.
Review of Resident #5's Physician's Progress Notes dated August 2023 through October 2023 revealed no documentation of the incident with Resident #4. Further review revealed no documentation of changes in plan of care.
Review of Resident #5's Nurse's Notes dated August 2023 through October 2023 revealed no documentation of the incident with Resident #4. Further review revealed no documentation of changes in plan of care.
Review of Resident #5's most recent Care Plan revealed no documentation related to the incident with Resident #4 and no documentation of any changes to her plan of care related to sexual abuse.
An interview was conducted on 10/04/2023 at 1:05 p.m. with Resident #5. She stated, about a month ago, she had an encounter with Resident #4 in the day room. She stated she was sitting in her wheelchair when Resident #4 approached her, grabbed her breast and did a milking motion on her breast. She told Resident #4 not to touch her and to get away from her. She stated the CNAs walked by and saw what was happening and separated him from her. She stated staff did not complete a physical assessment on her after he grabbed her breast and only asked if she was ok. She stated when Resident #4 grabbed her breast she felt degraded and violated. She stated now, when she sees Resident #4 coming in her direction, she turns to go the opposite way and purposely avoids him.
An interview was conducted on 10/04/2023 at 1:07 p.m. with S5LPN. She stated Resident #4 began having sexually inappropriate behaviors about a week after he was admitted to the facility. She stated Resident #4 was aware of his actions. She stated on 08/17/2023 she was performing care on Resident #4 when he began asking her to have sexual relations with him, and grabbed at her private area and her breasts. S5LPN reported this behavior to the NP. S5LPN stated the NP visited the facility the same day and sent Resident #4 to the psychiatric facility on 08/17/2023 after the resident grabbed the NP's buttocks. She stated there were no changes to Resident #4's medications when he returned to the facility on [DATE]. She confirmed Resident #4 continued to exhibit the same sexual behaviors after he returned to the facility on [DATE]. She stated the NP and MD were notified of Resident #4's continued sexual behaviors. She stated on 09/13/2023, Resident #4 grabbed Resident #5's breast. She stated after the incident dated 09/13/2023, Resident #4 was placed on 1:1 supervision for 72 hours. She confirmed other than being placed on 72 hour 1:1 supervision, there were not any other changes in his plan of care. She stated Resident #4 continued to exhibit sexual behaviors after the 1:1 was discontinued. She stated Resident #4 was seen masturbating in the dayroom with multiple residents present after his incident with Resident #5. S5LPN confirmed there were no new interventions put into place once the 72 hour supervision ended to prevent Resident #4 from sexually abusing another resident.
An interview was conducted on 10/04/2023 at 1:19 p.m. with S4WC. She stated Resident #4 began having sexually inappropriate behaviors about a week after he was admitted to the facility. She stated Resident #4 was aware of his actions. She stated Resident #4 would attempt to grab her daily and spoke vulgar to her. She stated staff attempted to get him to cross his arms during care to prevent him from sexually grabbing them, but this was often ineffective. She stated the NP sent Resident #4 to the psychiatric facility on 08/17/2023 after the resident grabbed the NP's buttocks. She stated after Resident #4 returned to the facility on [DATE], there were no changes to his medications. She stated the resident continued to exhibit the same sexual behaviors. She stated the NP and MD were notified of Resident #4's continued sexual behaviors. She stated on 09/13/2023 Resident #4 grabbed Resident #5's breast. She stated after the incident dated 09/13/2023, Resident #4 was placed on 1:1 supervision for 72 hours. She confirmed other than the resident being placed on 72 hour 1:1 supervision, there had not been any other changes to his plan of care. She stated Resident #4 continued to exhibit sexual behaviors after the 1:1 was discontinued. S4WC confirmed there were no new interventions put into place once the 72 hour supervision ended to prevent Resident #4 from sexually abusing another resident.
An interview was conducted on 10/04/2023 at 2:10 p.m. with S2DON. He stated Resident #4 began having sexually inappropriate behaviors about a week after he was admitted to the facility. He stated Resident #4 was aware of his actions. He stated Resident #4 would inappropriately and sexually touch literally anyone. He stated the NP sent Resident #4 to the psychiatric facility on 08/17/2023 after the resident grabbed the NP's buttocks. He stated after Resident #4 returned to the facility on [DATE], there were no changes to his medications. He stated the resident continued to exhibit the same sexual behaviors. He stated the NP and MD were notified of Resident #4's continued sexual behaviors. He stated on 09/13/2023 Resident #4 grabbed Resident #5's breast. S2DON stated staff did not assess Resident #5 to see if she had been physically or mentally injured after Resident #4 grabbed her breast. He stated after the incident dated 09/13/2023, Resident #4 was placed on 1:1 supervision for 72 hours. He confirmed other than the resident being placed on 72 hour 1:1 supervision, there had not been any other changes to his plan of care. He stated Resident #4 continued to exhibit sexual behaviors after the 1:1 was discontinued. He stated the development of a plan to further protect residents from Resident #4 would depend on how many incidents occurred. S2DON confirmed there were no new interventions put into place once the 72 hour supervision ended to prevent Resident #4 from sexually abusing another resident.
An interview was conducted on 10/04/2023 at 2:22 p.m. with S13NP. She stated Resident #4 began having sexually inappropriate behaviors about a week after he was admitted to the facility. She stated Resident #4 was aware of his actions. She stated on 08/17/2023 staff verbalized concern that Resident #4 might try to touch a resident inappropriately. She stated Resident #4 was sent to the psychiatric facility on 08/17/2023 after the resident grabbed her buttocks. She stated after Resident #4 returned to the facility on [DATE], there were no changes to his medications. She stated the resident continued to exhibit the same sexual behaviors. She stated on 09/13/2023 Resident #4 grabbed Resident #5's breast. She stated after the incident dated 09/13/2023, Resident #4 was placed on 1:1 supervision for 72 hours. She confirmed other than the resident being placed on 72 hour 1:1 supervision, there had not been any other changes to his plan of care. She stated Resident #4 continued to exhibit sexual behaviors after the 1:1 was discontinued. She stated she received multiple phone calls from staff about Resident #4's sexually inappropriate behaviors which included touching. She stated physicians did not like to send residents to psychiatric facilities often for behaviors because it could confuse the resident. She stated the physician did not change any medications or put Resident #4 on further 1:1 supervision from admission to now. S13NP confirmed there were no new interventions put into place once the 72 hour supervision ended to prevent Resident #4 from sexually abusing another resident.
An interview was conducted on 10/04/2023 at 3:30 p.m. with S1ADM. He stated Resident #4 began having sexually inappropriate behaviors about a week after he was admitted to the facility. He stated Resident #4 was aware of his actions. He stated Resident #4 was sent to the psychiatric facility on 08/17/2023 after the resident grabbed the NP's buttocks. He stated after Resident #4 returned to the facility on [DATE] there were no changes to his medications. He stated the resident continued to exhibit the same sexual behaviors. He stated the NP and MD were notified of Resident #4's continued sexual behaviors. He stated on 09/13/2023 Resident #4 grabbed Resident #5's breast. He stated after the incident dated 09/13/2023, Resident #4 was placed on 1:1 supervision for 72 hours. He confirmed other than the resident being placed on 72 hour 1:1 supervision, there had not been any other changes to his plan of care. He stated Resident #4 continued to exhibit sexual behaviors after the 1:1 was discontinued. He stated Resident #4 should have been on 1:1 supervision following his return from the psychiatric facility on 08/29/2023. He stated if Resident #4 had been on 1:1 supervision, staff could have prevented Resident #5 from being touched inappropriately by Resident #4. He stated Resident #4 had only 1 incident of touching another resident inappropriately that they were aware of. He explained since it was only once, they did not initiate any further supervision.
An observation was made on 10/04/2023 at 4:02 p.m. of Resident #4 in his room. A nurse entered the room with surveyors and observed Resident #4 was masturbating in front of male roommate, nurse, and surveyors. The nurse instructed Resident #4 to stop that.
An interview was conducted on 10/04/2023 at 4:05 p.m. with Resident #4. He stated he loved to touch people and didn't see what the problem was. He stated he remembered when he grabbed Resident #5's breast in the dayroom.
An interview was conducted on 10/04/2023 at 6:00 p.m. with S16MDS. She stated Resident #4's care plan was not completed. She confirmed Resident #4 had inappropriate sexual behaviors upon admission, and should have been care planned with appropriate interventions in place as well as after his incident with another resident on 09/13/2023.
An interview was conducted on 10/04/2023 at 6:02 p.m. with S15SW. She stated Resident #4 began having sexually inappropriate behaviors about a week after he was admitted to the facility. She stated Resident #4 was aware of his actions. She stated on 08/17/2023 she was performing a BIMS assessment on Resident #4 when he began asking her to have sexual relations with him, and grabbed at her private area and her breasts. S15SW reported this behavior to the NP. S15SW stated the NP visited the facility the same day and sent Resident #4 to the psychiatric facility on 08/17/2023 after the resident grabbed the NP's buttocks. She stated there were no changes to Resident #4's medications when he returned to the facility on [DATE]. She confirmed Resident #4 continued to exhibit the same sexual behaviors after he returned to the facility on [DATE]. She stated on 09/13/2023, Resident #4 grabbed Resident #5's breast. She stated after the incident dated 09/13/2023, Resident #4 was placed on 1:1 supervision for 72 hours. She confirmed other than being placed on 72 hour 1:1 supervision, there were not any other changes in his plan of care. She stated Resident #4 continued to exhibit sexual behaviors after the 1:1 was discontinued. S5LPN confirmed there were no new interventions put into place once the 72 hour supervision ended to prevent Resident #4 from sexually abusing another resident.
An interview was conducted on 10/05/2023 at 8:40 a.m. with S11CNA. She stated Resident #4 began having sexually inappropriate behaviors about a week after he was admitted to the facility. She stated Resident #4 was aware of his actions. She stated on 09/13/2023, she was in the nurse's station when she saw Resident #4 wheel his wheelchair up to Resident #5 in the day room and grabbed her breast. She stated she immediately separated the residents and reported the incident to S6LPN. She stated she regularly bathed Resident #4, and it was very difficult to bathe him or provide peri care due to his inappropriate sexual remarks and constantly touching her inappropriately. She stated his behaviors happened everyday. She stated she notified the nurse on most incidents. She stated she tried to redirect Resident #4, but it was ineffective.
An interview was conducted on 10/05/2023 at 11:05 a.m. with S6LPN. She stated staff was aware of Resident #4 having a previous diagnosis of hypersexual behaviors from the facility he was at prior to coming to this facility. She stated the previous facility had reported to the nursing staff when he grabbed at them inappropriately, they would tell him to put his arms across his chest. She stated that would sometimes be effective but not long after, he needed further redirection. She stated she would frequently tell Resident #4 to keep his hands to himself. She stated Resident #4 was able to mobilize around the facility on his own in his wheelchair. She stated she was at the nurse's station on 09/13/2023 when Resident #4 wheeled his wheelchair to Resident #5, reached out, and grabbed her breast. She stated Resident #5 told Resident #4 to not touch her and get away from her. She stated staff separated the residents, and she notified the doctor. She stated there were no new orders given. She stated she did not complete a physical assessment on Resident #5 after the incident. She stated she did speak with Resident #5 and asked her if she was ok. She confirmed no physical assessment was performed on Resident #5 after Resident #4 grabbed her breast. S13NP confirmed there were no new interventions put into place once the 72 hour supervision ended to prevent Resident #4 from sexually abusing another resident.
CRITICAL
(K)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Immediate Jeopardy (IJ) - the most serious Medicare violation
Administration
(Tag F0835)
Someone could have died · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to ensure it was administered in a manner that enabled it to use its ...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to ensure it was administered in a manner that enabled it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. The facility failed to ensure 1 (Resident #5) of 6 (#1, #2, #3, #4, #5, and #6) sampled residents reviewed for sexual abuse were free from sexual abuse by failing to:
1. Protect 1 (Resident #5) female resident from sexual abuse by Resident #4, a resident with known sexually inappropriate behaviors; and
2. Implement interventions to prevent further sexual abuse by Resident #4.
The deficient practice resulted in an Immediate Jeopardy situation on 08/29/2023 when Resident #4, a moderately cognitively impaired resident, returned to the facility from a psychiatric hospital stay for sexually inappropriate behaviors. Upon Resident #4 returning to the facility on [DATE], he continued to exhibit sexually inappropriate behaviors with staff. On 09/13/2023 at 1:45 p.m., Resident #4 grabbed Resident #5's breast. After the incident, Resident #4 was placed on 1:1 supervision for 72 hours. After 72 hours, the 1:1 supervision was discontinued and no new interventions were implemented to ensure Resident #4 would not sexually abuse another resident. Staff interviews revealed Resident #4 continued to exhibit sexually inappropriate behaviors after the incident on 09/13/2023. Due to the lack of new interventions, there was a likelihood of Resident #4 sexually abusing other residents if not immediately corrected.
S1ADM, S2DON, and S3CVP were notified of the Immediate Jeopardy on 10/04/2023 at 6:55 p.m.
The Immediate Jeopardy was removed on 10/05/2023 at 2:50 p.m. when the facility submitted an acceptable Plan of Removal. Through observations, interviews and record reviews, the surveyors confirmed the following had been initiated and/or implemented prior to exit. The Immediate Jeopardy Plan of Removal included the following:
-On 10/04/2023 Resident #4's care plan was updated to include intervention of one on one observation and inpatient behavioral services.
-On 10/04/2023 at 7:30 p.m. Immediately Resident #4 was placed on one on one observation.
-On 10/04/2023 physician was notified and orders noted to send Resident #4 to inpatient behavioral health services. Resident discharged from building at 10:00 p.m. on 10/04/2023 to behavioral inpatient. Resident is not to return to the facility.
-On 10/04/2023 at 10:00 p.m. Resident #4 was transported to inpatient behavioral health services.
-On 10/05/2023 76 Residents with BIMS (Brief Interview for Mental Status) of 9 or greater were interviewed by IDT Team to ensure that they had not been abused and had not witnessed any abuse or neglect of a fellow resident as well as to inquire about their safety. Process initiated on 10/04/2023 8:00 p.m. Time of completion on assessments: 10/05/2023 8:30 a.m.
-On 10/05/2023 26 Residents were assessed by licensed nurses conducting skin sweeps for suspicious injuries. Process initiated on 10/04/2023 8:00 p.m. Time of completion on assessments: 10/05/2023 8:30 a.m.
-On 10/05/2023 Resident #5 to receive psychiatric consultation and ongoing weekly monitoring by psychiatric services and social worker.
-Quality Assurance Performance Committee (QAPI) met on 10/04/2023 at 9:30 p.m. to review 09/13/2023 incident of Resident #4's inappropriate sexual behavior and determine a Root Cause. Meeting was led by Assistant Regional [NAME] President of Operations and Executive Director. Attendees were Executive Director (ED), Regional [NAME] President of Operations (RVPO), Social Services Director (SSD), Housekeeping Supervisor (HKS), Business Office Manager (BOM), and Director of Nursing (DON), Activities Director (AD, Therapy Manager (TM), Maintenance Supervisor (MS), Licensed Nurse (LPN) and Medical Records Clerk (MRC) and Director of Sales and Marketing (DSM). The Root Cause was determined to be that the facility failed to ensure resources were effectively and efficiently used to put interventions in place to prevent sexual abuse.
-On 10/04/2023 at 8:00 p.m. education was conducted with the Executive Director (ED) and the Director of Nursing (DON) by the Regional [NAME] President of Operations (RVPO) on Abuse, Neglect, and Misappropriation and on ensuring resources are effectively and efficiently used to put interventions in place to prevent sexual abuse by Residents with inappropriate sexual behavior.
-Quality Monitoring on effectiveness of education to be reviewed by Assistant Regional [NAME] President of Operations by weekly visitation with the Regional Director of Clinical Services, Director of Nursing, and Executive Director weekly for 4 weeks and monthly for 3 months following. Monitoring will be held weekly by Administrator, Director of Nursing, Business Development Director, Admissions Coordinator, and Social Services Director or comparable designee. Monitoring team will review confirmed admission packets for potential hyper-sexual behaviors or tendencies. Any adverse findings will be rectified through care planning and appropriate interventions. Team will review baseline care plans of recent admissions. A random sample of 10 residents shall be interviewed for psychosocial well-being and reviewed with corporate leadership. To begin on 10/06/2023 and complete on 02/06/2024. All findings of reviews will be reported monthly to IDT through the QAPI meeting.
-On 10/05/2023 7:00 a.m. education was conducted on Abuse, Neglect, and Misappropriation with emphasis on sexual abuse and appropriate interventions for a Resident with sexually inappropriate behaviors to prevent sexual abuse. All present staff completed on 10/05/2023 at 10:00 a.m., including MDS staff. Expected completion time on Full-Time staff by 10/06/2023 6:00 p.m. PRN staff will be requiring education prior to working their next shift. No staff shall be allowed to work his or her assignment until training has been completed.
-Employees will receive training upon hire and prior to accepting assignment.
The deficient practice continued at a potential for more than minimal harm for the 97 residents currently residing in the facility.
Findings:
Cross Reference F600
Review of Resident #4's Pre-facility admission Hospital Records dated 08/03/2023, revealed in part, the following: Resident #4 was admitted to the hospital on [DATE] with hypersexual behaviors, verbally aggressive with staff, and masturbating in front of staff over the past few days. On 08/11/2023 Resident #4 was discharged and transferred to the nursing facility.
Review of Resident #4's Nurse's Notes 09/13/2023 at 1:52 p.m., at approximately 1:45 p.m., it was reported that Resident #4 was rolling his wheelchair through the dayroom when he stopped by another resident grabbing Resident #5's whole breast and feeling on it. Resident #5 stated she was pushing his hand away and telling him don't touch me. The aide that was walking through the room got the resident away from victim and redirected to resident's room and reported it to the nurse. RP aware. S6LPN.
Review of the clinical record revealed Resident #5 was admitted to the facility on [DATE] with diagnosis, which included Hemiplegia, Major Depressive Disorder, Generalized Anxiety, and Lack of Coordination.
Review of the quarterly MDS with an ARD of 07/27/2023 revealed Resident #5 had a BIMS of 14 which indicated she was cognitively intact.
An interview was conducted on 10/04/2023 at 6:02 p.m. with S15SW. She stated Resident #4 began having sexually inappropriate behaviors about a week after he was admitted to the facility. She stated Resident #4 was aware of his actions. She stated on 08/17/2023 she was performing a BIMS assessment on Resident #4 when he began asking her to have sexual relations with him, and grabbed at her private area and her breasts. S15SW reported this behavior to the NP. S15SW stated the NP visited the facility the same day and sent Resident #4 to the psychiatric facility on 08/17/2023 after the resident grabbed the NP's buttocks. She stated there were no changes to Resident #4's medications when he returned to the facility on [DATE]. She confirmed Resident #4 continued to exhibit the same sexual behaviors after he returned to the facility on [DATE]. She stated on 09/13/2023, Resident #4 grabbed Resident #5's breast. She stated after the incident dated 09/13/2023, Resident #4 was placed on 1:1 supervision for 72 hours. She confirmed other than being placed on 72 hour 1:1 supervision, there were not any other changes in his plan of care. She stated Resident #4 continued to exhibit sexual behaviors after the 1:1 was discontinued. S5LPN confirmed there were no new interventions put into place once the 72 hour supervision ended to prevent Resident #4 from sexually abusing another resident.
An interview was conducted on 10/04/2023 at 2:10 p.m. with S2DON. He stated Resident #4 began having sexually inappropriate behaviors about a week after he was admitted to the facility. He stated Resident #4 was aware of his actions. He stated Resident #4 would inappropriately and sexually touch literally anyone. He stated the NP sent Resident #4 to the psychiatric facility on 08/17/2023 after the resident grabbed the NP's buttocks. He stated after Resident #4 returned to the facility on [DATE], there were no changes to his medications. He stated the resident continued to exhibit the same sexual behaviors. He stated on 09/13/2023 Resident #4 grabbed Resident #5's breast. S2DON stated staff did not assess Resident #5 to see if she had been physically or mentally injured after Resident #4 grabbed her breast. He stated after the incident dated 09/13/2023, Resident #4 was placed on 1:1 supervision for 72 hours. He confirmed other than the resident being placed on 72 hour 1:1 supervision, there had not been any other changes to his plan of care. He stated Resident #4 continued to exhibit sexual behaviors after the 1:1 was discontinued. He stated the development of a plan to further protect residents from Resident #4 would depend on how many incidents occurred. S2DON confirmed there were no new interventions put into place once the 72 hour supervision ended to prevent Resident #4 from sexually abusing another resident.
An interview was conducted on 10/04/2023 at 2:22 p.m. with S13NP. She stated Resident #4 began having sexually inappropriate behaviors about a week after he was admitted to the facility. She stated Resident #4 was aware of his actions. She stated on 08/17/2023 staff verbalized concern that Resident #4 might try to touch a resident inappropriately. She stated Resident #4 was sent to the psychiatric facility on 08/17/2023 after the resident grabbed her buttocks. She stated after Resident #4 returned to the facility on [DATE], there were no changes to his medications. She stated the resident continued to exhibit the same sexual behaviors. She stated on 09/13/2023 Resident #4 grabbed Resident #5's breast. She stated after the incident dated 09/13/2023, Resident #4 was placed on 1:1 supervision for 72 hours. She confirmed other than the resident being placed on 72 hour 1:1 supervision, there had not been any other changes to his plan of care. She stated Resident #4 continued to exhibit sexual behaviors after the 1:1 was discontinued. She stated she received multiple phone calls from staff about Resident #4's sexually inappropriate behaviors which included touching. She stated physicians did not like to send residents to psychiatric facilities often for behaviors because it could confuse the resident. She stated the physician did not change any medications or put Resident #4 on further 1:1 supervision from admission to now. S13NP confirmed there were no new interventions put into place once the 72 hour supervision ended to prevent Resident #4 from sexually abusing another resident.
An interview was conducted on 10/04/2023 at 3:30 p.m. with S1ADM. He stated Resident #4 began having sexually inappropriate behaviors about a week after he was admitted to the facility. He stated Resident #4 was aware of his actions. He stated Resident #4 was sent to the psychiatric facility on 08/17/2023 after the resident grabbed the NP's buttocks. He stated after Resident #4 returned to the facility on [DATE] there were no changes to his medications. He stated the resident continued to exhibit the same sexual behaviors. He stated on 09/13/2023 Resident #4 grabbed Resident #5's breast. He stated after the incident dated 09/13/2023, Resident #4 was placed on 1:1 supervision for 72 hours. He confirmed other than the resident being placed on 72 hour 1:1 supervision, there had not been any other changes to his plan of care. He stated Resident #4 continued to exhibit sexual behaviors after the 1:1 was discontinued. He stated Resident #4 should have been on 1:1 supervision following his return from the psychiatric facility on 08/29/2023. He stated if Resident #4 had been on 1:1 supervision, staff could have prevented Resident #5 from being touched inappropriately by Resident #4. He stated Resident #4 had only 1 incident of touching another resident inappropriately that they were aware of. He explained since it was only once, they did not initiate any further supervision.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0657
(Tag F0657)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews the facility failed to ensure the Care Plan was revised for 2 (#4 and #5) of 6 (#1, #2, #3...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews the facility failed to ensure the Care Plan was revised for 2 (#4 and #5) of 6 (#1, #2, #3, #4, #5, and #6) sampled residents reviewed for care plans.
Findings:
Review of the policy titled Plans of Care revealed, in part:
-Review, update, and/or revise the comprehensive plan of care based on changing goals, preferences and needs of the resident and in response to current interventions after the completion of each assessment, and as needed. The interdisciplinary team shall ensure the plan of care addresses any resident needs and that the plan is oriented toward attaining or maintaining the highest practicable physical, mental, and psychosocial well-being.
-Plan of care may include but is not limited to the following:
-Services to attain nor maintain the resident's highest practicable physical, mental, and psychosocial well-being as required by state and federal regulatory requirements.
-Individualized interventions that honor the resident's preferences and promote achievement of the resident's goals.
Resident #4
Review of Resident #4's clinical records revealed he was admitted to the facility on [DATE] with diagnosis, which included: Alzheimer's disease, Unspecified Dementia, and Delirium Due to Known Physiological Condition.
Review of Resident #4's Baseline Care Plan revealed, in part, the following:
Date: 08/11/2023
Resident Problem: Sexually inappropriate behaviors.
Resident Goal: Will have fewer episodes of sexually inappropriate behaviors.
Interventions: Monitor behaviors.
Review of Resident #4's most recent Care Plan revealed no documentation related to the incident with Resident #5 and no documentation of any changes to his plan of care related to inappropriate sexual behaviors.
Review of Resident #4's Nurse's Notes dated August 2023 through October 2023 revealed the following:
09/13/2023 at 1:52 p.m., at approximately 1:45 p.m., it was reported that Resident #4 was rolling his wheelchair through the dayroom when he stopped by another resident grabbing Resident #5's whole breast and feeling on it. Resident #5 stated she was pushing his hand away and telling him don't touch me. The aide who was walking through the room at the time of the incident redirected Resident #4 away from Resident #5 and reported it to the nurse. S6LPN.
Resident #5
Review of the clinical record revealed Resident #5 was admitted to the facility on [DATE] with diagnosis, which included Hemiplegia, Major Depressive Disorder, Generalized Anxiety, and Lack of Coordination.
Review of Resident #5's most recent Care Plan revealed no documentation related to the incident with Resident #4 and no documentation of any changes to her plan of care related to sexual abuse.
An interview was conducted on 10/04/2023 at 2:10 p.m. with S2DON. He stated MDS was responsible for revising care plans. He stated on 09/13/2023 Resident #4, who had known sexually inappropriate behaviors, grabbed Resident #5's breast. He stated Resident #4 and Resident #5's care plans were not revised after the incident on 09/13/2023 and should have been.
An interview was conducted on 10/04/2023 at 6:00 p.m. with S16MDS. S16MDS stated she was responsible for revising care plans. She stated on 09/13/2023 Resident #4, who had known sexually inappropriate behaviors, grabbed Resident #5's breast. She confirmed Resident #4 and Resident #5's care plans were not revised after the incident on 09/13/2023 and should have been.
Jul 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
Assessment Accuracy
(Tag F0641)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to ensure resident assessments accurately reflected the resident's st...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to ensure resident assessments accurately reflected the resident's status. The facility failed to ensure 1 (#3) of 3 (#1, #3, and #5) residents reviewed for Resident Assessment had an accurate MDS that reflected the resident's fall history.
Findings:
Review of Resident #3's Clinical Record revealed he was admitted to the facility on [DATE] with diagnoses, which included Muscle Weakness and Lack of Coordination.
Review of Resident #3's Quarterly MDS with an ARD of 04/24/2023 revealed a BIMS of 3, which indicated he was severely cognitively impaired. Further review revealed the following questions and answers related to falls:
Has the resident had any falls since admission/entry or reentry or the prior assessment (OBRA or Scheduled PPS), whichever is more recent?
0.
No
1.
Yes
Code entered: 0
Number of falls since Admission/Entry or Reentry or Prior Assessment (OBRA or Scheduled PPS), whichever is more recent.
0.
None
1.
One
2.
Two or more
Code boxes: blank
Review of the Facility's Incident Log revealed Resident #3 had a fall on 03/25/2023, 03/31/2023, 04/06/2023, and 04/11/2023.
On 07/26/2023 at 11:32 a.m., an interview was conducted with S2MDS. She stated she was responsible for resident's MDS assessments. She stated if a resident had a fall after their previous MDS assessment, their fall would be coded in the next assessment. She stated on 02/17/2023, Resident #3 had a 5 day MDS completed. She stated Resident #3's next MDS was completed on 04/24/2023. She reviewed Resident #3's chart and verified he had fallen on 03/25/2023, 03/31/2023, 04/06/2023, and 04/11/2023. She reviewed the Quarterly MDS and confirmed Resident #3 should have been coded for falls and was not.
On 07/26/2023 at 11:46 a.m., an interview was conducted with S1DON. He reviewed Resident #3's Quarterly MDS and confirmed Resident #3 had falls on 03/25/2023, 03/31/2023, 04/06/2023, and 04/11/2023, and they were not captured on the MDS.
Jun 2023
4 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0578
(Tag F0578)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to ensure all medical records regarding the resident's code status co...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to ensure all medical records regarding the resident's code status consistently reflected the resident's wishes for 1 (#42) of 25 residents reviewed in the initial screening for advanced directives.
Findings:
Review of Resident #42's clinical record revealed she was admitted to the facility on [DATE]. Her diagnoses included Cerebral Infarction, Unspecified Dementia, and Aphasia.
Review of the Significant Change MDS with an ARD of 03/07/2023 revealed Resident #42 was unable to complete the BIMS due to an inability to be interviewed.
Review of Resident #42's May 2023 Physician Orders revealed:
11/03/2022-Full Code-Status: Active
02/28/2023-Admit to Hospice. Status: Active.
Review of Resident #42's Hospice Admit Orders in hard physical chart revealed:
02/28/2023-Admit to Hospice.
Dx: CVA
DNR
Signed by Hospice MD
Review of Resident #42's Advance Directive in hard physical chart dated 02/28/2023 revealed the following, in part:
Cardiopulmonary Resuscitation: Box checked-Withhold
Verbal consent given by Resident #42's daughter/Responsible Party. Facility Representative: Signed by two facility staff members
Review of Resident #42's Care Plan dated 03/13/2023 revealed the following, in part:
Problem: Resident #42 has advanced directives related to family wishes for her to be a Full Code.
Interventions: Discuss advanced directives with Resident #42 and/or her representative.
Review of Resident #42's Nurse's Notes revealed the following, in part:
02/23/2023-SSD spoke to Resident #42's daughter .She stated she had been having a hard time deciding how she wants to proceed. She stated she still has a lot of questions for hospice. SSD discussed Resident #42's code status. She stated she has thought about it but wants to keep her a full code for now. SSD discussed the quality of life over quantity of life. SSD offered her support. -Signed, former Social Worker
03/06/2023-SSD spoke to the hospice nurse about Resident #42's code status. They spoke to Resident #42's daughter who decided to change Resident #42 to a DNR. SSD called Resident #42's daughter who stated she would come sign when she visits in the next couple of days. SSD explained that she will continue to be a Full Code until paperwork is completed. She voiced understanding. -Signed, former Social Worker
04/18/2023-SSD spoke to Resident #42's daughter about Resident #42's code status. She stated she wanted to talk to one of her brothers about it before changing it. She understood if something were to happen Resident #42 would be coded. -Signed, former Social Worker.
On 05/31/2023 at 9:09 a.m., an interview was conducted with S9CNA. She stated she looked in the resident's electronic medical record, under the [NAME], to obtain their code status. She looked in Resident #42's electronic medical record at the [NAME] and stated Resident #42 was a full code.
On 05/31/2023 at 10:05 a.m., an interview was conducted with Resident #42's daughter/Responsible Party. She stated she spoke with someone at the facility and changed Resident #42 to a DNR, but could not recall the date or who she spoke with.
On 05/31/2023 at 10:16 a.m., an interview was conducted with the Hospice Clinical Care Coordinator. She stated Resident #42 had been a DNR since 02/28/2023 according to their paperwork.
On 05/31/2023 at 12:10 p.m., an interview was conducted with S5LPN. She stated she looked in the resident's electronic medical record to obtain their code status, but it could also be found in the resident's hard physical chart. She looked in Resident #42's electronic medical record and stated Resident #42 was a full code. She stated it was the social workers responsibility to make code status changes.
On 05/31/2023 at 12:25 p.m., an interview was conducted with S11SW. She stated when a code status changed, medical records was responsible for making the change in the resident's chart. She stated Resident #42 was a DNR.
On 05/31/2023 at 12:35 p.m., an interview was conducted with S6LPN. She stated she was the facility's medical record personnel. She stated when a resident had a change in code status, she was responsible for putting the change in their hard physical chart. She stated the nurse taking care of the resident was responsible for making the change to the electronic medical record. She looked in Resident #42's electronic medical record and verified it indicated she was a full code. She stated Resident #42 had paperwork in her hard physical chart indicating she was a DNR. She confirmed code statuses for a resident should match, and Resident #42's did not.
On 05/31/2023 at 12: 40 p.m., an interview was conducted with S2DON. He stated when a resident had a change in code status, social services made the change in the electronic medical record. He looked in Resident #42's electronic medical record and verified it indicated Resident #42 was a full code. Then, he reviewed Resident #42's Advanced Directive in her hard physical chart and verified it indicated she was a DNR. He stated he did not know how the discrepancy happened. He confirmed both code statuses in the electronic medical record and hard physical chart should match, and Resident #42's did not.
On 05/31/2023 at 1:55 p.m., an interview was conducted with S2DON. He stated the Advanced Directives in Resident #42's hard physical chart was void since Resident #42's daughter did not sign it. He stated it was not the facility's policy to obtain verbal consent from family members for a change in code status. He stated until Resident #42's daughter signed the Advanced Directive, Resident #42 remained a full code. S2DON confirmed the Advanced Directive indicating Resident #42 was a DNR should not have been placed in her physical chart if she was a full code.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
PASARR Coordination
(Tag F0644)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to ensure a resident with an identified mental health diagnosis was r...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to ensure a resident with an identified mental health diagnosis was referred for a Preadmission Screening and Resident Review (PASRR) Level II evaluation as required for 1(#14) of 1 (#14) sampled resident records reviewed for PASRR.
Findings:
Review of the Clinical Record revealed Resident #14 was admitted to the facility on [DATE] with diagnoses which included: Diabetes Type 2. Further review revealed additional medical diagnoses of Major Depressive Disorder (09/09/2022), Schizoaffective Disorder (10/01/2022), and Unspecified Psychosis disorder (12/02/2022).
On 05/31/2023 at 3:25 p.m., an interview was conducted with S11SW. She stated when a resident acquired a new mental health diagnosis she submitted a Resident Review form to the Office of Behavioral Health for a PASRR Level II referral. She verified Resident #14 had a new diagnosis of Schizoaffective Disorder on 10/01/2022. She confirmed a Resident Review Form was not sent to Office of Behavioral Health for the new diagnosis and should have been. She confirmed there was no PASRR Level II determination for the new diagnosis on file.
On 05/31/23 at 3:30 p.m., an interview was conducted with S2DON. He confirmed Resident #14 acquired a diagnosis of Schizoaffective Disorder after she was admitted to the facility. He confirmed a Resident Review form should have been submitted to the Office of Behavioral Health upon receiving the above diagnosis. He confirmed there was no PASRR Level II on file.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0658
(Tag F0658)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record review the facility failed to ensure services were provided by the facility to meet...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record review the facility failed to ensure services were provided by the facility to meet quality professional standards. The facility failed to ensure staff observed 2 of 2(# 44, # 387) residents take their medications.
Findings:
Review of the Louisiana Administrative Code, Title 46, Professional and Occupational Standard, Part. XLVII, Nurses: Practical Nurses and Registered Nurses (As amended through December, 2009) Subpart, I. Practical Nurse, under subchapter E. Curriculum Requirements revealed in part:
3. Development of those qualities and personal characteristics needed to practice practical nursing safely, effectively and with compassion, including increased and ongoing development of self-awareness, sound judgement, [NAME], ethical thing and behaviors, problem solving and critical thinking abilities.
7. Principles and Practice of Nursing-presenting the application of concepts which will provide basic principles of nursing care and correlated experiences to develop competency in medical-surgical nursing, geriatric nursing, obstetrical nursing, pediatric nursing, and mental health. Clinical experience shall include, but not be limited to, the performance of basic and advanced nursing skills, general health and physical assessment, critical thinking and critical problem solving, medication administration, patient education, health screening, health promotion, health restoration and maintenance, supervision and management, safety and infection control, communication and documentation, and writing as member of the interdisciplinary health care team.
Review of the facility's Policy titled Staff Administered Medication Procedure revealed the following:
Policy: The medications are administered by staff members as indicated by State regulations.
Procedure:
6. Offer the resident the ordered medication as indicated by the Medication sheets. Use a paper medicine cup, not your hands. Hand the medication to the resident and observe him or her swallow it. Never leave a medication unattended when it is outside of the medication cupboard.
On 05/30/2023 at 9:45 a.m., an observation was made of 6 pills in a plastic medicine cup at Resident #387 bedside.
On 05/30/2023 at 10:40 a.m., an additional observation was made of pills in a plastic medicine cup at Resident # 387 bedside.
On 05/30/2023 at 10:52 a.m., an observation was conducted with S2DON at Resident #387's bedside. He confirmed the medications being present at Resident #387's bedside.
On 05/30/2023 at 10:55 a.m., an interview was conducted with S3LPN. She confirmed the medications being present at Resident #387 bedside. She confirmed she should have visualized Resident#387 take morning medications prior to exiting and did not. An observation was made by this surveyor with S3LPN of 6 pills in plastic medication cup at bedside: 1 orange pill, 3 white pills, 1 brown pill, and 1 yellow pill. S3LPN reviewed Resident #387's MAR and confirmed the pills to be the following: Coreg, Renvela, Nifedipine, Lasix, Effexor, and Protonix.
On 05/31/2023 at 7:52 a.m., an observation was made of 6 pills in a plastic medication cup at Resident # 44 bedside. Resident #44 stated she had consumed several of the smaller medications prior to this observation.
On 05/31/2023 at 7:56 a.m., an interview was conducted with S4LPN. She stated she did not observe Resident #44 consume her morning medications prior to exiting the room and should have remained present in the room until Resident #44 consumed medications. S4LPN reviewed Resident #44's MAR and confirmed she distributed the following pills during morning medication pass: Cymbalta, Lasix, Aspirin, Keppra, Cyproheptadine, Eliquis, Vitamin C, Colace, Potassium, and Gabapentin.
On 06/01/2023 at 9:15 a.m., an interview was conducted with S2DON. He confirmed no medications should remain at bedside unattended at any time and medication consumption needed to be visualized prior to exiting the room.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Free from Abuse/Neglect
(Tag F0600)
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 each resident had the right to be free from physical abuse...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews and interviews, the facility failed to ensure each resident had the right to be free from physical abuse by another resident for 3 (#39, #54, and #74) of 3 (#39, #54, and #74) residents reviewed for resident-to-resident altercations. The facility failed to:
1.
Protect Resident #39 from being hit on the arm by Resident #51 on 05/20/2023;
2.
Protect Resident #74 from being punched on the arm by Resident #51 on 05/29/2023;
3.
Protect Resident #54 from being punched on the arm by Resident #15 on 05/27/2023.
Findings:
Review of the facility's Abuse, Neglect, Exploitation & Misappropriation policy revealed the following, in part:
Each resident at the center has the right to be free from abuse, neglect, mistreatment, exploitation and/or misappropriation of property.
Physical abuse includes but is not limited to: Hitting, Slapping, Punching, Biting, Kicking
1.)
Resident #39
Review of the Clinical Record revealed Resident #39 was admitted to the facility on [DATE] with diagnoses, which included Fracture of Nasal Bones, Chronic Obstructive Pulmonary Disease, and Hemiplegia and Hemiparesis.
Review of the Quarterly MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 04/11/2023 revealed Resident #39 had a BIMS (Brief Interview of Mental Status) score of 14, which indicated he was cognitively intact.
Resident #51
Review of the Clinical Record revealed Resident #51 was admitted to the facility on [DATE] with diagnoses, which included Anxiety Disorder, Bipolar Disease, Schizoaffective Disorder and Dementia with Behavioral Disturbances.
Review of the most recent MDS with an ARD of 03/28/2023 revealed Resident #51 had a BIMS of 99, which indicated he was unable to complete the interview.
Review of the facility's Investigative Report revealed the following:
Accused Allegations- Physical Abuse
Date/Time - 05/20/2023 at 12:45 p.m.
Type of Injury- Redness, Skin Tear
Incident Reported by- S1ED
Narrative of incident and description of injuries: On this date at approx. 12:45 p.m., Resident #51 and Resident #39 were sitting outside in the facility courtyard and yelling was heard by staff. Staff entered courtyard and observed Resident #51 hitting Resident #39 on left wrist causing a skin tear. Both residents separated and placed on 15 minute watch. Primary Care Provider and Family notifications made. The initial investigation revealed Resident #51 accused Resident #39 of stealing his cigarettes, and confronted Resident #39 and hit him on the left wrist, causing a skin tear.
Review of the facility's Nursing Notes revealed the following, in part:
On 05/20/2023 at 12:36 p.m., S7LPN documented: Heard yelling from outside, walked out to find Resident #51 hitting Resident #39. Staff immediately separated the two residents. Assessed Resident #39 for injury. Monitoring both closely.
On 05/30/23 at 01:00 p.m., an interview was conducted with Resident #39. He stated he remembered Resident #51 grabbing his arm because he wanted his cigarettes. He stated Resident #51 hit him on his left arm causing scratches.
On 06/01/23 at 10:43 a.m., an interview was conducted with S10CNA. She stated she remembered the incident on 05/20/2023. She said Residents #51 and #39 were outside on the patio when she saw Resident #51 hitting Resident #39. She stated staff separated the residents, and she reported the incident to S7LPN.
On 06/01/23 at 11:15 a.m., an interview was conducted with S7LPN. She stated on 05/20/2023, she and S10CNA were walking past the patio and they heard yelling on the patio. She stated she walked outside and saw Resident #51 hitting Resident #39. She stated staff immediately separated the residents, removed Resident #51, and placed him on one on one monitoring until her shift was over. She stated she reported the incident to S2DON and made sure S1ED was aware.
2.)
Resident #74
Review of the Clinical Record revealed Resident #74 was admitted to the facility on [DATE] with diagnoses, which included Hemiplegia and Hemiparesis following Cerebral Infarction affecting Right Dominant Side.
Review of the Quarterly MDS with an ARD of 03/03/2023 revealed Resident #74 had a BIMS score of 6, which indicated he was severely cognitively impaired.
Review of the facility's Investigative Report revealed the following:
Accused Allegations- Physical Abuse
Date/Time - 05/29/2023 at 10:00 a.m.
Type of Injury- None
Incident Reported by- S1ED
Narrative of incident and description of injuries: On 05/29/2023 Resident #51 punched Resident #74 in the arm. No injuries were noted. Both residents were separated immediately and Resident #51 was placed on one to one supervision, then sent to the behavioral hospital. Primary Care Provider and family notified.
Review of the facility's Nursing Notes revealed the following, in part:
On 05/29/2023 at 10:40 a.m., S13UM documented: Resident #74 was punched in the right arm 3 times by another resident. Resident had no visible injury. Denied any pain at this time. Doctor was notified, no new orders. RP was notified . Will continue to monitor.
On 06/01/2023 at 9:06 a.m., an interview was conducted with Resident #74. He stated he recalled when Resident #51 punched him on 05/29/2023. He stated he was at the nurse's station and Resident #51 walked out of his room and started yelling. He stated he told Resident #51 everything would be ok and to quit yelling. He stated Resident #51 punched him multiple times. He denied any injuries.
On 06/01/2023 at 11:14 a.m., an interview was conducted with S7LPN. She stated on 05/29/2023, she was at the nurse's station, and Resident #74 was in his wheelchair in front of the nurse's station. She stated Resident #51 walked out of his room and started yelling for help. She stated she jumped up to help him, but he did not tell her what he needed help with. She stated she was going to give him a snack because snacks calmed him down. She stated when she reached for the snack, she saw Resident #51 punch Resident #74. She stated there was no reason for Resident #51 to hit Resident #74. She stated she separated the two residents immediately, and Resident #51 was placed on one to one supervision. She stated she notified the doctor, S2DON, and S1ED. She stated the doctor placed an order to send Resident #51 to the behavioral hospital. She stated she assessed Resident #74, and he had no injuries.
3.)
Resident #54
Review of the Clinical Record revealed Resident #54 was admitted to the facility on [DATE] with diagnoses, which included Hemiplegia and Hemiparesis following Cerebral Infarction Affecting Right Dominant Side and Dysphagia.
Review of the Quarterly MDS with an ARD of 04/17/2023 revealed Resident #54 had a BIMS score of 15, which indicated he was cognitively intact.
Resident #15
Review of the Clinical Record revealed Resident #15 was admitted to the facility on [DATE] with diagnoses, which included Unspecified Dementia, Unspecified Mood Disorder, Anxiety Disorder, and Major Depressive Disorder.
Review of the Quarterly MDS with an ARD of 05/26/2023 revealed Resident #15 had a BIMS score of 11, which indicated he was moderately cognitively impaired.
Review of the facility's Investigative Report revealed the following:
Accused Allegations- Physical Abuse
Date/Time - 05/27/2023 at 10:25 a.m.
Type of Injury- None
Incident Reported by- S1ED
Narrative of incident and description of injuries: On 05/27/2023 in the main dining area, Resident #15 was apparently bullying Resident #54 by telling him to get out of his way. Resident #54 said no, and he was pushed and hit in the arm by Resident #15. Staff separated residents. Primary Care Provider was notified and order received to send Resident #15 to behavioral hospital. No injuries noted to Resident #54.
Review of Nurse's Notes for Resident #15 revealed the following, in part:
On 05/27/2023 at 10:23 a.m., S8LPN documented: Resident was brought to the nurse's station by CNA. Resident #15 pushed Resident #54 and hit him on the arm. The two kitchen employees, S12DA and another kitchen staff, witnessed the altercation and they stated Resident #15 was the aggressor and Resident #54 did not retaliate. Witness statement were obtained by all parties. Attempted to notify doctor. Nursing supervisor and S2DON notified. RP notified and stated that she is agreeing to send Resident #15 to behavioral hospital. Resident #15 stated he did not hit Resident #54, Resident #54 hit him. Resident #54 stated Resident #15 started bullying him telling him to get out of his way. Resident #54 said no and Resident #15 pushed his chair and hit him in the arm.
On 05/27/2023 at 11:00 a.m., S8LPN documented: Doctor notified of physical aggression and ordered to send to behavioral hospital.
On 06/01/2023 at 8:25 a.m., an interview was conducted with Resident #54. He stated Resident #15 bullied him and hit him on 05/27/2023. He stated he was trying to get coffee when Resident #15 told him to get out of the way then hit him. He stated Resident #15 tried to tell everyone what to do, and when someone did not listen, he got aggressive.
On 06/01/2023 at 9:10 a.m., an interview was conducted with S12DA. He stated he witnessed Resident #15 hit Resident #54 on 05/27/2023. He stated Resident #15 was at the coffee station, and Resident #54 wheeled up in his wheelchair to get coffee. He stated Resident #15 told Resident #54 to get out of his way or he was going to knock the s*** out of him. He stated Resident #54 said no, then Resident #15 hit him on his arm. He stated the residents were separated by CNA staff.
On 06/01/2023 at 08:30 a.m., an interview was conducted with S1ED related to facility investigative reports from Residents #39, #51, #74, #54, and #15. He confirmed the incidents occurred and were abuse.
Mar 2023
4 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
Free from Abuse/Neglect
(Tag F0600)
A resident was harmed · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record review, the facility failed to protect the residents' right to be free from physica...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record review, the facility failed to protect the residents' right to be free from physical abuse by staff for 1 (#7) of 5 (#1, #2, #4, #6, and #7) sampled residents.
This deficient practice resulted in an actual harm for Resident #7, who was dependent on staff for ADL care, on 03/21/2023 when S20CNA threw a bed remote at the resident's face resulting in a Non-displaced Nasal Bone Fracture. Resident #7 was sent to the emergency room with a laceration. The injury caused Resident #7 severe pain and required an irrigation and debridement of the nasal cavity and wound care.
Findings:
Review of facility's policy titled Abuse, Neglect, Exploitation and Misappropriation revealed, in part, the following:
It is inherent in the nature and dignity of each resident at the center that he/she be afforded basic human rights, including the right to be free from abuse, neglect, mistreatment, exploitation and/or misappropriation of property.
Physical abuse includes but is not limited to:
Hitting with an object.
Review of Resident #7's clinical record revealed he was admitted to the facility on [DATE] with diagnoses which included, Unspecified Sequelae of Cerebral Infarction, Hemiplegia and Hemiparesis Following Cerebral Infarction Affecting Left Non-Dominant Side, Rhabdomyolysis, Other Lack of Coordination, and Muscle Weakness.
Review of the MDS with an ARD of 01/03/2023, revealed the Resident #7 was assessed by the facility to have a BIMS of 12, which indicated he was moderately cognitively intact. Further review revealed the resident required 2 person assistance with transfers, dressing, toileting, bed mobility and sit to lying position changes. Resident #7 was unable to walk with or without assistance.
Review of Resident #7's current Care Plan revealed the following, in part:
Onset date: 01/03/2023
Problem: Resident had an ADL self-care performance deficit.
Approaches: Resident required 2 person assistance with transfers. Resident required 2 person assistance with dressing. Resident required 2 person assistance with toileting. Resident required 2 person assistance with chair to bed transfer. Resident is dependent.
Review of Resident #7's Progress Notes documented by Direct Care Staff on 03/21/2023, revealed, in part, the following:
8:01 a.m., Called to room by S16CNA. Resident states S20CNA hit him in the face with a bed remote. Upon assessing face of resident, small amount of swelling noted to left cheek area, no bruising nor discoloration noted. New order noted, CT of Maxillofacial related to pain/swelling. Signed by S8UM.
Review of Physician's Orders dated from admission through 03/20/2023, revealed no active orders to treat pain.
Review of the facility's Internal Investigation Report dated 03/21/2023, revealed, in part, the following:
Detailed Description of Event/Allegation:
Resident #7 alleges S20CNA threw a bed remote and hit him in the face. Resident named employee and stated it happened on night shift.
Accused Allegations: Physical Abuse
Allegation Findings: Substantiated
Review of the local Emergency Department's discharge documentation dated 03/21/2023 at 11:32 a.m., revealed, in part, the following:
Resident #7 was brought to the Emergency Department with a chief complaint of nasal drainage and nasal pain.
Assessment of head: Left swelling, laceration, left lateral brow area with 0.5cm laceration without bleeding.
Assessment of nose: Moderate tenderness, swelling, left side worse than right, serosanguinous drainage from bilateral nares, left greater than right.
CT Maxillofacial Findings: There is nasal soft tissue swelling noted. There is a non-displaced nasal bones fracture identified. There is tortuosity of the nasal septum.
Review of Resident #7's Facility Physician's Orders placed after ER visit on 03/21/2023, revealed, in part, the following:
Referral to ENT. New appointment for ENT on 03/23/2023 related to non-displaced nasal bone fracture and soft tissue swelling and Tramadol HCL Oral Tablet. Give 1 tablet by mouth every 8 hours as needed for pain.
Review of Resident #7's Progress Notes documented by Direct Care Staff, on 03/21/2023, revealed, in part, the following:
3:30 p.m., CT results received showing non-displaced nasal bone fracture and soft tissue swelling. New order noted referral to ENT. Signed by S8UM.
Review of the facility's CNA schedule dated 03/20/2023 revealed S20CNA was assigned to care for Resident #7 from 6:00 p.m. on 03/20/2023 through 6:00 a.m. on 03/21/2023.
On 03/22/2023 at 2:35 p.m., an observation was made of Resident #7. Resident #7 was observed on the EMS stretcher being transferred to the local Emergency Department for evaluation. Resident #7's nose was observed to be reddened and swollen. Resident #7's left cheek was swollen.
On 03/22/2023 at 2:40 p.m., an interview was conducted with S3RDOCS. She stated Resident #7 was being transferred to the Emergency Department for a third time to be evaluated for nasal drainage after S20CNA allegedly threw a remote, hitting the resident in the face and breaking his nose.
On 03/23/2023 at 8:40 a.m., an attempt was made to conduct a telephone interview with S20CNA. No answer or return call received.
On 03/23/2023 at 11:15 a.m., an interview was conducted with S8UM. She confirmed caring for Resident #7 and described him as a reliable source that could verbally communicate his wants and needs. She stated due to weakness after having a stroke, Resident #7 would not be able to get himself off the floor and back into bed without staff assistance if he fell. She stated she was notified by S16CNA on 03/21/2023 at 8:50 a.m. that Resident #7 reported S20CNA hit him in the face with a bed remote during the night of 03/20/2023. She stated upon assessment of Resident #7, his nose and left cheek were swollen. She stated Resident #7 told her S20CNA came to assist him with incontinent care, and before leaving his room, S20CNA grabbed the bed remote and threw it at his face. She stated Resident #7 said S20CNA threw the remote at his face on purpose. She confirmed S20CNA provided care for Resident #7 on 03/20/2023 from 6:00 p.m. through 03/21/2023 at 6:00 a.m. She confirmed throwing an object and hitting a resident was physically abusive. She stated Resident #7 was sent to the Emergency Department on 03/21/2023 and then again twice on 03/22/2023 related to the nasal fracture.
On 03/23/2023 at 11:23 a.m., an interview was conducted with S11LPN. She stated if Resident #7 fell, he would not be able to get himself back into bed without staff assistance due to weakness after having a stroke. She stated Resident #7 was a reliable source that could verbally communicate his wants and needs. She stated a staff member throwing an object and hitting a resident in the face was physically abusive. She stated Resident #7 returned from the Emergency Department on 03/21/2023 with a diagnosis of a nasal fracture and was then again sent to the Emergency Department twice on 03/22/2023 due to increased nasal drainage and an elevated temperature.
On 03/23/2023 at 11:34 a.m., an interview was conducted with S21CNA. She confirmed caring for Resident #7 and described him as a reliable source that could verbally communicate his wants and needs. She stated due to weakness after having a stroke, Resident #7 would not be able to get himself off the floor and back into bed without staff assistance if he fell. She stated on 03/21/2023 at 8:50 a.m., Resident #7 told her and S16CNA that S20CNA threw the bed remote at him and it hit his face. She stated the resident's face was swollen and red on his left cheek. She stated Resident #7 told her it was painful. She stated she and S16CNA notified S8UM immediately.
On 03/23/2023 at 12:05 p.m., an interview was conducted with S1ADM. He stated on 03/21/2023 at 08:50 a.m. he was notified Resident #7 alleged S20CNA threw a bed remote at his head and hit him in the face. He stated after investigation into the allegation of abuse, he determined physical abuse occurred after Resident #7's CT scan confirmed a nasal fracture. He described Resident #7 as a reliable source. He stated Resident #7 selected S20CNA in a photo lineup as the perpetrator of abuse during police investigation. He confirmed throwing an object and hitting a resident physical abuse.
On 03/23/2023 at 12:27 p.m., an attempt was made to conduct a telephone interview with S20CNA. No answer or return call received.
On 03/23/2023 at 1:30 p.m., an observation was made of Resident #7. Resident #7's nose was observed to be swollen and red. Resident #7's left cheek was observed to be swollen with a small laceration.
On 03/23/2023 at 1:31 p.m., an interview was conducted with Resident #7. Resident #7 stated S20CNA threw the bed remote at him and it hit him in the face on the night of 03/21/2023. He stated he did not know why the CNA threw it at him. He stated S20CNA threw the remote at him on purpose. He stated S20CNA did not say anything when it happened, and she just left. He stated he told the morning CNAs, S16CNA and S21CNA, what happened when they came on shift. He stated his face and nose were extremely painful, and now he had an abscess in his nose that the ENT had to stick with a needle. He stated if he had fallen out of his bed, he would not be able to get back into bed without staff assistance.
On 03/23/2023 at 1:55 p.m., an interview was conducted with S3RDOCS. She stated Resident #7 was able to voice his wants, needs, and was reliable in conversation. She stated she and S1ADM worked together to perform the investigation into Resident #7's allegation of physical abuse from S20CNA. She stated herself and S1ADM called S20CNA on 03/21/2023. S20CNA confirmed she provided care for Resident #7 on 03/20/2023 from 6:00 p.m. through 03/21/2023 at 6:00 a.m. She stated S20CNA would not confirm an incident happened with Resident #7 during her shift.
On 03/23/2023 at 2:00 p.m., a telephone interview was conducted with S23LPN. She confirmed caring for Resident #7 and described him as a reliable source that could verbally communicate his wants and needs. She stated due to weakness after having a stroke, Resident #7 would not be able to get himself off the floor and back into bed without staff assistance if he fell. She stated she gave Resident #7 his 10:00 p.m. medications on 03/20/2023 in his room. She stated at that time, Resident #7 had no complaints of pain and had no marks or swelling to his face. She confirmed S20CNA provided care for Resident #7 on 03/20/2023 from 6:00 p.m. through 03/21/2023 at 6:00 a.m.
On 03/23/2023 at 3:05 p.m., an interview was conducted with S16CNA. She confirmed caring for Resident #7 and described him as a reliable source that could verbally communicate his wants and needs. She stated due to weakness after having a stroke, Resident #7 would not be able to get himself off the floor and back into bed without staff assistance if he fell. She stated Resident #7 was resting in his bed when she entered his room on 03/21/2023 at 8:50 a.m. She stated she observed Resident #7's face to be swollen and red. She stated Resident #7 told her and S21CNA that S20CNA threw the bed remote and the remote hit him in the face. She stated Resident #7 stated his face was painful. She stated she and S21CNA then notified S8UM immediately.
Based on interviews and record reviews, the facility failed to protect the resident's right to be free from neglect for 1 (#2) of 5 (#1, #2, #4, #6, #7) sampled residents when S15CNA and S24CNA neglected to transfer Resident #2 according to his care plan.
This deficient practice resulted in an actual harm on the morning of 02/06/2023. Resident #2, a cognitively intact resident diagnosed with paraplegia, was transferred by S15CNA and S24CNA without the use of a mechanical lift. During the transfer, Resident #2 heard a pop in his right knee, and immediately reported this to S15CNA and S24CNA. Resident #2 developed severe pain and was later transferred to the emergency room and diagnosed with a Right Tibia Fracture.
Findings:
A review of the facility's policy and procedure titled: Abuse, Neglect, Exploitation, and Misappropriation revealed the following, in part:
Policy:
It is inherent that each resident be afforded the right to be free from neglect. Employees are charged with a continuing obligation to treat residents so they are free from neglect. No employee may at any time commit an act of neglect against any resident.
Definitions:
Neglect is the failure of the center, its employees or service providers to provide services to a resident that are necessary to avoid physical harm or pain. Examples include:
2. Failure to take precautionary measures to protect the health and safety of the resident.
3. Failure to provide services that result in harm to the resident.
A review of the facility's policy and procedure titled: Transfer/Mobility Evaluation Low Lift revealed the following, in part:
Policy:
Center will evaluate the transfer and lifting needs of the resident to safely and comfortably transfer according to their individualized needs.
Procedure:
4. Lift status will be indicated on the resident's care plan and [NAME].
A review of the facility's policy and procedure titled: Lifting and Moving Residents revealed the following, in part:
Use a mechanical lift to transfer a resident who cannot stand from the bed to the wheelchair.
Review of the medical records for Resident #2 revealed he was admitted to the facility on [DATE] with diagnoses which included Paraplegia, End Stage Renal Disease (Hemodialysis Dependent), Peripheral Vascular Disease, and Type 2 Diabetes Mellitus. Further review revealed Resident #2 was later diagnosed with a Fracture of the Right Tibia on 02/06/2023.
A review of the Significant Change MDS with an ARD of 02/13/2023 revealed Resident #2 had a BIMS of 15, which indicated he was cognitively intact. Further review revealed Resident #2 required two plus person physical assistance with mechanical lifts for transferring and was totally dependent upon staff for all mobility. Resident #2 had impairment to lower extremities on both side and was unable to stand, turn, or ambulate.
A review of the current Care Plan revealed the following, in part:
Onset: 06/17/2020
Resident #2 has an ADL self-care performance deficit related to paraplegia.
Transfer: The resident needs full assistance with staff X 2 and mechanical lift for transfers.
A review of the facility's incident report revealed
02/06/2023 S10LPN reported to S8UM: Resident #2 came to the nurses' station with complaints of right knee pain and unable to move his toes. He stated it happened while CNA's were transporting him from bed to chair this a.m. He heard a pop in his knee. S5MD was notified and instructed resident to go in to the ER when he returns from dialysis.
A review of the facility's Incident Investigation revealed the following statements dated 02/06/2023:
Resident #2 stated S15CNA and S24CNA came into my room to get me up. They told me they could not get the lift to work and they would have to stand and pivot me into my chair. After I stood up and went to pivot, my right foot stayed in place and didn't turn with my body. I heard a pop.
S24CNA stated she assisted another CNA with getting Resident #2 up and into his chair. S24CNA stood on the left side and the other CNA was on the right of him. They slid him in his chair. Resident #2 did state that he felt his leg pop and complained of pain afterwards. We placed his legs on the leg rest. We left his room. We did not use a lift because the battery was dead and because Resident #2 stated that he had to be up at that time to eat breakfast before dialysis.
S15CNA stated she had asked another CNA to help her get Resident #2 up for dialysis. We sat him up on the side of his bed. With the other CNA on one side and S15CNA on the other side, we proceeded to lift him up to put him in the chair. We didn't use the lift because it was being used on somebody else.
A review of the Nurse's Notes dated 02/06/2023 revealed the following, in part:
06:19 a.m. S10LPN entered: Resident #2 came to the nurse's station with a complaint of right knee pain and reported his toes won't move. Resident #2 stated it happened while CNA's were transporting him from his bed to his wheelchair this a.m. and he heard a pop in his knee. S5MD notified and instructed S10LPN to have Resident #2 go to the ER when he returns from dialysis. Resident #2 verbalized agreement.
A review of the medical records from the local dialysis center dated 02/06/2023 revealed the following, in part:
6:30 a.m. - Prior to arrival, Resident #2 called and reported that his knee got hurt this morning when he was moved to his wheelchair. He reported the facility didn't use the lift. He said that he was probably going to be taken to the ER.
7:09 a.m., Resident #2 in wheelchair, late for treatment. Resident #2 reported that the nursing home didn't use a mechanical lift this morning and hurt his right knee.
7:10 a.m., Noted a large knot below the right knee and broken skin with slight bleeding on the right side of the knee.
9:18 a.m., Resident #2 requested off dialysis early re: right knee/leg hurting.
9:45 a.m., Dialysis Nurse Practitioner rounded. Order noted to send Resident #2 to ER for leg and knee x-rays re: injury this morning. Called for transport.
A Review of the Dialysis Nurse Practitioner's note dated 02/06/2023 revealed the following, in part:
Seen and examined Resident #2 today. He complained of right knee pain with swelling. He reported that he was being placed in his wheelchair this morning without using a mechanical (Hoyer) lift.
9:30 a.m., Send to ED for x-ray right leg/knee.
On 03/22/2023 at 2:55 p.m. an interview was conducted with the dialysis RN Clinic Manager. She stated Resident #2 received dialysis treatments 3 times/week at the dialysis facility. She stated Resident #2 as cognitively intact. She stated Resident #2 arrived to dialysis late on 02/06/2023 and was complaining of pain to the right leg. She stated Resident #2 told her his right knee was injured at the nursing home prior to transportation to dialysis. She said Resident #2 described hearing a pop in his knee while being transferred by 2 CNA's without the use of a mechanical lift. She stated Resident #2's right leg had an obvious deformity with a large knot and a small break in the skin with a small amount of bright red blood near the right knee. She stated Resident #2 was always transferred with a mechanical lift at the dialysis facility due to his paraplegia.
On 03/22/2023 at 3:04 p.m. an interview was conducted with the dialysis RN. She stated Resident #2 received dialysis treatments 3 times/week. She stated Resident #2 was cognitively intact. She stated Resident #2 arrived to dialysis late on 02/06/2023, and was complaining of pain to right leg. She stated Resident #2 told her his right knee was injured at the nursing home prior to transportation to dialysis. She said Resident #2 described hearing a pop in his knee while being transferred by 2 CNA's. She said she observed a large hematoma and a small break in skin with a small amount of bloody discharge near the right knee. She stated Resident #2 was always transferred with a mechanical lift at the dialysis facility due to his paraplegia. She stated Resident #2 was noted to have facial grimacing during dialysis treatment, and treatment was stopped early due to pain in right leg.
On 03/22/2023 at 3:34 p.m. an interview was conducted with a Certified Hemodialysis Specialist. She stated on 02/06/2023 upon arrival to the dialysis facility, Resident #2 told her he was in pain. She stated Resident #2 told her his right knee was injured at the nursing home prior to transport to dialysis. She said Resident #2 described hearing a pop in his knee while being transferred by 2 CNA's without the use of a mechanical lift. She immediately notified the dialysis RN. She stated Resident #2 was always transferred with a mechanical lift at the dialysis facility due to his paraplegia.
On 03/22/2023 at 3:57 p.m. an interview was conducted with the dialysis Nurse Practitioner. She stated Resident #2 was cognitively intact and had sensation to his lower extremities. She stated on 02/06/2023, Resident #2 was complaining of moderate to severe pain in the right leg. She stated Resident #2 conveyed to her that 2 staff at the nursing home transferred him without using the mechanical lift this morning and he felt a pop in his right knee. She stated Resident #2 notified her that his provider was already notified and had given an order for Resident #2 to be sent to ER after completing dialysis. She stated she observed a large hematoma just below the right knee and a skin tear with bloody discharge. She stated during Resident #2's dialysis treatment, she became concerned the resident may have suffered from a vascular injury that required life or limb treatment. She stated she then stopped dialysis treatment early to send him back to the facility in order for him to be evaluated.
A review of Resident #2's Nurse's Notes dated 02/06/2023 revealed the following, in part:
10:20 a.m., Resident #2 arrived back from dialysis. S9LPN called report to the ER regarding the resident's right knee pain. EMS called for transport to ER.
A review of the Emergency Department's records dated 02/06/2023 revealed the following, in part:
Resident #2 arrived to the Emergency Department at 11:41 a.m. with a chief complaint of right knee pain and swelling. Resident #2 is paraplegic with diminished strength to lower extremities (chronic, unchanged). Reports intact sensation to lower extremities. Resident #2 informed the provider that he felt a pop in his knee earlier that day during a transfer at his nursing home facility. Resident #2 had acute onset of severe pain just distal to the right knee with associated swelling. Resident #2 appeared in mild distress secondary to pain. Resident #2 was in significant pain. Significant swelling and tenderness over the right tibial plateau. X-rays revealed an acute (right) tibial plateau fracture with extension into the tibial tuberosity. Orthopedic surgeon was consulted. Orthopedic surgeon did not recommend surgical repair due to comorbidities and being bed-bound. Resident #2 placed in knee immobilizer, then discharged back to nursing home facility with pain medication (Norco).
A review of the facility's Nurse's Notes dated 02/06/2023 revealed the following, in part:
9:00 p.m. S10LPN entered: Resident #2 returned from the ER with a new diagnosis of a closed fracture of the right Tibial Plateau. New orders: Do not put weight on leg; Norco 10/325 (hydrocodone-acetaminophen) every 6 hours prn pain, (7-day supply,); Continue previous meds; Refer to orthopedic to be seen within one week.
02/07/2023 at 8:55 a.m. S9LPN entered: Resident #2 complaining of right leg pain uncontrolled. Provider notified. Pain medication increased to every four hours as needed for 48 hours then resume to every six hours as needed for pain.
On 03/23/2023 at 12:30 p.m. a telephone interview was conducted with Resident #2. He stated he was paraplegic but has sensation to his lower extremities. He stated on the morning of 02/06/2023 he was transferred from his bed to his wheelchair by 2 CNAs, but he was unable to recall their names. He stated he was always transferred with a mechanical lift, but this day he was told the lift was not working. He stated the mechanical lift sling was placed in his wheelchair prior to transfer. Resident #2 stated during the transfer, his right foot did not pivot, and he heard a pop in his right knee. He said he immediately reported the pop to the CNAs that transferred him and then to S10LPN. He stated S10LPN told him S5MD wanted him to go to dialysis before going to the ER. He stated his pain was a 10/10 at that time. He stated once he got to dialysis he immediately reported his injury to the nurses and the NP assessed his right leg. He stated he had to stop dialysis early due to the severe pain in his right leg. He sent to the ER. He stated he had a fracture to the right lower leg. He stated he felt neglected by the CNAs when they made him transfer without a mechanical lift. He stated he still experiences pain in the right leg.
On 03/15/2023 at 3:24 p.m. an interview was conducted with S15CNA. She stated she cared for Resident #2 often. She stated Resident #2 required a mechanical lift with 2 person assistance for all transfers. She stated on 02/06/2023 she and S24CNA transferred Resident #2 from his bed to his wheelchair without using the mechanical lift. She stated one mechanical lift was being used by another resident and the other mechanical lift had a dead battery. She confirmed she had been trained on using the mechanical lift by the facility. She stated she did know how to change the battery in the mechanical lift, but did not attempt to before transferring Resident #2 on 02/06/2023. She confirmed knowing transferring Resident #2 without the mechanical lift was unsafe.
On 03/20/2023 at 1:18 p.m., an interview was conducted with S10LPN. She stated Resident #2 could communicate his needs and had sensation to his lower extremities. She stated Resident #2 required 2 staff and mechanical lift for transfers. She stated on 02/06/2023 she was responsible to care for Resident #2. She stated on 02/06/2023 prior to dialysis transport, Resident #2 notified her of right knee pain after CNAs transferred him from bed to wheelchair without the mechanical lift. She stated the CNAs should have used the mechanical lift but they had not on 02/06/2023. She stated. She stated it was neglectful to transfer Resident #2 without a mechanical lift.
On 03/20/2023 at 12: 55 p.m., an interview was conducted with S9LPN. She stated Resident #2 could communicate his needs and had sensation to his lower extremities. She stated resident #3 required a mechanical lift for all transfers. She stated upon arrival to work on 02/06/2023 just before 7:00 a.m., Resident #2 was notifying S10LPN of right knee pain. She heard Resident #2 state the right knee pain started immediately after being transferred from bed to wheelchair by 2 CNAs and he heard a pop. She stated S10LPN received an MD order to send Resident #2 to ER after dialysis. She stated Resident #2 returned from dialysis early due to increasing right knee pain. She stated she assessed Resident #2's right leg and observed swelling below the knee with a raised area. She stated Resident #2 was sent to the ER via ambulance. She stated on 02/07/2023 she cared for Resident #2, and he complained of significant pain to the right leg. She stated she notified S5MD and received an order to increase the frequency of pain medication for 48 hours. She stated it was neglectful to transfer Resident #2 without a mechanical lift.
On 03/20/2023 at 11:37 a.m., an interview was conducted with S5MD. He stated resident #2 was cognitively intact and required transfers with a mechanical lift. He stated on the morning of 02/06/2023, a nurse from the facility notified him Resident #2 was complaining of being inappropriately transferred and right knee pain. He stated he gave orders to send Resident #2 to the ER for evaluation and treatment after dialysis. He stated the local ER doesn't have dialysis capabilities and the resident was due for his dialysis treatment. He recalled Resident #2 returned from dialysis early due to right knee pain and was then sent to ER. He stated Resident #2 sustained a right tibial plateau fracture. He stated Resident #2 was in a lot of pain and was given Norco by the ER MD. He confirmed Resident #2 was transferred unsafely on 02/06/2023 and the resident suffered harm as a result of this neglect.
On 03/20/2023 at 10:29 a.m., an interview was conducted with S8UM. She stated Resident #2 could communicate his needs and he had sensation to lower extremities. She stated the incident involving Resident #2 from 02/06/2023 was discussed in the facility's morning meeting on 02/07/2023. She then initiated an incident report. She recalled getting a statement from S10LPN and Resident #2. She stated Resident #2 was in pain after this incident. She confirmed Resident #2's transfer status was a mechanical lift with 2 staff. She confirmed Resident #2 was care planned for mechanical lift with 2 staff. She confirmed on 02/06/2023 the care plan was not followed for transferring Resident #2. She confirmed on 02/06/2023, Resident #2 should have been transferred using a mechanical lift with 2 staff. She stated this was neglect.
On 03/20/2023 at 1:38 p.m. an interview was conducted with S6PTA. She stated Resident #2 could make his needs known and had sensation to lower extremities. She stated Resident #2 should always be transferred with a mechanical lift. She stated the mechanical lift was the safest way to transfer Resident #2 because he could not stand and pivot.
On 03/20/2023 at 2:16 p.m., an interview was conducted with S7MDS. She stated she was responsible for MDS assessments and care planning. She confirmed Resident #2 required 2 person assistance with mechanical lift for transfers and was care planned for this. She S15CNA and S24CNA should have used the mechanical lift on 02/06/2023 to transfer Resident #2. She confirmed it was neglect to transfer Resident #2 without a mechanical lift.
On 03/22/2023 at 11:30 a.m., an interview was conducted with S2DON. He confirmed if a resident requires a mechanical lift and both are in use, staff should not lift the resident until one is available. He stated if a battery is dead, the charging station has charged batteries at all times. He confirmed Resident #2's transfer status as a mechanical lift with 2 staff. He confirmed Resident #2 was care planned for transfers using a mechanical lift with 2 staff. He confirmed the care plan was not followed by S15CNA and S24CNA on 02/06/2023 when they transferred the resident without using the mechanical lift. He stated the transfer was unsafe, neglectful and resulted in harm to Resident #2.
On 03/22/2023 at 12:20 p.m. an interview was conducted with S1ADM. He confirmed on 02/06/2023, staff failed to follow the care plan related to transfers for Resident #2. He confirmed S15CNA and S24CNA neglected Resident #2 on 02/06/2023 when they transferred him without the mechanical lift.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Report Alleged Abuse
(Tag F0609)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews, the facility failed to ensure alleged violations of physical abuse, sexual abuse, and ne...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews, the facility failed to ensure alleged violations of physical abuse, sexual abuse, and neglect were reported within 2 hours to the state survey agency after allegations were made for 3 (#1, #2, and #4) of 5 (#1, #2, #4, #6, and #7) residents reviewed for abuse and neglect.
Findings:
A review of the facility's policies and procedures on Abuse, Neglect, Exploitation, & Misappropriation revealed, in part, the following:
Definitions:
Abuse:
Abuse is the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish. It include verbal abuse, sexual abuse, physical abuse, and mental abuse including abuse facilitated or enabled through the use of technology.
*Physical Abuse includes but is not limited to hitting, slapping, punching, biting kicking, or corporal punishment.
*Sexual Abuse is non-consensual sexual contact of any type with a resident. Sexual abuse includes but is not limited to:
1. Unwanted intimate touching of any kind especially of breast or perineal area.
Neglect:
Neglect is the failure of the center, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish or emotional distress. Examples include but are not limited to:
2. Failure to take precautionary measures to protect the health and safety of the resident.
Reporting:
Any employee or contracted service provider who witnesses or has knowledge of an act of abuse or an allegation of abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, to a resident, is obligated to report such information immediately, but no later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the Administrator and to other officials in accordance with State law. In the absence of the Executive Director, the Director of Nursing is the designated abuse coordinator.
Resident #1
Resident #1 was admitted to the facility on [DATE] with diagnoses, which included Chronic Obstructive Pulmonary Disease, Dysphagia, Muscle Weakness, and Major Depressive Disorder.
Review of the quarterly MDS with an ARD of 02/13/2023 revealed Resident #1 had a BIMS of 15, which indicated she was cognitively intact.
A review of the facility's incident report revealed the following, in part:
On 02/05/2023 at 6:22 p.m. an incident of alleged sexual abuse was reported to staff by Resident #1. She reported to a nurse (she couldn't recall the name) that Resident #6 touched her breast as he passed by her in the hallway.
On 03/14/2023 at 10:42 a.m. an interview was conducted with Resident #1. She recalled an incident from last month where Resident #6 touched her breast, but could not recall the exact date. She stated the incident happened as they passed each other while in their wheelchairs in the hallway. She stated as Resident #6 was passing her, he reached out and touched her left breast. She stated neither herself nor Resident #6 stopped; they both kept going in opposite directions. She stated she reported the incident to S11LPN immediately after the incident.
On 03/14/2023 at 2:50 p.m. an interview was conducted with S11LPN. She stated on 02/05/2023, Resident #1 reported to her that Resident #6 touched her breast as they passed each other in the hallway. She verified she reported the incident to S8UM immediately.
On 03/16/2023 at 10:43 a.m., an interview was conducted with S8UM. She recalled on 02/05/2023 she was notified of about an incident of alleged sexual abuse of Resident #1 by Resident #6. She said as soon as she was notified, she notified S2DON and the administrator.
Review of the facility's investigative report filed with the state revealed the following, in part:
Incident entered on 02/06/2023 at 12:48 p.m.
Accused Allegations: Sexual Abuse
On 03/16/2023 at 10:25 a.m., an interview was conducted with S2DON. He confirmed this incident was not reported within the 2 hour time frame.
On 03/16/2023 at 12:00 p.m., an interview was conducted with S1ADM. He confirmed the state report was not entered for Resident #1 within the 2 hour deadline.
Resident #2
Resident #2 was admitted to the facility on [DATE] with diagnoses which included Paraplegia, Fracture of Right Tibia, End Stage Renal Disease (Hemodialysis Dependent), Peripheral Vascular Disease, and Type 2 Diabetes Mellitus.
A review of the Significant Change MDS with an ARD of 02/13/2023 revealed Resident #2 had a BIMS of 15 which indicated he was cognitively intact. Further review revealed Resident #2 required two person physical assistance with mechanical lift for transferring.
A review of the Nurse's Notes dated 02/06/2023 revealed the following, in part:
6:19 a.m., Resident #2 came up to the nurse's station with a complaint of right knee pain and reported his toes won't move. Resident #2 stated it happened while CNA's were transporting him from his bed to his wheelchair this a.m. and he heard a pop in his knee. S5MD notified and instructed S10LPN to have Resident #2 go in to the ER when he returned from dialysis. Resident #2 verbalized agreement. Reported to oncoming nurse. -S10LPN
10:20 a.m., S9LPN called report to the ER regarding resident's right knee pain. EMS called for transport to ER. -S9LPN
3:28 p.m., Report received from ER - right tibia plateau fracture. Resident #2 placed in knee immobilizer and needs to follow up with an orthopedist. -S9LPN
9:00 p.m., Resident #2 returned from the ER on stretcher with EMS. Resident #2 had a new diagnosis of closed fracture of right Tibial Plateau. -S10LPN
A review of Emergency Department Physician's Provider Notes dated 02/06/2023 revealed the following, in part:
Resident #2 arrived to the Emergency Department on 02/06/2023 at 11:41 a.m. with a chief complaint of right knee pain and swelling. X-rays revealed an acute right tibial plateau fracture with extension into the tibial tuberosity.
Review of the facility's investigative report filed with the state revealed the following, in part:
Incident occurred on 02/06/2023 at 6:00 a.m.
Incident discovered on 02/06/2023 at 2:15 p.m.
Incident entered on 02/07/2023 at 10:22 a.m.
Accused Allegations: Neglect
A review of the facility's incident report revealed the following, in part:
On 02/06/2023 S10LPN reported to S8UM: Resident #2 came up to the nurses' station with complaints of right knee pain and unable to his toes. He stated it happened while CNA's were transporting him from bed to chair this a.m. He heard a pop in his knee. S5MD was notified and instructed resident to go in to the ER when he returns from dialysis. Resident #2 verbalized agreement. Reported to oncoming nurse.
Resident #2 stated: Two CNAs came into my room to get me up. They told me they could not get the lift to work and they would have to stand and pivot me into my chair. After I stood up and went to pivot, my right foot stayed in place and didn't turn with my body. I heard a pop.
Resident #2 sent to ER after returned early from dialysis. This incident resulted in Right Lower Leg Fracture.
S24CNA stated she assisted another CNA with getting Resident #2 up and into his chair. S24CNA stood on the left side and the other CNA was on the right of him. They slid him in his chair. Resident #2 did state that he felt his leg pop and complained of pain afterwards. We placed his legs on the leg rest. We left his room. We did not use a lift because the battery was dead and because Resident #2 stated that he had to be up at that time to eat breakfast before dialysis.
S15CNA stated she had asked another CNA to help her get Resident #2 up for dialysis. We sat him up on the side of his bed. With the other CNA on one side and S15CNA on the other side, we proceeded to lift him up to put him in the chair. We didn't use the lift because it was being used on somebody else.
On 03/23/2023 at 12:30 p.m. a phone interview was conducted with Resident #2. He stated he is paraplegic but has sensation to his lower extremities. He stated on 02/06/2023 he was transferred from his bed to his wheelchair by 2 CNAs, but he was unable to recall their names. He stated the CNAs didn't use the mechanical lift for the transfer. Resident #2 stated he heard a pop in his right knee during this transfer. He stated he immediately reported hearing a pop in his right knee told the 2 CNAs that transferred him. He stated they left his room. He stated he then reported the incident to S10LPN.
On 03/15/2023 at 3:24 p.m. an interview was conducted with S15CNA. She stated Resident #2 required a mechanical lift with 2 person assistance for all transfers. She stated on 02/06/2023 she and S24CNA transferred Resident #2 from his bed to his wheelchair without using the mechanical lift. She confirmed she should not have transferred Resident #2 without the mechanical lift.
On 03/20/2023 at 1:18 p.m., an interview was conducted with S10LPN. She stated on 02/06/2023, Resident #2 notified her of right knee pain after S15CNA and S24CNA transferred Resident #2 from bed to wheelchair. She stated Resident #2 required 2 staff and mechanical lift for transfers. She stated the CNAs should have used the mechanical lift but they had not.
On 03/20/2023 at 12:55 p.m., an interview was conducted with S9LPN. She stated upon arrival to work on 02/06/2023 just before 7:00 a.m., Resident #2 was notifying S10LPN of right knee pain. She heard Resident #2 state that the right knee pain started immediately following being transferred from his bed to his wheelchair by 2 CNAs and he heard a pop. She stated S10LPN received an MD order to send Resident #2 to ER after dialysis. She stated Resident #2 was sent to the ER via ambulance, and the resident did not return on her shift.
On 03/20/2023 at 11:37 a.m., an interview was conducted with S5MD. He stated on the morning of 02/06/2023, a nurse from this facility notified him of Resident #2's complaint right knee pain. He stated he gave orders to send Resident #2 to the ER for evaluation and treatment after his dialysis appointment. He stated Resident #2 sustained a right tibial plateau fracture with transfer.
On 03/20/2023 at 10:29 a.m., an interview was conducted with S8UM. She stated the incident involving Resident #2 from 02/06/2023 was discussed in the facility's morning meeting on 02/07/2023.
On 03/22/2023 at 11:30 a.m., an interview was conducted with S2DON. He confirmed knowledge of the incident involving Resident #2 during a transfer on 02/06/2023. He confirmed this incident was not reported within the 2 hour time frame.
On 03/22/2023 at 12:20 p.m. an interview was conducted with S1ADM. He confirmed that the state report was not entered for Resident #1 within the 2 hour deadline.
Resident #4
Resident #4 was admitted to the facility on [DATE] with diagnoses of Heart Failure, Dysphagia, Contracture of Muscle-Right Hand, Muscle Weakness, and Major Depressive Disorder.
Review of the MDS with an ARD of 12/22/2022 revealed the residents BIMS was 8 which indicated Resident #4 was moderately cognitively impaired.
Review of the facility's incident report dated 03/01/2023 revealed the following, in part:
Resident #4 stated an incident occurred, but was not sure what the person looked like or when the incident occurred. When asked, Resident #4 put her hands up in a boxing pose. S2DON asked Resident #4 if it was a dream she had, and she could not remember, then said later that it was not. S2DON asked Resident #4 to point to where she was hit and she pointed to her face.
On 03/14/2023 at 1:00 p.m., an interview was conducted with S2DON. He stated he thought the previous Administrator filed the report and investigated the allegation. He verified if state office didn't have a copy of the report, then it was not put in. He verified a report should have been filed with the State Agency within 2 hours of the allegation of abuse.
On 03/15/2023 at 8:40 a.m., an interview was conducted with S4SSD. She said Resident #4's 2 nieces were visiting and Resident #4 told them she was hit in the face. She said the allegation was reported to S2DON. She said their process is to report it to the DON and Administrator and the Administrator was supposed to conduct the investigation and report to the State Agency within 2 hours.
On 03/15/2023 at 11:00 a.m., a telephone interview was conducted with Resident #4's niece #1. She said when her and her sister visited, the first thing her aunt told her was she got in a fight with one of the aides and she put her fist up. She said Resident #4 told her she was hit in the head. She said she reported it to S4SSD.
On 03/15/2023 at 11:25 a.m., a telephone interview was conducted with Resident #4's niece #2. She said on 03/01/2023 when she and her sister walked into the room, the first thing her aunt told her was she got into a fight. They thought it was a verbal disagreement but she kept repeating herself and she said she slapped her and she put her fist up and said, she went at me. She said they reported it to S4SSD.
On 03/15/2023 at 1:30 p.m., an interview was conducted with S29LPN. She said Resident #4 told her two nieces she had been in a fight. She said she and S4SSD spoke to Resident #4. She said Resident #4 told them she had been in a fight. She said they didn't question staff about the incident because the resident was confused. She said the allegation of abuse was reported to S2DON.
On 03/16/2023 at 12:00 p.m., an interview was conducted with S1ADM. He confirmed a state report was not entered for Resident #1, Resident #2, or Resident #4 within the 2 hour deadline and it 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
Investigate Abuse
(Tag F0610)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews, the facility failed to have evidence that all alleged violations of abuse or neglect, in...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews, the facility failed to have evidence that all alleged violations of abuse or neglect, including injuries of unknown source, were thoroughly investigated for 2 (#1, #4) of 5 (#1, #2, #4, #6, and #7) residents reviewed for abuse.
Findings:
Review of facility's policy titled Abuse, Neglect, Exploitation and Misappropriation revealed, in part, the following:
Definitions:
Abuse:
Abuse is the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish. It includes verbal abuse, sexual abuse, physical abuse, and mental abuse including abuse facilitated or enabled through the use of technology.
*Physical Abuse includes but is not limited to hitting, slapping, punching, biting kicking, or corporal punishment.
*Sexual Abuse is non-consensual sexual contact of any type with a resident. Sexual abuse includes but is not limited to:
1. Unwanted intimate touching of any kind especially of breast or perineal area.
Neglect:
Neglect is the failure of the center, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish or emotional distress. Examples include but are not limited to:
2. Failure to take precautionary measures to protect the health and safety of the resident.
Procedure:
5. Investigation- The Abuse Coordinator or his/her designee shall investigate all reports or allegations of abuse, neglect, misappropriation and exploitation. A social service representative may be offered in the role of resident advocate during any questioning of or interviewing of residents. Investigations will be accomplished in the following manner.
-Preliminary Investigation:
Immediately upon an allegation of abuse or neglect, the suspect shall be segregated from the residents pending the investigation of the resident allegation.
The nurse or Director of Nursing/designee shall perform and document a thorough nursing evaluation, and notify the attending physician.
An incident report shall be filed by the individual in charge who receives the report in conjunction with the person who reported the abuse. This report shall be filed as soon as possible in order to provide the most accurate information in a timely fashion, and submitted to the Abuse Coordinator.
-Investigation:
The Abuse Coordinator and/or Director of Nursing shall take statements from the victim, the suspect(s) and all possible witnesses including all other employees in the vicinity of the alleged abuse. He/She shall also secure all physical evidence. Upon completion of the investigation, a detailed report shall be prepared.
6. Protection
*Any suspect(s) who is an employee or contract service provider, once he/she has (have) been identified, will be suspended pending the investigation.
*The resident will be evaluated for any signs of injury, including a physical exam and/or psychosocial assessment, as appropriate.
*Increased supervision of the alleged victim and residents.
*Room or staffing changes, if necessary, to protect the resident(s) from the alleged perpetrator.
*Protection from retaliation.
*Provide the resident with emotional support and counseling during and after the investigation, if needed.
Resident #1
Resident #1 was admitted to the facility on [DATE] with diagnoses, which included Chronic Obstructive Pulmonary Disease, Dysphagia, Muscle Weakness, and Major Depressive Disorder.
Review of the quarterly MDS with an ARD of 02/26/2023 revealed Resident #1 had a BIMS of 15, which indicated she was cognitively intact.
A review of the facility's Incident Report dated 02/05/2023 at 6:22 p.m. revealed the following, in part:
An incident of alleged sexual abuse was reported to staff by Resident #1. She reported to a nurse that Resident #6 touched her breast as he passed by her in the hallway. Resident #1 made an official statement. Resident #1 came to the nurse's station and stated, Resident #6 was being pushed down the hall and he passed me and grabbed my boob. Previous administrator, S2DON, and S5MD were notified. A local mental health facility was contacted to send Resident #6, no bed available. Awaiting further instructions for placement. Resident #1 was AAOx4. Resident #6 was not oriented to situation. No witnesses found.
The facility was unable to provide evidence that a thorough investigation was conducted/completed for the incident involving Resident #1 and Resident #6.
On 03/14/2023 at 10:42 a.m., an interview was conducted with Resident #1. She recalled an incident from last month where Resident #6 touched her breast. She stated she reported the incident to S11LPN immediately after the incident.
On 03/14/2023 at 2:50 p.m. an interview was conducted with S11LPN. She stated on 02/05/2023, Resident #1 reported Resident #6 touched her breast as they passed each other in the hall. She stated she reported it to S8UM.
On 03/16/2023 at 9:30 a.m., a telephone interview was conducted with S29LPN. She said Resident #1 came up to the nursing station and told her Resident #6 had grabbed her on her boob. She said she brought Resident #1 to the nurse on the hall and told her what happened. She said she called the supervisor and made them aware.
On 03/16/2023 at 10:25 a.m., an interview was conducted with S2DON. He confirmed he was unable to provide evidence that a thorough investigation was conducted/completed when an allegation of sexual abuse was made by Resident #1 on 02/05/2023. He wasn't aware if any staff or residents were interviewed related to this incident.
On 03/16/2023 at 12:00 p.m., an interview was conducted with S1ADM. He confirmed the designated Abuse Coordinator was the previous administrator at the time of this incident. He wasn't aware if any staff or other residents were interviewed. He confirmed he was unable to provide evidence that a thorough investigation was conducted/completed when Resident #1 alleged Resident #6 touched her breast on 02/05/2023.
Resident #4
Resident #4 was admitted to the facility on [DATE] with diagnoses which included Heart Failure, Dysphagia, Contracture of Muscle-Right Hand, Muscle Weakness, and Major Depressive Disorder.
Review of the Quarterly MDS with an ARD of 12/22/2022 revealed Resident #4 had a BIMS of 08 which indicated she had moderate cognitive impairment.
Review of the facility's Incident Reports dated 03/01/2023 revealed the following, in part:
Resident #4 reported an incident. When asked what happened the resident put her hands up in a boxing pose and pointed to where she was hit on her face. Resident #4 could not recall who did it or when it happened.
There were no records revealing an investigation was conducted when Resident #4 reported an allegation of physical abuse on 03/01/2023.
On 03/15/2023 at 8:40 a.m., an interview was conducted with S4SSD. She said Resident #4's nieces stated Resident #4 couldn't remember what happened.
On 03/15/2023 at 11:00 a.m., a telephone interview was conducted with Resident's #4's niece. She said when she and her sister visited, the first thing Resident #4 told her was she got in a fight with one of the aides and Resident #4 put up her fist. Resident #4's niece stated when she asked Resident #4 if she was hit, Resident #4 pointed to her head. Resident #4's niece said they reported it to the social worker.
On 03/16/2023 at 12:00 p.m., an interview was conducted with S1ADM. He confirmed the allegations of physical abuse for Resident #4 was not investigated thoroughly 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
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 interviews and record review the facility failed to develop and implement a comprehensive person-centered care plan for...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review the facility failed to develop and implement a comprehensive person-centered care plan for 1 (#2) of 7 (#1, #2, #3, #4, #5, #6 and #7) sampled residents reviewed for care plans. The facility failed to ensure Resident #2's care plan was updated when he returned from the hospital with a knee immobilizer in place.
Findings:
Review of the medical records for Resident #2 revealed he was a year [AGE] year old male admitted to the facility on [DATE] with diagnoses which included Paraplegia, Fracture of Right Tibia, End Stage Renal Disease (Hemodialysis Dependent), Peripheral Vascular Disease, and Type 2 Diabetes Mellitus.
A review of the Significant Change MDS with an ARD of 02/13/2023 revealed Resident #2 had a BIMS of 15 which indicated he was cognitively intact.
A review of the emergency room After Visit Summary dated 02/06/2023 revealed the following, in part:
Instructions:
You have a tibial plateau fracture. The knee immobilizer has been supplied. You need to wear this at all times, except when bathing. You cannot put weight on the leg.
Review of the current Care Plan for Resident #2 revealed no documentation his care plan was updated when he returned from the emergency room with a knee immobilizer in place.
On 03/20/2023 at 10:29 a.m., an interview was conducted with S8UM. She stated the floor nurse caring for Resident #2 was responsible for entering/updating physician's orders by using the After Visit Summary instructions. She confirmed there were no orders entered for Resident #2's knee immobilizer. She confirmed Resident #2 wasn't care planned for knee immobilizer.
On 03/20/2023 at 12: 55 p.m., an interview was conducted with S9LPN. She stated the floor nurse caring for Resident #2 upon his return from the ER was responsible for entering new/updated orders using the After Visit Summary or calling the provider. She stated she would have expected Resident #2 to have orders related to the knee immobilizer. She stated on 02/07/2023 when she realized there were no orders in place for the knee immobilizer, she should have called the provider to get orders related to the knee immobilizer.
On 03/20/2023 at 1:18 p.m., an interview was conducted with S10LPN. She did recall Resident #2 returning from the ER during her night shift on 02/06/2023 diagnosed with a right tibial fracture and wearing a knee brace.
On 03/20/2023 at 1:38 p.m. an interview was conducted with S6PTA. She stated therapy taught Resident #2 and nursing staff how to use the knee immobilizer.
On 03/20/2023 at 2:16 p.m., an interview was conducted with S7MDS. She stated she was responsible for MDS assessments/updates and care planning. She stated care plans were updated daily after receiving/reviewing newly entered physician's orders and at the time of each MDS assessment. She stated when a resident returned from an emergency room visit, the facility's After Visit Summary or Discharge Summary should be used to update and/or enter new physician's orders. She stated the floor nurse caring for the resident should enter new physician's orders into the electronic medical record. She confirmed ER orders were not entered for this resident; therefore his care plan wasn't updated to include the knee immobilizer.
On 03/22/2023 at 11:30 a.m., an interview was conducted with S2DON. He confirmed it was the floor nurse's responsibility to enter updated/new orders from the ER. He would expect the floor nurse to use the After Visit Summary for new/updated orders. He confirmed Resident #2 didn't have orders entered for the knee immobilizer and wasn't care planned for a knee immobilizer.
On 03/22/2023 at 12:20 p.m. an interview was conducted with S1ADM. He stated the floor nurse receiving the resident was responsible for entering/updating MD orders when a resident returned from the ER. The floor nurse should use the After Visit Summary for new/updated orders or call the provider for clarification. He, also, confirmed Resident #2 didn't have orders entered for a knee immobilizer and wasn't care planned for a knee immobilizer.
Feb 2023
8 deficiencies
3 IJ (3 facility-wide)
CRITICAL
(L)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Immediate Jeopardy (IJ) - the most serious Medicare violation
Administration
(Tag F0835)
Someone could have died · This affected most or all residents
⚠️ Facility-wide issue
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record reviews, the facility failed to ensure it was administered in a manner that enabled...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record reviews, the facility failed to ensure it was administered in a manner that enabled it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident by failing to ensure an effective system was implemented for preventing and controlling COVID-19 infections. The facility failed to ensure:
1.
A staff member (S5CNA) reported signs and symptoms of COVID-19 prior to providing direct care to the residents residing on Hall C;
2.
A staff member (S5CNA) did not care for 3 (#R14, #R15, and #R16) non-positive COVID-19 residents after she tested positive on 02/08/2023 at 11:06 p.m.;
3.
COVID-19 testing was being performed and documented on all staff during an outbreak;
4.
S10KDM was trained to perform COVID-19 testing accurately on self and kitchen staff (S17RD, S8KC, S7KA);
5.
Nursing and kitchen staff (S6KA, S7KA, S8KC, S9CNA, S20LPN, S28DOM, S29ADOM, S30CNA, S31LPN, and S34LPN) wore a face mask during a COVID-19 outbreak;
6.
Visitors were notified of active COVID-19 infections, provided a face mask, and educated on hand hygiene and social distancing prior to entering the facility; and
7.
Outpatient facilities and transportation providers were notified of a COVID-19 outbreak in the facility.
This deficient practice resulted in an Immediate Jeopardy situation with the likelihood of severe injury and/or death to facility residents beginning on 02/08/2023 at 6:59 p.m., when S5CNA entered the facility with signs and symptoms of COVID-19 and began providing direct patient care to non-COVID-19 positive residents on Hall C. On 02/08/2023 at 11:06 p.m., S5CNA tested positive for COVID-19 and continued to provide direct care for 3 non-COVID-19 positive residents (#R14, #R15, and #R16). On 02/08/2023 observations were made of facility staff failing to wear masks while providing resident care and handling resident food. Staff also failed to educate visitors on the facility's COVID-19 outbreak, signs and symptoms of COVID -19, provide masks, or instruct on infection control measures prior to the visitors entering the facility. Interviews with staff revealed staff and visitors had not been screened for signs and symptoms of COVID-19, visitors were not notified of the facility's COVID-19 outbreak and provided education and a face mask, and all staff that worked in the facility were not tested for COVID-19 since the outbreak began on 02/01/2023. Due to the facility failing to implement infection control measures, Residents #R6 and #R7 tested positive for COVID-19 on 02/08/2023 and Resident #R17 tested positive for COVID-19 on 02/09/2023. As of 02/09/2023, there were 102 residents residing in the facility with 10 active resident COVID-19 cases.
S1ADM was notified of the immediate jeopardy on 02/09/2023 at 7:18 p.m.
The facility presented the following Plan of Removal on 02/10/2023 at 4:20 p.m.:
Plan of Removal:
Brief Summary of Events:
On 2/09/23 at 7:18 PM the State Agency (SA) notified the Executive Director (ED) of an immediate jeopardy related to F-835 Administration. The facility administration failed to ensure an effective system was in place to prevent and control the spread of COVID-19 infections in the facility since an outbreak dated 02/01/2023. An immediate jeopardy (IJ) template was provided to the ED by the SA.
Immediate Action started on 02/09/2023 at 7:30 p.m.:
-
Signage was posted at both entrances on Visitor Infection Control and Stop Notification to notify facility of any symptoms of COVID-19 or COVID-19 Positive results on 02/09/2023. QI Monitoring Tool will be conducted by the ED/designee to ensure signage is posted at both entrances on Visitor Infection Control and Stop Notification to notify facility of any symptoms of COVID -19 or COVID-19 Positive results for three times per week for four weeks and then monthly for two months.
-
Employee screening log placed at front entrance for staff to begin screening prior to work and was initiated on 02/10/2023 using the Employee Screening form and will continue until facility is no longer in COVID-19 outbreak. QI Monitoring Tool will be conducted by the ED/designee to ensure employee screening logs placed at front entrance for staff to begin screening prior to work for three times per week for four weeks and then monthly for two months.
-
Employee testing log implemented on 02/10/2023. Infection Control Preventionist will maintain logs to ensure appropriate employees are tested during COVID-19 outbreak. QI monitoring tool will be conducted by DON or designee to ensure appropriate employees are tested two times per week for four weeks and then monthly for two months.
-
COVID-19 testing competency check-offs were initiated on 02/10/2023 by Regional Director of Clinical Services 2 (RDCS2). QI monitoring tool will be conducted by DON or designee to ensure competency in COVID-19 testing two times per week for four weeks, then weekly for 1 week, and then monthly for two months.
-
Executive Director education and competency was conducted by Regional [NAME] President of Operations on 02/10/2023 on the aforementioned education.
Resident Specific Action:
-
Resident #R6, #R7 and #R17 room assignments were reassigned to accommodate cohorting positive COVID-19 with positive COVID-19 and exposed negative COVID-19 with exposed negative COVID-19.
QAPI:
-
On 02/09/23 at 7:30PM the Quality Assurance Performance Improvement (QAPI) Committee met to review the F-835 Infection Control IJ template and conduct a Root Cause Analysis (RCA) and review policy and procedures for changes. Attendees were the Executive Director (ED), Interim Director of Nursing (DON), Activities Director (AD), Housekeeping Supervisor (HIC), Regional Director of Clinical Services (RDCS), Director of Therapy (DOR), Assistant Director of Nursing (ADON), Business Office Manager (BOM), and Human Resources Director (HRD). The Medical Director (MD) was notified by phone.
-
The RCA determined the facility administration failed to ensure an effective system was in place to prevent and control the spread of COVID-19 infections.
-
The facility failed to alert visitors of active COVID-19 cases, provide education to visitors regarding infection control related to COVID-19, and provide face mask while visiting in the facility.
-
The facility failed to ensure staff were screened for COVID-19 prior to working in the facility.
-
The facility failed to maintain tracking and documentation of COVID-19 testing.
-
The facility failed to ensure staff were knowledgeable and trained to accurately perform point of care COVID-19 testing.
Education:
- Current Employees including agency and contract, will receive training upon hire and prior to working with emphasis on the following:
- Visitors will be alerted to active COVID -19 infections, provided education, screened and provided face mask prior to entering the facility. Signage will be provided at entrance to include Infection Control information regarding COVID-19. Education and competency initiated by Regional Director of Clinical Services 2 (RDCS2) on 02/10/2023. Education and competency will be completed by 02/13/2023. Current staff will be screened prior to working within the facility. Education and competency initiated by Regional Director of Clinical Services 2 (RDCS2) on 02/10/2023. Education and competency will be completed by 02/13/2023.
- Tracking and documentation of COVID-19 will be maintained by the infection Control Preventionist. Education and competency initiated by Regional Director of Clinical Services 2 (RDCS2) on 02/10/2023. Education and competency will be completed by 02/13/2023.
- Current staff will be knowledgeable and trained to accurately perform point of care COVID-19 testing. Education and competency initiated by Regional Director of Clinical Services 2 (RDCS2) on 02/10/2023. Education and competency will be completed by 02/13/2023.
- No current employee or new hire will work without the aforementioned education.
- A reconciliation will be completed on education records and current employee list to ensure the aforementioned education is completed by 02/15/2023.
The Immediate Jeopardy was removed on 02/10/2023 at 4:20 p.m. when the provider presented an acceptable plan of removal. Through observations, interviews and record review, the surveyors confirmed the above components of the plan of removal had been initiated and/or implemented prior to exit.
This deficient practice continued at more than minimal harm for the remaining 92 non-positive COVID-19 residents residing in the facility that were at risk for contracting COVID-19.
Findings:
Cross Reference F-880
Cross Reference F-882
An interview was conducted with S2IDON on 02/08/2023 at 9:30 a.m. She stated she was currently in charge of the Infection Control Program and she was the facility's Infection Preventionist. She stated her and S27DON were responsible for tracking infections, identifying patterns, monitoring infection practices, and implementing practices to improve quality. She stated she was responsible for implementation of COVID-19 infection control practices. She stated the facility outbreak dated 02/01/2023 began from an employee, S11CNA, who tested positive for COVID-19. She stated she was unsure what the current COVID-19 community transmission rate was. She stated there was a COVID-19 rapid testing document the nurses were supposed to fill out for staff and residents after they were tested for COVID-19, but she did not know how the COVID-19 testing was being tracked. She confirmed all facility staff should have been tested last week. She confirmed the facility provided all COVID-19 tests performed after the start of the outbreak on 02/01/2023 and there were staff members that had been working after the outbreak without a COVID-19 test result. She stated all staff should have been wearing a N95 mask covering their mouth and nose in resident care areas, including during the provision of care and while preparing food for the residents. She stated it was never acceptable for the staff to provide care for a resident unmasked.
An interview was conducted on 02/09/2023 at 12:45 p.m. with S2IDON, S3ADON and S4CN. S2IDON stated pre-shift screening on employees was not required and had not been implemented since the start of the outbreak on 02/01/2023. She stated she depended on staff to report if they were experiencing symptoms. She stated she expected an employee with any kind of illness to report that to their supervisor before they reported to work. She stated she would have expected the staff to be educated on reporting symptoms of COVID-19 prior to their shift. She stated on 02/08/2023, after S5CNA tested positive for COVID-19, she was allowed to stay the remainder of her shift. S2IDON confirmed S5CNA should not have been allowed to care for any non-COVID-19 positive residents. S3ADON stated she would have expected the positive COVID-19 employee to separate from the negative COVID-19 employees. S4CN stated S5CNA should not have been allowed to work in the facility after testing positive for COVID-19. S2IDON stated there was no documentation COVID-19 testing was being conducted on all facility and contract staff weekly. She stated the system for tracking COVID-19 testing of staff was to keep the COVID-19 Rapid Test Result sheet for each staff. She confirmed she could not find all COVID-19 test results for all staff. She stated there was not a log or documentation kept by administration to ensure each staff member was tested for COVID-19. She confirmed it was the responsibility of the facility to ensure COVID-19 testing of facility and contract staff was being completed. S2IDON confirmed visitors were not being screened related to COVID-19. She stated she expected the staff to provide each visitor entering the facility with a mask. She stated she would not expect the staff to notify a visitor of an outbreak of COVID-19 in the facility. She stated she would not provide a visitor with any type of education regarding infection control practices if the resident they were visiting was not on isolation. S2IDON and S4CN confirmed any outside facility, day program, and/or transportation company utilized by the facility should have been immediately notified of the facility's COVID-19 Outbreak Status. S2IDON confirmed she did not know if there was a process in place on how the facility handled a COVID-19 outbreak. S2IDON stated any staff could perform COVID-19 testing as long as they had been trained. S2IDON stated she was unsure if staff were trained to perform COVID-19 testing. S2IDON stated the facility should have retained any training for the COVID-19 testing. S2IDON was unable to answer what the contract staff were trained to perform. S2IDON confirmed she had not performed any training or skills check-offs regarding COVID-19 testing or self-swabbing. S2IDON also confirmed she was not aware of and could not put her hands on any documentation to indicate facility or contracted staff had been trained or evaluated via skill check-off for COVID-19 self-swabbing. S2IDON then confirmed she expected all facility and contract staff to have been trained followed by return demonstration to ensure an adequate sample was obtained. S3ADON confirmed she had not performed any training or skills check-offs regarding COVID-19 testing or self-swabbing. S3ADON also confirmed she was not aware of and could not put her hands on any documentation to indicate facility or contracted staff had been trained or evaluated via skill check-off for COVID-19 self-swabbing. S3ADON confirmed any staff member performing COVID-19 testing should have been trained. S4CN confirmed you should wait for 15 minutes after performing a COVID-19 rapid swab and document the result. S4CN confirmed it was not best practice to allow staff to self-swab for COVID-19 testing. S2CN confirmed the test should have been performed by a trained medical professional and not dietary/kitchen staff. S4CN stated if an adequate specimen was not obtained and if the testing procedure was not followed according to manufacturer instructions, the test results could have been inaccurate. S4CN stated when performing the [NAME] BinaxNOW (Trademark) COVID-19 Ag CARD test, the results required a minimum of 15 minutes and maximum of 30 minutes to process after the application of the antigen drops to the swab. Both S2IDON and S3ADON verbalized agreement with S4CN's two above statements.
A telephone interview was conducted with S27DON on 02/08/2023 at 11:43 a.m. He stated he was responsible for keeping track of staff COVID-19 testing for the week of 02/01/2023 when the COVID-19 outbreak began. He stated he thought all staff had been tested but did not have documentation they had been. He stated he did not track COVID-19 testing for contract staff, which included therapy, housekeeping, laundry, and dietary staff. He stated he notified each department head that their staff needed to be tested for COVID-19 weekly, but did not follow up to ensure the staff were actually being tested. He stated it was the department head's responsibility to ensure each of their staff was being tested weekly.
An interview was conducted with S27DON on 02/14/2023 at 12:45 p.m. He confirmed all outside facilities, day programs and/or transportation companies utilized by the facility should have been immediately notified of the COVID-19 Outbreak Status within the facility.
An interview was conducted with S1ADM on 02/09/2023 at 11:18 a.m. He confirmed he was notified of S5CNA testing positive for COVID-19 around 11:00 p.m. on 02/08/2023. He stated the decision was made to assign her to the rooms on Hall C that had COVID-19 positive residents in them. He confirmed there were 3 rooms on Hall C that contained a COVID-19 positive and a COVID-19 negative resident. He stated it was not acceptable for S5CNA, a COVID-19 positive employee, to provide direct care to any non-COVID-19 positive residents.
An interview was conducted on 02/09/2023 at 1:35 p.m. with S1ADM. He confirmed the current COVID-19 outbreak began on 02/01/2023. He stated he was not sure if he expected staff to screen prior to their shift during a COVID-19 outbreak. He stated if a staff member was in the facility and began having symptoms of COVID-19, he would have expected them be tested and leave the facility immediately. He stated he was not notified S5CNA was symptomatic of COVID-19. He stated the current system the facility had to ensure COVID-19 testing was being completed on all staff was not working. He stated visitors should have been asked to wear a mask. He stated there should have been signage posted to make visitors aware of the facility's COVID-19 outbreak and there was not. He stated outpatient facilities should have been notified of the facility's COVID-19 outbreak. He confirmed he had not reviewed or verified the manufacturer's guidelines and/or instructions to ensure the facility was performing the COVID-19 testing procedure appropriately, to verify if it allowed for self-swabbing or to verify if this type of test could be performed by an unqualified or untrained person. He stated he assumed since the company made a similar test for at home use, it would have been fine for anyone to self-swab. He stated staff should have been trained on rapid swabbing for COVID-19 used in the facility. He confirmed the processing time of the [NAME] BinaxNOW (Trademark) COVID-19 Ag CARD test was a minimum of 15 minutes and max of 30 minutes from the time the nasal swabbing was performed. He confirmed a test that was performed incorrectly could yield an inaccurate result. He stated he expected staff to let the rapid COVID-19 test sit for 15 minutes prior to reading a result. He stated he expected masking at all times in the facility. He stated the administrative staff had been inconsistent. He stated training had not been completed on his new administrative staff. He stated the retention of staff should not have affected the quality of care for the residents or the facility's Infection Program
An interview was conducted with S18MD on 02/09/2023 at 3:50 p.m. He confirmed he was the Medical Director for the facility. He confirmed staff should have worn a face mask covering their mouth and nose at all times when interacting with residents or during the preparation of food. He confirmed a COVID-19 positive staff member should not have been allowed to continue their shift and care for non-COVID-19 positive residents. He stated he expected the facility to notify visitors of the COVID-19 outbreak status. He confirmed the facility should have notified outside facilities and outside transportation companies of the COVID-19 outbreak status in the facility. He confirmed staff should have been trained prior to performing COVID-19 testing. He confirmed if COVID-19 testing was performed incorrectly it could yield inaccurate results.
CRITICAL
(L)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Immediate Jeopardy (IJ) - the most serious Medicare violation
Infection Control
(Tag F0880)
Someone could have died · This affected most or all residents
⚠️ Facility-wide issue
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to ensure an effective infection control and preventio...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to ensure an effective infection control and prevention program was implemented for preventing and controlling COVID-19 infections for 92 non-positive residents who resided in the facility during a COVID-19 outbreak. The facility failed to ensure:
1.
A staff member (S5CNA) reported signs and symptoms of COVID-19 prior to providing direct care to the residents residing on Hall C;
2.
A staff member (S5CNA) did not care for 3 (#R14, #R15, and #R16) non-positive COVID-19 residents after she tested positive on 02/08/2023 at 11:06 p.m.;
3.
COVID-19 testing was being performed and documented on all staff during an outbreak;
4.
S10KDM was trained to perform COVID-19 testing accurately on self and kitchen staff (S17RD, S8KC, S7KA);
5.
Nursing and kitchen staff (S6KA, S7KA, S8KC, S9CNA, S20LPN, S28DOM, S29ADOM, S30CNA, S31LPN, and S34LPN) wore a face mask during a COVID-19 outbreak;
6.
Visitors were notified of active COVID-19 infections, provided a face mask, and educated on hand hygiene and social distancing prior to entering the facility; and
7.
Outpatient facilities and transportation providers were notified of a COVID-19 outbreak in the facility.
This deficient practice resulted in an Immediate Jeopardy situation with the likelihood of severe injury and/or death to facility residents beginning on 02/08/2023 at 6:59 p.m., when S5CNA entered the facility with signs and symptoms of COVID-19 and began providing direct patient care to non-COVID-19 positive residents on Hall C. On 02/08/2023 at 11:06 p.m., S5CNA tested positive for COVID-19 and continued to provide direct care for 3 non-COVID-19 positive residents (#R14, #R15, and #R16). On 02/08/2023 observations were made of facility staff failing to wear masks while providing resident care and handling resident food. Staff also failed to educate visitors on the facility's COVID-19 outbreak, signs and symptoms of COVID -19, provide masks, or instruct on infection control measures prior to the visitors entering the facility. Interviews with staff revealed staff and visitors had not been screened for signs and symptoms of COVID-19, visitors were not notified of the facility's COVID-19 outbreak and provided education and a face mask, and all staff that worked in the facility were not tested for COVID-19 since the outbreak began on 02/01/2023. Due to the facility failing to implement infection control measures, Residents #R6 and #R7 tested positive for COVID-19 on 02/08/2023 and Resident #R17 tested positive for COVID-19 on 02/09/2023. As of 02/09/2023, there were 102 residents residing in the facility with 10 active resident COVID-19 cases.
S1ADM was notified of the immediate jeopardy on 02/09/2023 at 7:18 p.m.
The facility presented the following Plan of Removal on 02/10/2023 at 4:20 p.m.:
Brief Summary of Events:
On 02/09/2023 at 7:18 p.m., the State Agency (SA) notified the Executive Director (ED) of an immediate jeopardy related to F-880 Infection Control. The facility failed to implement a system for preventing and controlling COVID -19 infections within the facility after a confirmed outbreak on 02/01/2023. An immediate jeopardy (IJ) template was provided to the ED by the SA.
Immediate Action started on 02/09/2023 at 7:30 p.m.
- Signage was posted at both entrances on Visitor Infection Control and Stop Notification to notify facility of any symptoms of COVID-19 or COVID-19 Positive results on 02/09/2023. QI Monitoring Tool will be conducted by the ED/designee to ensure signage is posted at both entrances on Visitor Infection Control and Stop Notification to notify facility of any symptoms of COVID-19 or COVID-19 Positive results for three times per week for four weeks and then monthly for two months.
- Visitor screening placed at entrance for visitor sign in area on 02/10/2023 using the Visitor/Vendor Screening form and will continue until facility is no longer in COVID-19 outbreak. QI Monitoring Tool will be conducted by the ED/designee to ensure visitor screening is placed at the entrance sign in area for three times per week for four weeks and then monthly for two months.
- Quality rounds were performed on 02/09/2023 to ensure nursing staff donned face mask while providing direct patient care and kitchen staff donned face mask while prepping/serving meals during COVID-19 outbreak. QI Monitoring Tool will be conducted by the ED/designee to ensure quality rounds are performed to ensure nursing staff donned face mask while providing direct patient care and kitchen staff donned face mask while prepping/serving meals during COVID-19 outbreak for three times per week for four weeks and then monthly for two months.
- Facility notified outpatient facilities and outpatient transportation providers on 02/09/2023 and will continue notifying weekly of a current COVID-19 outbreak in the facility and will continue until facility is no longer in COVID-19 outbreak. QI Monitoring Tool will be conducted by the ED/designee to notify outpatient facilities and outpatient transportation providers of a current COVID-19 outbreak in the facility weekly for four weeks and then monthly for two months.
- Employee screening log placed at front entrance for staff to begin screening prior to work and initiated on 02/10/2023 using the Employee Screening Form and will continue until facility is no longer in COVID-19 outbreak. QI Monitoring Tool will be conducted by the ED/designee to ensure employee screening logs placed at front entrance for staff to begin screening prior to work for three times per week for four weeks and then monthly for two months.
- S5CNA was relieved of duty on 02/09/2023 for a minimum of 10 days related to confirmed positive.
Resident Specific Action:
Resident #R6, Resident #R7 and Resident #R17 room assignments were reassigned to accommodate cohorting positive COVID-19 with positive COVID-19 and exposed negative COVID-19 with exposed negative COVID-19.
QAPI:
- On 02/09/2023 at 7:30 p.m. the Quality Assurance Performance Improvement (QAPI) Committee met to review the F-880 Infection Control IJ template and conduct a Root Cause Analysis (RCA) and review policy and procedures for changes. Attendees were the Executive Director (ED), Interim Director of Nursing (IDON), Activities Director (AD), Housekeeping Supervisor (HKS), Regional Director of Clinical Services (RDCS), Director of Therapy (DOR), Assistant Director of Nursing (ADON), Business Office Manager (BOM), and Human Resources Director (HRD). The Medical Director (MD) was notified by phone.
- The RCA determined the facility failed to implement infection control measures for Resident R6 and Resident R7 who tested positive for COVID-19 on 02/08/2023 and Resident R17 who tested positive for COVID-19 on 02/09/2023.
- The facility failed to alert visitors of active COVID-19 cases, provide education to visitor regarding infection control related to COVID-19, and provide face mask while visiting in the facility.
- Direct care nursing staff were not donned in masks while providing direct care.
- Kitchen staff were not donned in face mask while prepping and serving meals.
- Outpatient facilities and outpatient transportation were not notified of a COVID-19 outbreak in the facility.
- A Certified Nursing Assistant (CNA) who became symptomatic during a shift and tested positive for COVID-19 continued to provide care to COVID-19 positive and COVID-19 negative residents.
Education:
Current Employees including agency and contract, will receive training upon hire and prior to working with emphasis on the following:
- Visitors will be alerted to active COVID-19 infections, provided education, screening and provided face mask prior to entering the facility. Signage will be provided at entrance to include Infection Control information regarding COVID-19. Education initiated by Regional Director of Clinical Services 2 (RDCS 2) on 0 2/10/2023 don face mask when prepping and serving meals and to be completed by the receipt date of statement of deficiencies.
- Nursing staff will don face mask while providing direct resident care and kitchen staff will don face mask when prepping and serving meals. Education initiated by Interim Director of Nurses (IDON) on 02/10/2023 with nursing staff will don face mask while providing direct resident care and kitchen staff will don face mask when prepping and serving meals and to be completed by the receipt date of statement of deficiencies.
- Facility will notify outpatient facilities and outpatient transportation providers of a COVID-19 outbreak in facility. Education initiated by Regional Director of Clinical Services 1 (RDCS 1) on 02/09/2023 with Interdisciplinary Team (IDT) and to be completed by the receipt date of statement of deficiencies.
- Staff who test positive for COVID-19 with signs and symptoms of COVID-19 will self-report to their immediate supervisor, be relieved of duties, and exit the facility. Education initiated by IDON on 02/10/2023 with current staff to ensure staff who test positive for COVID-19 with signs and symptoms of COVID-19 will self-report to their immediate supervisor, be relieved of duties, and exit the facility.
- No current employee or new hire will work without the aforementioned education.
- A reconciliation will be completed on education records and current employee list to ensure the aforementioned education is completed by 02/15/2023.
The Immediate Jeopardy was removed on 02/10/2023 at 4:20 p.m. when the provider presented an acceptable plan of removal. Through observations, interviews and record review, the surveyors confirmed the above components of the plan of removal had been initiated and/or implemented prior to exit.
This deficient practice continued at more than minimal harm for the remaining 92 non-positive COVID-19 residents residing in the facility that were at risk for contracting COVID-19.
Findings:
1. and 2.
Review of the facility's policy titled, COVID-19 - Pandemic Plan revealed the following, in part:
Employee Health:
28. Practices are in place that addresses the needs of symptomatic staff and facility staffing needs, including:
- handling staff members who develop symptoms at work
Review of the list of employees with positive COVID-19 test results revealed S5CNA tested positive on 02/08/2023.
Review of the Time Card for S5CNA dated 02/08/2023 to 02/09/2023 revealed she clocked in for work at 6:59 p.m. on 02/08/2023 and clocked out at 5:51 a.m. on 02/09/2023.
An interview was conducted with S42HR on 02/09/2023 at 9:56 a.m. S42HR reviewed S5CNA's time stamps and confirmed S5CNA worked in the facility from 6:59 p.m. on 02/08/2023 to 5:51 a.m. on 02/09/2023.
A telephone interview was conducted with S5CNA on 02/09/2023 at 10:24 a.m. She stated when she entered the facility on 02/08/2023 for her night shift, she was feeling very tired, had body aches, and a headache. She stated the staff did not have to screen for signs and symptoms of COVID-19 prior to starting their shift. She stated she was assigned to care for the residents on Hall C at the beginning of her shift on 02/08/2023. She stated she took a COVID-19 test at the facility around 11:06 p.m. after realizing she could not taste her food and the results were positive. She stated she did not want to leave the facility short staffed and worked until around 6:00 a.m. on 02/09/2023. She further explained after testing positive, the night shift supervisor changed her room assignments so she cared for the isolation rooms on Hall C the remainder of her shift. She stated she was assigned to 5 isolation rooms with 2 residents in each. She stated she did not know if there were COVID-19 negative residents in the isolation rooms she cared for. She stated she did not limit her movement within the facility during her shift.
An interview was conducted with S1ADM on 02/09/2023 at 11:18 a.m. He confirmed he was notified of S5CNA testing positive for COVID-19 around 11:00 p.m. on 02/08/2023. He stated the decision was made to assign her to the rooms on Hall C that had COVID-19 positive residents in them. He confirmed there were 3 rooms on Hall C that contained a COVID-19 positive and a COVID-19 negative resident. He stated it was not acceptable for S5CNA, a COVID-19 positive employee, to provide direct care to any non-COVID-19 positive residents.
An interview was conducted with S36LPN on 02/09/2023 at 11:25 a.m. She stated there was a total of five COVID-19 isolation rooms on Hall C. She stated out of the 5 rooms there were 3 rooms that housed a COVID-19 positive resident with a non-COVID-19 positive resident. She stated the residents that were not COVID-19 positive and were housed with a COVID-19 positive resident were Residents #R14, #R15, and #R16.
An interview was conducted with S30CNA on 02/08/2023 at 5:08 a.m. She confirmed staff were not required to perform screening for signs or symptoms of COVID-19 prior to their shift.
An interview was conducted with S20LPN on 02/08/2023 at 5:16 a.m. She stated the staff were not required to screen for signs and symptoms of COVID-19 prior to their shift.
An interview was conducted with S31LPN on 02/08/2023 at 5:20 a.m. She stated she did not screen for signs and symptoms of COVID-19 prior to beginning her shift and could not recall the last time she had done so. She explained staff were no longer required to screen for signs and symptoms of COVID-19 prior to the start of their shift.
An interview was conducted with S9CNA on 02/08/2023 at 5:30 a.m. She stated she was not required to screen for signs or symptoms of COVID-19 prior to working in the facility
An interview was conducted with S32CNA on 02/08/2023 at 5:35 a.m. She stated staff were no longer required to self-screen for signs and symptoms of COVID-19 prior to beginning their shift. She confirmed she did not self-screen prior to the start of her shift tonight and could not recall the last time she had done so.
An interview was conducted of S6KA on 02/08/2023 at 6:10 a.m. She confirmed staff were no longer being screened for signs and symptoms of COVID-19 prior to entering the facility to start her shift.
An interview was conducted with S35CNA on 02/08/2023 at 6:15 a.m. She stated she was not required to screen for signs and symptoms of COVID-19 prior to starting her shift.
An interview was conducted with S36LPN on 02/08/2023 at 7:37 a.m. She confirmed she was not screened for signs and symptoms of COVID-19 prior to entry into the facility.
An interview was conducted with S37LPN on 02/08/2023 at 7:51 a.m. She confirmed since the start of the facility's COVID-19 outbreak staff were not required to screen for signs and symptoms of COVID-19 prior to starting their shift.
An interview was conducted with S38CNA on 02/08/2023 at 9:56 a.m. She confirmed she was not screened for signs and symptoms of COVID-19 prior to the start of her shift this morning and had not been screened since the start of the current COVID-19 outbreak.
A telephone interview was conducted with S12LPN on 02/08/2023 at 11:16 a.m. She stated there was not a screening process for staff prior to entering the facility.
An interview was conducted with S39HKLS on 02/08/2023 at 1:37 p.m. She stated the staff were not required to screen for signs or symptoms of COVID-19 prior to their shift.
An interview was conducted with S2IDON, S3ADON and S4CN on 02/09/2023 at 12:45 p.m. S2IDON stated pre-shift screening on employees was not required and had not been implemented since the start of the outbreak on 02/01/2023. S2IDON stated she depended on staff to report if they were experiencing symptoms. S2IDON stated she expected an employee with any kind of illness to report that to their supervisor before they reported to work. S2IDON stated she would have expected the staff to be educated on reporting symptoms of COVID-19 prior to their shift. S2IDON stated on 02/08/2023, after S5CNA tested positive for COVID-19, she was allowed to stay the remainder of her shift. S2IDON confirmed S5CNA should not have been allowed to care for any non-COVID-19 positive residents. S3ADON stated she would have expected the positive COVID-19 employee to separate from the negative COVID-19 employees. S4CN stated S5CNA should not have been allowed to work in the facility after testing positive for COVID-19.
An interview was conducted with S1ADM on 02/09/2023 at 1:35 p.m. He stated he was not sure if he expected staff to screen prior to their shift during a COVID-19 outbreak. He stated if a staff member was in the facility and began having symptoms of COVID-19, he would have expected them be tested and leave the facility immediately. He stated he was not notified S5CNA was symptomatic of COVID-19.
An interview was conducted with S18MD on 02/09/2023 at 3:50 p.m. He confirmed a COVID-19 positive staff member should not have been allowed to continue their shift and care for non-COVID-19 positive residents.
3.
Review of the facility's policy titled, COVID-19 - Pandemic Plan revealed the following, in part:
Testing:
Outbreak Investigation:
iii. Staff and residents who are identified as close contacts or on affected units/floor or specific area of the center, regardless of vaccination status, will be tested.
1.
Test immediately but not earlier than 24 hours after exposure, and if negative, a gain in 48 hours after the first negative test and, if negative, again 48 hours after the second negative test.
v. If additional cases are identified consider shifting to a broad-based testing approach if not already being performed .As part of the broad based approach, testing should continue on affected unit/floor(s) or facility-wide every 3-7 days until there are not new cases for 14 days.
Documentation:
Outbreak Investigation includes:
-Date case was identified
-Date other residents and staff were tested.
-Date residents and staff were retested
-Results of all tests.
Review of the COVID-19 Community Transmission rate for the facility from the week of 02/03/2023 revealed it was high.
Review of the COVID-19 test results for the residents that tested positive for COVID-19 since the beginning of the facility's outbreak on 02/01/2023 revealed the following:
Date: 02/05/2023, Resident: Resident #R12, COVID - 19 Rapid test result: Positive
Date: 02/05/2023, Resident: Resident #5, COVID - 19 Rapid test result: Positive
Date: 02/05/2023, Resident: Resident #R11, COVID - 19 Rapid test result: Positive
Date: 02/05/2023, Resident: Resident #R8, COVID - 19 Rapid test result: Positive
Date: 02/05/2023, Resident: Resident #R10, COVID - 19 Rapid test result: Positive
Date: 02/05/2023, Resident: Resident #R13, COVID - 19 Rapid test result: Positive
Date: 02/05/2023, Resident: Resident #R9, COVID - 19 Rapid test result: Positive
Date: 02/08/2023, Resident: Resident #R6, COVID - 19 Rapid test result: Positive
Date: 02/08/2023, Resident: Resident #R7, COVID - 19 Rapid test result: Positive
Date: 02/09/2023, Resident: Resident #R17, COVID - 19 Rapid test result: Positive
Review of the list of employees with positive COVID-19 infection from 02/01/2023 through 02/13/2023 revealed the following employees tested positive on the following dates:
S11CNA - 02/01/2023
S13RHB - 02/01/2023
S12LPN - 02/06/2023
S14COTA - 02/07/2023
S5CNA - 02/08/2023
S15LS - 02/08/2023
S40CNA - 02/08/2023
S41LPN - 02/13/2023
S20LPN - 02/13/2023
Review of the facility's COVID-19 Staff Testing Results for the week of 02/01/2023 compared to the facility's list of 112 active employees revealed 79 active employees did not have a COVID-19 test result during the current outbreak.
Review of the list of current contract dietary staff provided by S10KDM revealed no COVID-19 test was conducted on the 9 staff members identified on the list between the dates of 02/01/2023 to 02/09/2023.
Review of the current contract therapy staff provided by S13RHB revealed 15 of the 17 staff members on the list were not tested for COVID-19 between the dates of 02/01/2023 to 02/09/2023.
Review of the current contract housekeeping and laundry staff provided by S39HKLS revealed 11 of the 12 staff members on the list were not tested for COVID-19 between the dates of 02/01/2023 to 02/09/2023.
An interview was conducted with S3ADON on 02/08/2023 at 11:00 a.m. She confirmed the facility provided all documentation for staff COVID-19 testing that began with the outbreak on 02/01/2023. She confirmed she could not provide COVID-19 test results for the above staff members.
A telephone interview was conducted with S27DON on 02/08/2023 at 11:43 a.m. He stated he was responsible for keeping track of staff COVID-19 testing for the week of 02/01/2023 when the COVID-19 outbreak began. He stated he thought all staff had been tested but did not have documentation they had been. He stated he did not track COVID-19 testing for contract staff, which included therapy, housekeeping, laundry, and dietary staff. He stated he notified each department head that their staff needed to be tested for COVID-19 weekly, but did not follow up to ensure the staff were actually being tested. He stated it was the department head's responsibility to ensure each of their staff was being tested weekly.
An interview was conducted with S2IDON on 02/08/2023 at 9:30 a.m. She stated she was currently in charge of the Infection Control Program and she was the facility's Infection Preventionist. She stated her and S27DON were responsible for tracking infections, identifying patterns, monitoring infection practices, and implementing practices to improve quality. She stated she was responsible for implementation of COVID-19 infection control practices. She stated the facility outbreak dated 02/01/2023 began from an employee (S11CNA) who tested positive for COVID-19. She stated she was unsure what the current COVID-19 community transmission rate was. She stated there was a COVID-19 rapid testing document the nurses were supposed to fill out for staff and residents after they were tested for COVID-19, but she did not know how the COVID-19 testing was being tracked. She confirmed all facility staff should have been tested last week. She confirmed the facility provided all COVID-19 tests performed after the start of the outbreak on 02/01/2023 and there were staff members that had been working after the outbreak without a COVID-19 test result. She stated all staff should have been wearing a N95 mask covering their mouth and nose in resident care areas, including during the provision of care. She stated it was never acceptable for the staff to provide care for a resident unmasked.
An interview was conducted with S39HKLS on 02/08/2023 at 1:37 p.m. She confirmed she and her staff were contract employees. She explained housekeeping and laundry staff went to the nurses' station in the facility to be tested for COVID-19 and S2IDON tracked to ensure they
were tested. She confirmed she did not track to ensure all of her staff were being tested for COVID-19 weekly.
An interview was conducted with S2IDON on 02/09/2023 at 12:45 p.m. S2IDON confirmed she did not know if there was a process in place on how the facility handled a COVID-19 outbreak. S2IDON stated there was no documentation COVID-19 testing was being conducted on all facility and contract staff weekly. She stated the system for tracking COVID-19 testing of staff was to keep the COVID-19 Rapid Test Result sheet for each staff. She confirmed she could not find all COVID-19 test results for all staff. She stated there was not a log or documentation kept by administration to ensure each staff member was tested for COVID-19. She confirmed it was the responsibility of the facility to ensure COVID-19 testing of facility and contract staff was being completed.
An interview was conducted with S1ADM on 02/09/2023 at 1:35 p.m. He stated the current system the facility had to ensure COVID-19 testing was being completed on all staff was not working. He stated the administrative staff had been inconsistent. He stated training had not been completed on his new administrative staff. He stated the retention of staff should not have affected the quality of care for the residents or the facility's Infection Program. He confirmed the current COVID-19 outbreak began on 02/01/2023.
4.
Review of the facility's policy titled, COVID-19 - Pandemic Plan revealed the following, in part:
Testing:
Point of Care (POC) Antigen Testing:
-Center has identified and trained staff member(s) to utilize the POC device - as designated by the DON
Review of the Product Guide for the [NAME] BinaxNOW (Trademark) COVID-19 Ag CARD revealed, in part, the following:
Frequently Asked Questions:
What kind of test and is it accurate?
. The visually read test . provides results in 15 minutes.
What PPE to use/wear to perform the test?
. Change gloves between handling of specimens.
How do we dispose of test materials after testing?
All components of the . test kit should be discarded as biohazard waste .
Review of the FDA's Guide and Instructions For Use for the [NAME] BinaxNOW (Trademark) COVID-19 Ag CARD revealed, in part, the following:
The BinaxNOW (Trademark) COVID-19 Ag Card is intended for use by medical professionals or trained operators. NOTE: Failure to follow the instructions may result in inaccurate test results.
Part 1 - Sample Test Procedure
3. Rotate (twirl) swab shaft 3 times CLOCKWISE (to the right).
* Used test cards should be discarded as Biohazard waste .
Precautions:
1. Failure to follow the instructions may result in inaccurate test results.
5. Treat all specimens as potentially infectious. Follow universal precautions when handling samples, this kit and its contents.
16. Change gloves between handling of specimens .
17. Do not read test results before 15 minutes . Results read before 15 minutes . may lead to a false positive, false negative, or invalid result.
19. False Negative results can occur if the sample swab is not rotated (twirled) prior to closing the card.
An interview was conducted with S10KDM on 02/09/2023 at 9:30 a.m. He confirmed he was responsible for performing the COVID-19 testing of kitchen staff. He confirmed he tested using the [NAME] BinaxNOW (Trademark) COVID-19 Ag CARD. He then confirmed the facility had never trained him or performed a competency skills check-off for the performance of COVID-19 testing nor did he have any documentation of completing the training at another facility. He then confirmed he would let the test process for no longer than 5 minutes before reading and documenting the results. He stated he brought the result forms to S2IDON and did not track the results himself.
An observation was conducted with S10KDM on 02/09/2023 at 9:50 a.m. S10KDM donned a pair of clear white kitchen gloves then opened the [NAME] BinaxNOW (Trademark) COVID-19 Ag CARDs test kit packets. At 10:00 a.m., S17RD, S8KC, S7KA, and S10KDM performed their self-swab. The employees then placed their swabs into their test card, and S10KDM placed the testing drops onto each of the test cards. He was not observed to perform the required swirling motion of the swabs following the application of the drops. At 10:04 a.m., S10KDM verbalized and transcribed all 4 results and stated they needed no longer than 5 minutes to process. At 10:05 a.m., S10KDM gathered the four processed tests and placed them in a coffee cup then placed them into a standard trash bag. An interview was conducted with S10KDM on 02/09/2023 at 10:10 a.m. He confirmed he performed all 4 tests without changing gloves and no one swirled the swab after the application of the testing drops. He confirmed he had allowed the tests to process for a total of 5 minutes from the time the employees performed their self-swab to the time he read the results. He then confirmed he discarded the dirty gloves and processed testing cards/swabs into a regular trashcan.
An interview was conducted with S2IDON, S3ADON and S4CN. S2IDON on 02/09/2023 at 12:45 p.m. S2IDOnstated any staff could perform COVID-19 testing as long as they had been trained. S2IDON stated she did not know what staff were trained to perform COVID-19 testing. S2IDON stated the facility should have retained any training for the COVID-19 testing. S4CN confirmed you should wait for 15 minutes after performing a COVID-19 rapid swab and document the result. S4CN confirmed it was not best practice to allow staff to self-swab for COVID-19 testing. S4CN confirmed the test should have been performed by a trained medical professional and not dietary/kitchen staff. S2IDON stated she was unsure if staff were trained on performing swabbing for COVID-19. S2IDON was unable to answer what the contract staff were trained to perform. S2IDON confirmed she had not performed any training or skills check-offs regarding COVID-19 testing or self-swabbing. S2IDON also confirmed she was not aware of and could not put her hands on any documentation to indicate facility or contracted staff had been trained or evaluated via skill check-off for COVID-19 self-swabbing. S2IDON then confirmed she expected all facility and contract staff to have been trained followed by return demonstration to ensure an adequate sample was obtained. S3ADON confirmed she had not performed any training or skills check-offs regarding COVID-19 testing or self-swabbing. S3ADON also confirmed she was not aware of and could not put her hands on any documentation to indicate facility or contracted staff had been trained or evaluated via skill check-off for COVID-19 self-swabbing. S3ADON confirmed any staff member performing COVID-19 testing should have been trained. S4CN stated if an adequate specimen was not obtained and if the testing procedure was not followed according to manufacturer instructions, the test results could have been inaccurate. S4CN stated when performing the [NAME] BinaxNOW (Trademark) COVID-19 Ag CARD test, the results required a minimum of 15 minutes and maximum of 30 minutes to process after the application of the antigen drops to the swab. Both S2IDON and S3ADON verbalized agreement with S4CN's two above statements.
An interview was conducted with S1ADM on 02/09/2023 at 1:35 p.m. He confirmed he had not reviewed or verified the manufacturer's guidelines and/or instructions to ensure the facility was performing the COVID-19 testing procedure appropriately, to verify if it allowed for self-swabbing or to verify if this type of test could be performed by an unqualified or untrained person. He stated he assumed since the company made a similar test for at home use, it would have been fine for anyone to self-swab. He stated staff should have been trained on rapid swabbing for COVID-19 used in the facility. He confirmed the processing time of the [NAME] BinaxNOW (Trademark) COVID-19 Ag CARD test was a minimum of 15 minutes and max of 30 minutes from the time the nasal swabbing was performed. He confirmed a test that was performed incorrectly could yield an inaccurate result. He stated he expected staff to let the rapid COVID-19 test sit for 15 minutes prior to reading a result.
An interview was conducted with S18MD on 02/09/2023 at 3:50 p.m. He confirmed he was the Medical Director for the facility. He confirmed staff should have been trained prior to performing COVID-19 testing. He confirmed if COVID-19 testing was performed incorrectly it could yield inaccurate results.
5.
An observation was conducted at Entry J prior to entering the facility on 02/08/2023 at 5:00 a.m. The front door and surrounding floor to ceiling windows were noted to be clear glass with an unobstructed line of sight into the facility from the exterior. 4 staff members were observed walking throughout the interior of the facility [TRUNCATED]
CRITICAL
(L)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Immediate Jeopardy (IJ) - the most serious Medicare violation
Deficiency F0882
(Tag F0882)
Someone could have died · This affected most or all residents
⚠️ Facility-wide issue
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to ensure the individual designated as the Infection P...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to ensure the individual designated as the Infection Preventionist established and maintained an effective infection prevention and control program to prevent the spread of COVID-19.
This deficient practice resulted in an Immediate Jeopardy situation with the likelihood of severe injury and/or death to facility residents beginning on 02/08/2023 at 6:59 p.m., when S5CNA entered the facility with signs and symptoms of COVID-19 and began providing direct patient care to non-COVID-19 positive residents on Hall C. On 02/08/2023 at 11:06 p.m., S5CNA tested positive for COVID-19 and continued to provide direct care for 3 non-COVID-19 positive residents (#R14, #R15, and #R16). On 02/08/2023 observations were made of facility staff failing to wear masks while providing resident care and handling resident food. Staff also failed to educate visitors on the facility's COVID-19 outbreak, signs and symptoms of COVID -19, provide masks, or instruct on infection control measures prior to the visitors entering the facility. Interviews with staff revealed staff and visitors had not been screened for signs and symptoms of COVID-19, visitors were not notified of the facility's COVID-19 outbreak and provided education and a face mask, and all staff that worked in the facility were not tested for COVID-19 since the outbreak began on 02/01/2023. Due to the facility failing to implement infection control measures, Residents #R6 and #R7 tested positive for COVID-19 on 02/08/2023 and Resident #R17 tested positive for COVID-19 on 02/09/2023. As of 02/09/2023, there were 102 residents residing in the facility with 10 active resident COVID-19 cases.
S1ADM was notified of the immediate jeopardy on 02/09/2023 at 7:18 p.m.
The facility presented the following Plan of Removal on 02/10/2023 at 4:20 p.m.:
Plan of Removal:
Brief Summary of Events:
On 02/09/2023 at 7:18 p.m. the State Agency (SA) notified the Executive Director (ED) of an immediate jeopardy related to F-882 Infection Preventionist Qualifications/Role. The facility failed to ensure the Infection Preventionist established and maintained an effective infection prevention and control program to prevent the spread of COVID-19. An immediate jeopardy (IJ) template was provided to the ED by the SA.
Immediate Action started on 02/09/2023 at 7:30 p.m.:
- Signage was posted at both entrances on Visitor Infection Control and Stop notification to notify facility of any symptoms of COVID-19 or COVID-19 Positive results on 02/09/2023. QI Monitoring Tool will be conducted by the ED/designee to ensure signage is posted at both entrances on Visitor Infection Control and Stop Notification to notify facility of any symptoms of COVID-19 or COVID-19 Positive results for three times per week for four weeks and then monthly for two months.
- Visitor screening placed at entrance for visitor sign in area on 02/10/2023 using the Visitor/Vendor Screening form and will continue until facility is no longer in COVID-19 outbreak. QI Monitoring Tool will be conducted by the ED/designee to ensure visitor screening is placed at the entrance sign in area for three times per week for four weeks and then monthly for two months.
- Quality rounds were performed on 02/09/2023 to ensure nursing staff donned face mask while providing direct patient care and kitchen staff donned face mask while prepping/serving meals during COVID-19 outbreak. QI Monitoring Tool will be conducted by the ED/designee to ensure quality rounds are performed to ensure nursing staff donned face mask while providing direct patient care and kitchen staff donned face mask while prepping/serving meals during COVID-19 outbreak for three times per week for four weeks and then monthly for two months.
- Facility notified outpatient facilities and outpatient transportation providers on 02/09/2023 and will continue notifying weekly of a current COVID-19 outbreak in the facility form and will continue until facility is no longer in COVID-19 outbreak. QI Monitoring Tool will be conducted by the ED/designee to notify outpatient facilities and outpatient transportation providers of a current COVID-19 outbreak in the facility weekly for four weeks and then monthly for two months.
- Employee screening log placed at front entrance for staff to begin screening prior to work and initiated on 02/10/2023 using the Employee Screening form and will continue until facility is no longer in COVID-19 outbreak. QI Monitoring Tool will be conducted by the ED/designee to ensure employee screening logs placed at front entrance for staff to begin screening prior to work for three times per week for four weeks and then monthly for two months.
- S5CNA was relieved of duty on 02/09/2023 for a minimum of 10 days related to confirm positive.
- Employee testing log implemented on 02/10/2023. Infection Control Preventionist will maintain log to ensure appropriate employees are tested during COVID-19 outbreak. QI monitoring tool will be conducted by DON or designee to ensure appropriate employees are tested two times per week for four weeks and then monthly for two months.
- COVID-19 testing competency check-offs were initiated on 02/10/2023 by Regional Director of Clinical Services 2 (RDCS2). QI monitoring tool will be conducted by DON or designee to ensure competency in COVID-19 testing two times per week for four weeks, then weekly for 1 week, and then monthly for two months.
Resident/Staff Specific Action:
- Resident R6, Resident R7, and Resident R17 room assignments were reassigned to accommodate cohorting positive COVID-19 with positive COVID-19 and exposed negative COVID-19 with exposed COVID-19.
QAPI:|
- On 02/09/2023 at 7:30 p.m. the Quality Assurance Performance Improvement (QAPI) Committee met to review the F-882 Infection Preventionist Qualifications/Role IJ template and conduct a Root Cause Analysis (RCA) and review policy and procedures for changes. Attendees were the Executive Director (ED), Interim Director of Nursing (IDON), Activities Director (AD), Housekeeping Supervisor (HO), Regional Director of Clinical Services (RDCS), Director of Therapy (DOR), Assistant Director of Nursing (ADON), Business Office Manager (BOM), Human Resources Director (HRD).The Medical Director (MD) was notified by phone.
- The RCA determined the facility failed to ensure the Infection Preventionist established and maintain an effective Infection Control program by failing to provide oversight.
- The facility failed to alert visitors of active COVID -19 cases, provide education to visitor regarding infection control related to COVID-19, and provide face mask while visiting in the facility.
- Direct care nursing staff were not donned in masks while providing direct care.
- Kitchen staff were not donned in face mask while prepping and serving meals.
- Outpatient facilities and outpatient transportation was not notified of a COVID19 outbreak in the facility.
- A Certified Nursing Assistant (CNA) who became symptomatic during a shift and tested positive for COVID-19 continued to provide care to COVID-19 positive and COVID-19 negative residents.
- The facility failed to ensure staff were screened for COVID-19 prior to working in the facility.
- The facility failed to maintain tracking and documentation of COVID-19 testing.
- The facility failed to ensure staff were knowledgeable and trained to accurately perform point of care COVID-19 testing.
Education:
Current Infection Control Preventionist received training on 02/10/2023 by the Regional Director of Clinical Services 1 (RDCS1) on Infection Control with emphasis on:
- Visitors will be alerted to active COVID -19 infections, provided education, screening and provided face mask prior to entering the facility. Signage will be provided at entrance to include Infection Control information regarding COVID-19. Education initiated by Regional Director of Clinical Services 2 (RDCS 2) on 02/10/2023.
- Nursing staff will don face mask while providing direct resident care and kitchen staff will don face mask when prepping and serving meals. Education initiated by Interim Director of Nurses (IDON) on 02/10/2023 with nursing staff will don face mask while providing direct resident care and kitchen staff will don face mask when prepping and serving meats and to be completed by the receipt date of statement of deficiencies.
- Facility will notify outpatient facilities and outpatient transportation providers of a COVID -19 outbreak in facility. Education initiated by Regional Director of Clinical Services 1 (RDCS 1) on 02/09/2023 with Interdisciplinary Team (IDT) and to be completed by the receipt date of statement of deficiencies.
- Staff who test positive for COVID -19 with signs and symptoms of COVID -19 will self-report to their immediate supervisor, be relieved of duties, and exit the facility. Education initiated by DON on 02/10/2023 with current staff to ensure staff who test positive for COViD-19 with signs and symptoms of COVID-19 will self-report to their immediate supervisor, be relieved of duties, and exit the facility. Current employees including agency and contract, will receive training upon hire and prior to working with emphasis on staff who test positive for COVID-19 with signs and symptoms of COVID -19 will self-report to their immediate supervisor, be relieved of duties, and exit the facility.
- Current staff will be screened prior to working within the facility. Education and competency initiated by Regional Director of Clinical Services 2 (RDCS2 2) on 02/10/2023. Educa and competency will be completed by 02/13/2023.Tracking and documentation of COVID-19 will be maintained by the Infection Control Preventionist. Education and competency initiated by Regional Director of Clinical Services 2 (RDCS2 2) on 02/10/2023. Education and competency will be completed by 02/13/2023.
- Current staff will be knowledgeable and trained to accurately perform point of care COVID-19 testing. Education and competency initiated by Regional Director of Clinical Services 2 (RDCS2 2) on 02/10/2023. Education and competency will be completed by 02/13/2023.
-
No current employee or new hire will work without the aforementioned education.
-
A reconciliation will be completed on education records and current employee list of the aforementioned education is completed by 02/15/2023.
The Immediate Jeopardy was removed on 02/10/2023 at 4:20 p.m. when the provider presented an acceptable plan of removal. Through observations, interviews and record review, the surveyors confirmed the above components of the plan of removal had been initiated and/or implemented prior to exit.
This deficient practice continued at more than minimal harm for the remaining 92 non-positive COVID-19 residents residing in the facility that were at risk for contracting COVID-19.
Findings:
Cross Reference F-880
An interview was conducted with S2IDON on 02/08/2023 at 9:30 a.m. She stated she was currently in charge of the Infection Control Program and she was the facility's Infection Preventionist. She stated her and S27DON were responsible for tracking infections, identifying patterns, monitoring infection practices, and implementing practices to improve quality. She stated she was responsible for implementation of COVID-19 infection control practices. She stated the facility outbreak dated 02/01/2023 began from an employee, S11CNA, who tested positive for COVID-19. She stated she was unsure what the current COVID-19 community transmission rate was. She stated there was a COVID-19 rapid testing document the nurses were supposed to fill out for staff and residents after they were tested for COVID-19, but she did not know how the COVID-19 testing was being tracked. She confirmed all facility staff should have been tested last week. She confirmed the facility provided all COVID-19 tests performed after the start of the outbreak on 02/01/2023 and there were staff members that had been working after the outbreak without a COVID-19 test result. She stated all staff should have been wearing a N95 mask covering their mouth and nose in resident care areas, including during the provision of care and while preparing food for the residents. She stated it was never acceptable for the staff to provide care for a resident unmasked.
An interview was conducted on 02/09/2023 at 12:45 p.m. with S2IDON, S3ADON and S4CN. S2IDON stated pre-shift screening on employees was not required and had not been implemented since the start of the outbreak on 02/01/2023. She stated she depended on staff to report if they were experiencing symptoms. She stated she expected an employee with any kind of illness to report that to their supervisor before they reported to work. She stated she would have expected the staff to be educated on reporting symptoms of COVID-19 prior to their shift. She stated on 02/08/2023, after S5CNA tested positive for COVID-19, she was allowed to stay the remainder of her shift. S2IDON confirmed S5CNA should not have been allowed to care for any non-COVID-19 positive residents. S3ADON stated she would have expected the positive COVID-19 employee to separate from the negative COVID-19 employees. S4CN stated S5CNA should not have been allowed to work in the facility after testing positive for COVID-19. S2IDON stated there was no documentation COVID-19 testing was being conducted on all facility and contract staff weekly. She stated the system for tracking COVID-19 testing of staff was to keep the COVID-19 Rapid Test Result sheet for each staff. She confirmed she could not find all COVID-19 test results for all staff. She stated there was not a log or documentation kept by administration to ensure each staff member was tested for COVID-19. She confirmed it was the responsibility of the facility to ensure COVID-19 testing of facility and contract staff was being completed. S2IDON confirmed visitors were not being screened related to COVID-19. She stated she expected the staff to provide each visitor entering the facility with a mask. She stated she would not expect the staff to notify a visitor of an outbreak of COVID-19 in the facility. She stated she would not provide a visitor with any type of education regarding infection control practices if the resident they were visiting was not on isolation. S2IDON and S4CN confirmed any outside facility, day program, and/or transportation company utilized by the facility should have been immediately notified of the facility's COVID-19 Outbreak Status. S2IDON confirmed she did not know if there was a process in place on how the facility handled a COVID-19 outbreak. S2IDON stated any staff could perform COVID-19 testing as long as they had been trained. S2IDON stated she was unsure if staff were trained to perform COVID-19 testing. S2IDON stated the facility should have retained any training for the COVID-19 testing. S2IDON was unable to answer what the contract staff were trained to perform. S2IDON confirmed she had not performed any training or skills check-offs regarding COVID-19 testing or self-swabbing. S2IDON also confirmed she was not aware of and could not put her hands on any documentation to indicate facility or contracted staff had been trained or evaluated via skill check-off for COVID-19 self-swabbing. S2IDON then confirmed she expected all facility and contract staff to have been trained followed by return demonstration to ensure an adequate sample was obtained. S3ADON confirmed she had not performed any training or skills check-offs regarding COVID-19 testing or self-swabbing. S3ADON also confirmed she was not aware of and could not put her hands on any documentation to indicate facility or contracted staff had been trained or evaluated via skill check-off for COVID-19 self-swabbing. S3ADON confirmed any staff member performing COVID-19 testing should have been trained. S4CN confirmed you should wait for 15 minutes after performing a COVID-19 rapid swab and document the result. S4CN confirmed it was not best practice to allow staff to self-swab for COVID-19 testing. S2CN confirmed the test should have been performed by a trained medical professional and not dietary/kitchen staff. S4CN stated if an adequate specimen was not obtained and if the testing procedure was not followed according to manufacturer instructions, the test results could have been inaccurate. S4CN stated when performing the [NAME] BinaxNOW (Trademark) COVID-19 Ag CARD test, the results required a minimum of 15 minutes and maximum of 30 minutes to process after the application of the antigen drops to the swab. Both S2IDON and S3ADON verbalized agreement with S4CN's two above statements.
A telephone interview was conducted with S27DON on 02/08/2023 at 11:43 a.m. He stated he was responsible for keeping track of staff COVID-19 testing for the week of 02/01/2023 when the COVID-19 outbreak began. He stated he thought all staff had been tested but did not have documentation they had been. He stated he did not track COVID-19 testing for contract staff, which included therapy, housekeeping, laundry, and dietary staff. He stated he notified each department head that their staff needed to be tested for COVID-19 weekly, but did not follow up to ensure the staff were actually being tested. He stated it was the department head's responsibility to ensure each of their staff was being tested weekly.
An interview was conducted with S27DON on 02/14/2023 at 12:45 p.m. He confirmed all outside facilities, day programs and/or transportation companies utilized by the facility should have been immediately notified of the COVID-19 Outbreak Status within the facility.
An interview was conducted with S1ADM on 02/09/2023 at 11:18 a.m. He confirmed he was notified of S5CNA testing positive for COVID-19 around 11:00 p.m. on 02/08/2023. He stated the decision was made to assign her to the rooms on Hall C that had COVID-19 positive residents in them. He confirmed there were 3 rooms on Hall C that contained a COVID-19 positive and a COVID-19 negative resident. He stated it was not acceptable for S5CNA, a COVID-19 positive employee, to provide direct care to any non-COVID-19 positive residents.
An interview was conducted on 02/09/2023 at 1:35 p.m. with S1ADM. He confirmed the current COVID-19 outbreak began on 02/01/2023. He stated he was not sure if he expected staff to screen prior to their shift during a COVID-19 outbreak. He stated if a staff member was in the facility and began having symptoms of COVID-19, he would have expected them be tested and leave the facility immediately. He stated he was not notified S5CNA was symptomatic of COVID-19. He stated the current system the facility had to ensure COVID-19 testing was being completed on all staff was not working. He stated visitors should have been asked to wear a mask. He stated there should have been signage posted to make visitors aware of the facility's COVID-19 outbreak and there was not. He stated outpatient facilities should have been notified of the facility's COVID-19 outbreak. He confirmed he had not reviewed or verified the manufacturer's guidelines and/or instructions to ensure the facility was performing the COVID-19 testing procedure appropriately, to verify if it allowed for self-swabbing or to verify if this type of test could be performed by an unqualified or untrained person. He stated he assumed since the company made a similar test for at home use, it would have been fine for anyone to self-swab. He stated staff should have been trained on rapid swabbing for COVID-19 used in the facility. He confirmed the processing time of the [NAME] BinaxNOW (Trademark) COVID-19 Ag CARD test was a minimum of 15 minutes and max of 30 minutes from the time the nasal swabbing was performed. He confirmed a test that was performed incorrectly could yield an inaccurate result. He stated he expected staff to let the rapid COVID-19 test sit for 15 minutes prior to reading a result. He stated he expected masking at all times in the facility. He stated the administrative staff had been inconsistent. He stated training had not been completed on his new administrative staff. He stated the retention of staff should not have affected the quality of care for the residents or the facility's Infection Program
An interview was conducted with S18MD on 02/09/2023 at 3:50 p.m. He confirmed he was the Medical Director for the facility. He confirmed staff should have worn a face mask covering their mouth and nose at all times when interacting with residents or during the preparation of food. He confirmed a COVID-19 positive staff member should not have been allowed to continue their shift and care for non-COVID-19 positive residents. He stated he expected the facility to notify visitors of the COVID-19 outbreak status. He confirmed the facility should have notified outside facilities and outside transportation companies of the COVID-19 outbreak status in the facility. He confirmed staff should have been trained prior to performing COVID-19 testing. He confirmed if COVID-19 testing was performed incorrectly it could yield inaccurate results.
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 interviews, the facility failed to ensure a resident's representative was notified of a change in con...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to ensure a resident's representative was notified of a change in condition for 1 (#2) of 3 (#2, #3, #4) residents reviewed for falls.
Findings:
Review of the facility's policy and procedure titled, Fall Management revealed, in part:
Overview:
. A fall refers to unintentionally coming to rest on the ground, floor or other lower level but not as the result of an overwhelming force . Unless there is evidence suggesting otherwise, when a resident is found on the floor, a fall is considered to have occurred.
Process:
C. Post Fall Strategies:
3. Notify the Physician and Resident Representative.
Review of Resident #2's Clinical Record revealed he was admitted to the facility on [DATE] with diagnoses which included, in part, the following; Encephalopathy; Psychosis Not Due to a Substance or Known Psychological Condition; Generalized Weakness; Lack of Coordination and Difficulty in Walking.
Review of Resident #2's most recent Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 01/09/2023, indicated resident was assessed to have a Brief Interview of Mental Status (BIMS) of 99, which indicated severe cognitive impairment.
Review of the facility's Fall Log revealed Resident #2 had an unwitnessed fall on 02/04/2023 at 6:28 a.m.
Review of the facility's Incident Report #186 for Resident #2 revealed, in part, the following:
Incident Report #186
Date/Time: 02/04/2023 at 6:28 a.m. (handwritten on computerized report by facility staff)
Incident Location: Resident's room
Description: Resident found lying on floor, denied pain, no bruises or pain noted. MD notified.
Immediate Action Taken: assessment, notified MD.
Review of Resident #2's Nurses Note written on 02/04/2023 at 6:39 a.m. by S47LPN indicated resident was found lying on floor. Resident denies pain. No bruises or pain noted. MD notified.
On 02/14/2023 at 10:00 a.m., an interview was conducted with Resident #2's son. He confirmed their family was not aware of his father having a fall on 02/04/2023.
On 02/13/2023 at 11:45 a.m., an interview was conducted with S27DON. He confirmed Resident #2 experienced an unwitnessed fall on 02/04/2023. He also confirmed there was no documentation to indicate anyone in his family had been notified of the fall. He then confirmed he would have expected the resident's assigned nurse to notify the resident's family that the fall had occurred.
On 02/14/2023 at 11:35 a.m., an interview was conducted with S1ADM. He confirmed Resident #2 was indicated on their fall log as having an unwitnessed fall on 02/04/2023. He confirmed he would have expected the resident's assigned nurse to notify the resident's family that a fall had occurred.
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
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to ensure services were provided to meet quality professional standar...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to ensure services were provided to meet quality professional standards for 1 (#2) of 3 (#2, #3, #4) residents reviewed for falls.
The facility failed to ensure:
1. Resident #2's unwitnessed fall was accurately and thoroughly documented via Incident Report and SBAR;
2. Resident #2 was assessed via Neurological Checks following an unwitnessed fall;
3. Resident #2 was re-evaluated for Fall Risk following an unwitnessed fall;
4. Resident #2 was assessed and monitored via Post Fall Evaluation following an unwitnessed fall; and
5. Resident #2's unwitnessed fall was reviewed and discussed by the Interdisciplinary Team.
Findings:
Review of the facility's policy and procedure titled, Fall Management revealed, in part, the following:
Overview:
Residents are evaluated for fall risk. A fall refers to unintentionally coming to rest on the ground, floor or other lower level . Unless there is evidence suggesting otherwise, when a resident is found on the floor, a fall is considered to have occurred.
Purpose:
Is to identify residents at risk for falls and establish/modify interventions to decrease the risk of a future fall(s) and minimize the potential for resulting injury.
Process:
C. Post Fall Strategies:
2. Initiate Neurological Checks as per policy or directed by physician's order.
3. Notify the . Resident Representative.
4. Re-evaluate fall risk utilizing the Post Fall Evaluation.
6. Initiate post fall documentation every shift for 72 hours.
7. Interdisciplinary Team to review fall documentation and complete root cause analysis.
9. Review resident weekly x4.
Review of the facility's policy and procedure titled, Neurological Evaluation revealed, in part, the following:
Procedure:
1. Identify Resident.
4. Perform neurological checks as follows unless otherwise ordered by a physician (for hitting head and/or unwitnessed falls)
a. Every 15 minutes for 1 hour,
b. Every hour for 4 hours,
c. Every 4 hours for the next 19 hours.
5. Document neurological checks, vital signs and observations on the appropriate form or electronic equivalent.
7. Place completed form in medical record.
Review of Resident #2's Clinical Record revealed he was admitted to the facility on [DATE] with diagnoses which included, in part, the following; Encephalopathy; Psychosis Not Due to a Substance or Known Psychological Condition; Generalized Weakness; Lack of Coordination and Difficulty in Walking.
Review of Resident #2's most recent Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 01/09/2023, indicated resident was assessed to have a Brief Interview of Mental Status (BIMS) of 99, which indicated severe cognitive impairment.
Review of Resident #2's Nurses Note written on 02/04/2023 at 6:39 a.m. by S47LPN indicated resident was found lying on floor.
Review of the facility's Fall Log revealed Resident #2 had an unwitnessed fall on 02/04/2023 at 6:28 a.m.
Review of the facility's Incident Report #186 for Resident #2 revealed, in part, the following:
Incident Report #186
Date/Time: 02/04/2023 at 6:28 a.m. (handwritten on computerized report by facility staff)
Incident Location: Resident's room
Reporting: S47LPN
Description: Resident found lying on floor, denied pain, no bruises or pain noted. MD notified.
Immediate Action Taken: assessment, notified MD.
Taken to hospital? No
Injury Type: No injuries observed at time of incident.
Level of Pain: Not documented.
Level of Pain/Level of Consciousness/Mobility: Not documented.
Mental Status: Not documented.
Level of Pain: Not documented.
Predisposing Factors:
Physiological: Not documented.
Situation: Not documented.
Other info: Not documented.
Witnesses: No witnesses found.
Agencies/People Notified: Not documented.
Notes: Not documented.
Review attempted of the Resident #2's Change in Condition (SBAR-CHC) following an unwitnessed fall on 02/04/2023 with no documentation provided.
Review attempted of Resident #2's Post Fall Monitoring following an unwitnessed fall on 02/04/2023 with no documentation provided.
Review attempted of Resident #2's Neurological Checks following an unwitnessed fall on 02/04/2023 with no documentation provided.
Review attempted of Resident #2's Reevaluation of Fall Risk following an unwitnessed fall on 02/04/2023 with no documentation provided.
Review attempted of the facility's Interdisciplinary Team Meeting following Resident #2's unwitnessed fall on 02/04/2023 with no documentation provided.
On 02/14/2023 at 9:30 a.m., an interview was conducted with S36LPN. She stated following an unwitnessed fall, the nurses would perform neurological checks post fall at the appropriate intervals. She stated she would receive a post fall neurological check sheet from the off going nurse to alert her they needed to be done. She also stated if the nurse who had the resident at time of fall put the fall into the computer, the charting system would alert her they needed to be done also. She stated if the nurse hadn't put everything from the fall into the computer, there would be no alert and if the nurse hadn't passed along to her that the neurological checks and monitoring needed to be done, she would have no way of knowing they were required.
On 02/14/2023 at 10:54 a.m., an interview was conducted with S19LPN. She confirmed they were required to complete an incident report, SBAR and post fall evaluation for any fall, witnessed or unwitnessed. She confirmed an unwitnessed fall would require neurological checks to be performed per protocol.
On 02/13/2023 at 10:15 a.m., an interview was conducted with S27DON. He stated unwitnessed falls required neurological checks per neurological check protocol. He stated all falls, witnessed or unwitnessed, would require the post fall evaluation monitoring. He confirmed both should be passed along by staff to the oncoming shift so they are aware of their responsibilities. He also stated all falls would require a complete incident report with SBAR and would be discussed daily in morning meetings with all documentation and evaluations reviewed at that time. He stated these meetings included all disciplines and confirmed post fall reevaluation of fall risks, care plans and MDS would be updated in that meeting immediately following falls. He then confirmed they had been a little behind on those meetings.
On 02/13/2023 at 11:55 a.m., an interview was conducted with S4CN. She confirmed the Incident Report following Resident #2's unwitnessed fall on 02/04/2023 was not completed in entirety and she would have expected it to be. She also confirmed they had been unable to locate an SBAR Report, Post Fall Evaluation, Post Fall Reevaluation of Fall Risk or Neurological Checks following Resident #2's unwitnessed fall on 02/04/2023. She also confirmed following the 02/04/2023 unwitnessed fall for Resident #2, there was no documentation located to indicate the Interdisciplinary Team had reviewed fall documentation and completed a root cause analysis or had begun to review the resident weekly. She confirmed she would have expected all of the above to have been completed per the facility's policy and procedure.
On 02/13/2023 at 12:15 p.m., an interview was conducted with S27DON. He confirmed the Incident Report following Resident #2's unwitnessed fall on 02/04/2023 was not completed in entirety and he would have expected it to be. He also confirmed he was unable to locate an SBAR Report, Post Fall Evaluation, Post Fall Reevaluation of Fall Risk, Neurological Checks or documentation of the Interdisciplary Team meeting and performing their required duties following Resident #2's unwitnessed fall on 02/04/2023. He confirmed he would have expected all of the above to have been completed per the facility's policy and procedure.
On 02/14/2023 at 11:35 a.m., an interview was conducted with S1ADM. He confirmed Resident #2 was indicated on their fall log as having an unwitnessed fall on 02/04/2023. He confirmed he would have expected staff to follow the post fall policy and protocol as it was written.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Accident Prevention
(Tag F0689)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews, the facility failed to ensure staff provided adequate supervision to prevent or reduce t...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews, the facility failed to ensure staff provided adequate supervision to prevent or reduce the risk of falls for a cognitively impaired resident for 1 (#2) of 3 (#2, #3, #4) residents reviewed for falls.
Findings:
Review of the facility's policy and procedure titled, Fall Management revealed, in part:
Overview:
Residents are evaluated for fall risk. Patient centered interventions are initiated based on resident risk. A fall refers to unintentionally coming to rest on the ground, floor or other lower level but not as the result of an overwhelming force (e.g. resident pushes another resident). Unless there is evidence suggesting otherwise, when a resident is found on the floor, a fall is considered to have occurred.
Purpose:
Is to identify residents at risk for falls and establish/modify interventions to decrease the risk of a future fall(s) and minimize the potential for resulting injury.
Review of Resident #2's Clinical Record revealed he was admitted to the facility on [DATE] with diagnoses which included, in part, the following; Encephalopathy; Psychosis Not Due to a Substance or Known Psychological Condition; Generalized Weakness; Lack of Coordination and Difficulty in Walking.
Review of Resident #2's most recent Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 01/09/2023, indicated resident was assessed to have a Brief Interview of Mental Status (BIMS) of 99, which indicated severe cognitive impairment.
Review of Resident #2's current Care Plan revealed, in part, the following:
Problem: At Risk for Falls related to Confusion.
Review of the facility's Fall Log revealed Resident #2 had an unwitnessed fall on 02/04/2023 at 6:28 a.m. and an unwitnessed fall on 02/09/2023 at 1:10 a.m.
Review of the facility's Incident Report #186 for Resident #2 revealed, in part, the following:
Incident Report #186
Date/Time: 02/04/2023 at 6:28 a.m. (handwritten on computerized report by facility staff)
Incident Location: Resident's room
Description: Resident found lying on floor, denied pain, no bruises or pain noted. Physician notified.
Taken to hospital? No
Injury Type: No injuries observed at time of incident.
Review of the facility's Incident Report #195 for Resident #2 revealed, in part, the following:
Incident Report #195
Date/Time: 02/09/2023 at 1:10 a.m. (handwritten on computerized report by facility staff)
Incident Location: Resident's room
Description: Resident slid out of bed onto floor into a seated position. Resident unable to give description.
Taken to hospital? No
Injury Type: No injuries observed at time of incident.
Review of the facility's Multidisciplinary Screening Form for Resident #2 indicated screening was performed on 02/10/2023 by S13RHB following 2 falls on 02/04/2023 at 6:28 a.m. and on 02/09/2023 at 1:10 a.m. Further review revealed resident was indicated to be very confused and unable to comply with safety measures.
On 02/13/2023 at 12:17 p.m., an interview was conducted with S45PT. She stated most days when they attempted to work with Resident #2 he was not capable of comprehending simple instructions or following commands and had very poor safety insight.
On 02/14/2023 at 9:17 a.m., interview was conducted with S44LPN. She stated during her night shift on 02/09/2023, she heard Resident #2 yelling and as she entered the room, he had slung his legs over the bedrails and was sliding out of the bed. She confirmed he came to rest on the ground unassisted by staff. She stated when she asked him what happened, he told her he was getting out of the car to go work on it.
On 02/14/2023 at 9:22 a.m., an interview was conducted with S46CNA. She stated Resident #2 frequently hallucinated and spoke out of his head. She also stated he constantly made attempts to get out of his bed unless someone were present to redirect him. She confirmed she was not aware of any attempts to provide him with 1:1 care and supervision but felt he needed it.
On 02/14/2023 at 9:30 a.m., an interview was conducted with S36LPN. She confirmed following a fall, a resident should receive increased supervision to prevent future falls.
On 02/13/2023 at 11:45 a.m., an interview was conducted with S27DON. He confirmed Resident #2 had experienced 2 unwitnessed falls since being admitted to the facility; once on 02/04/2023 and again on 02/09/2023. He confirmed both falls took place on night shift when resident was in his room lying in bed.
On 02/14/2023 at 11:35 a.m., an interview was conducted with S1ADM. He confirmed Resident #2 was indicated as having 2 unwitnessed falls on their fall log; 02/04/2023 and 02/09/2023.
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
ADL Care
(Tag F0677)
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 a resident who was unable to carry out activ...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, 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 (#4 and #5) of 5 (#1, #2, #3, #4, and #5) residents reviewed for ADLs.
Findings:
Review of the facility's policy titled, Activities of Daily Living revealed the following, in part:
Policy:
To encourage resident choice and participation of ADLs and provide oversight, cuing, and assistance as necessary.
ADLs includes bathing, dressing, grooming, hygiene .
Procedure:
2. CNA will provide needed oversight, cuing or assistance to resident.
Resident #4
Review of the Clinical Record for Resident #4 revealed he was admitted to the facility on [DATE] and had diagnoses which included Parkinson's Disease, Moderate Protein-Calorie Malnutrition, History of Falling, Extrapyramidal and Movement Disorder, and Orthostatic Hypotension.
Review of the Quarterly MDS with an ARD of 01/11/2023 for Resident #4 revealed he had a BIMS of 14, which indicated he was cognitively intact. Further review revealed he required extensive assistance of two staff members for transfers and personal hygiene, extensive assistance of one staff member for dressing, and was totally dependent of one staff member for bathing.
Review of the Nurses Notes for Resident #4 from January 2023 to February 2023 revealed no documentation he had refused baths, shaving, or nail care.
Review of the Bath Schedule provided by the facility revealed Resident #4 had baths scheduled twice weekly on Wednesdays and Saturdays.
Review of the Bath Documentation for Resident #4 from January 2023 to February 2023 revealed he had not received a bath twice weekly the week of 01/29/2023 through 02/04/2023.
An observation was conducted of Resident #4 on 02/14/2023 at 9:08 a.m. His hair was oily, he had facial hair on bilateral sides of his face, a beard, and a mustache that was unkempt. His mustache hair was long and curled over his upper lip. His fingernails had black and brown substances on under them. An interview was conducted with Resident #4 at that time. He stated he did not want facial hair. He stated he could not shave himself and needed a staff member to shave him. He stated there had not been a staff member available to shave him. He stated he needed his nails cleaned and trimmed. He stated he did not get a bath on set days. He stated his preference was daily baths. He stated a lot of times, the staff did not have time to bring him to the shower room so he would have to agree to a bed bath. He stated his options would be a bed bath or no bath so he would choose a bed bath.
An interview was conducted with S19LPN on 02/14/2023 at 10:52 a.m. She confirmed Resident #4 needed assistance with ADLs such as bathing and shaving. She stated Wednesdays and Saturdays were Resident #4's bath days. S19LPN confirmed the staff had to shave Resident #4. She stated Resident #4 could not shave himself related to his tremors. She stated it was the responsibility of the CNA to shave Resident #4 during his baths. She confirmed no staff had reported to her Resident #4 refused any ADLs. She stated if the CNA had reported a refusal to her, she would have documented it in the Nurses' Notes. She confirmed Resident #4 preferred to have a clean shaven face and he currently had full facial hair.
An interview was conducted with S48CNA on 02/14/2023 at 12:28 p.m. She stated the CNAs on the hall were responsible for bathing residents. She stated there was a sign on the kiosk for what rooms got a bath which days. She stated each resident should have been provided nail care and shaving during a bath. She confirmed Resident #4 preferred a clean shaven face. She further confirmed Resident #4 currently had a lot of facial hair that was unkempt, and he needed his face shaved. She confirmed Resident #4 was not capable of shaving his own face.
An interview was conducted with S49CNA on 02/14/2023 at 12:39 p.m. She confirmed she was assigned to Resident #4. She stated Resident #4 required assistance with ADLs. She stated Resident #4 was supposed to receive a bath twice a week. She stated she noticed Resident #4's facial hair was too long and unkempt. She stated she was not aware Resident #4 preferred a clean shaven face. She stated men were supposed to be shaven and nail care provided during a bath.
Resident #5
Review of the Clinical Record for Resident #5 revealed she was admitted to the facility on [DATE] and had diagnoses which included Mild Protein-Calorie Malnutrition, Anxiety, Presence of Right Artificial Hip Joint, History of Falling, Personal History of COVID-19, Unspecified Dementia, and Other Lack of Coordination.
Review of the Significant Change MDS with an ARD of 11/15/2022 for Resident #5 revealed she had a BIMS of 15, which indicated she was cognitively intact. Further review revealed she required extensive assistance of two staff members for bed mobility and one staff member physical assistance for bathing.
Review of the current Physician Orders for Resident #5 revealed the following, in part:
(Start date: 02/03/2022) Resident should be offered bath daily and document if resident received bath or refused. If resident refused, notify RP.
Review of the MARs for Resident #5 dated January 2023 and February 2023 revealed she refused a bath on 01/25/2023. Further review revealed no other documented refusals of baths.
Review of the Nurses Notes for Resident #5 from January 2023 to February 2023 revealed no documentation Resident #5 refused a bath.
Review of the Bath Schedule provided by the facility revealed Resident #5 had baths scheduled twice weekly on Mondays and Thursdays.
Review of the Bath Documentation for Resident #5 from January 2023 to February 2023 revealed she had not received a bath twice weekly. Further review revealed Resident #5 did not receive a bath from 01/14/2023 until 01/28/2023.
An interview was conducted with Resident #5 on 02/13/2023 at 1:42 p.m. She stated her preference was to get a bath every other day. She stated it had been one week since she received a bath. She stated she had not been getting a bath twice weekly.
An interview was conducted with S50LPN on 02/13/2023 at 2:30 p.m. She stated the CNAs were responsible to document when they gave each resident a bath.
An interview was conducted with S4CN on 02/13/2023 at 3:20 p.m. She stated the CNAs were responsible to document each time they bathed a resident.
An interview was conducted with S36LPN on 02/14/2023 at 10:39 a.m. She stated if Resident #5 refused a bath, the CNA would notify her. S36LPN stated she would notify Resident #5's family then document in her Nurses' Notes. She stated Resident #5 had not refused a bath recently.
An interview was conducted with S27DON on 02/14/2023 at 11:00 a.m. He confirmed the only documented bath refusal for Resident #5 was on 01/25/2023. He confirmed if Resident #5 had refused a bath, it should have been documented on the MAR or in the Nurses' Notes.
An interview was conducted with S27DON on 02/14/2023 at 11:45 a.m. He reviewed the bath documentation for Resident #4 and Resident #5. He confirmed Resident #4 had not been bathed twice weekly on the week of 01/29/2023. He stated Resident #4 should have had his face shaved if he preferred it clean shaven. He confirmed there was no documentation indicating Resident #5 had been bathed 01/14/2023 through 01/28/2023 and 02/07/2023 through 02/12/2023. He stated Resident #5 should have been bathed at least twice weekly and he expected the staff to follow the bath schedules for Resident #4 and Resident #5.
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, interviews, and observations, the facility failed to have sufficient certified nursing assistant staff t...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interviews, and observations, the facility failed to have sufficient certified nursing assistant staff to provide direct care and related services to maintain the highest practicable physical, mental, and psychosocial well-being of each resident based on the facility assessment. The deficiency had the potential to affect the facility's total census of 102 residents.
Findings:
Review of the facility's Facility Assessment, updated on 01/25/2022, revealed, in part, the following:
Part 1: Our Resident Profile
Number of residents licensed to provide care for: 121
Average daily census: 101
Part 1.5: Acuity
Major Categories (Based on 6 month trend) with Number/Average or Range or Residents:
Rehabilitation: 24
Reduced Physical Function: 36
Special Treatments and Conditions (Based on 6 month trend) with Number/Average or Range or Residents:
Mental Health:
Behavioral Health Needs: 82
Assistance with Activities of Daily Living (ADLs)
Bathing: 50-Assist of 1-2 staff; 50-Dependent
Dressing: 52-Assist of 1-2 staff; 27-Dependent
Transfer: 38-Assist of 1-2 staff; 30-Dependent
Eating: 69-Assist of 1-2 staff; 21-Dependent
Toileting: 69-Assist of 1-2 staff; 21-Dependent
Mobility: 30-Assistive Device to Ambulate; 64-In Chair Most of Time
Part 3.2: Staffing Plan - Total Number of Staff Needed for 24 hours:
Nurse Aides providing Direct Care: 33
Part 3.3: Individual Staff Assignment:
The staff assignments are based off resident acuity with assigning specific positions, halls, rooms varying between nurses and CNAs.
Review of the facility's Staffing Pattern revealed, in part, the following:
01/18/2023
Census: 103
Staff Assigned: Evening Shift: 8-CNA; Night Shift: 8-CNA
01/19/2023
Census: 104
Staff Assigned: Evening Shift: 7-CNA; Night Shift: 8-CNA
01/20/2023
Census: 103
Staff Assigned: Evening Shift: 8-CNA; Night Shift: 8-CNA
01/21/2023
Census: 103
Staff Assigned: Day Shift: 7-CNA; Evening Shift: 5-CNA; Night Shift: 4-CNA
01/22/2023
Census: 104
Staff Assigned: Day Shift: 7-CNA; Evening Shift: 5-CNA; Night Shift: 4-CNA
01/23/2023
Census: 103
Staff Assigned: Evening Shift: 8-CNA; Night Shift: 8-CNA
01/24/2023
Census: 105
Staff Assigned: Evening Shift: 6-CNA; Night Shift: 8-CNA
01/25/2023
Census: 104
Staff Assigned: Evening Shift: 9-CNA
01/26/2023
Census: 104
Staff Assigned: Evening Shift: 6-CNA; Night Shift: 8-CNA
01/27/2023
Census: 106
Staff Assigned: Evening Shift: 8-CNA; Night Shift: 8-CNA
01/28/2023
Census: 107
Staff Assigned: Day Shift: 9-CNA; Evening Shift: 6-CNA; Night Shift: 5-CNA
01/29/2023
Census: 107
Staff Assigned: Day Shift: 7-CNA; Evening Shift: 5-CNA; Night Shift: 5-CNA
01/30/2023
Census: 107
Staff Assigned: Night Shift: 7-CNA
01/31/2023
Census: 106
Staff Assigned: Evening Shift: 7-CNA; Night Shift: 5-CNA
02/01/2023
Census: 105
Staff Assigned: Evening Shift: 8-CNA; Night Shift: 7-CNA
02/02/2023
Census: 105
Staff Assigned: Evening Shift: 6-CNA; Night Shift: 6-CNA
02/03/2023
Census: 107
Staff Assigned: Evening Shift: 6-CNA; Night Shift: 7-CNA
02/04/2023
Census: 102
Staff Assigned: Day Shift: 9-CNA; Evening Shift: 4-CNA; Night Shift: 5-CNA
02/05/2023
Census: 102
Staff Assigned: Day Shift: 9-CNA; Evening Shift: 4-CNA; Night Shift: 5-CNA
02/06/2023
Census: 101
Staff Assigned: Evening Shift: 6-CNA; Night Shift: 8-CNA
02/07/2023
Census: 102
Staff Assigned: Day Shift: 9-CNA; Evening Shift: 5-CNA; Night Shift: 6-CNA
Review of the facility's CNA Staffing Assignment Sheets, dated 02/12/2023 to 02/14/2023, revealed, in part, the following:
02/12/2023 from 6:00 a.m. to 6:00 p.m.:
6-CNAs; Blank x2 for Whirlpool; and Blank x1 for Restorative Aide.
02/12/2023 from 6:00 p.m. to 6:00 a.m.:
5-CNAs; 1-Float CNA.
02/13/2023 from 6:00 a.m. to 6:00 p.m.
7-CNAs; Blank x2 for Whirlpool; and Blank x1 for Restorative Aide.
02/13/2023 from 6:00 p.m. to 6:00 a.m.
5-CNAs.
02/14/2023 from 6:00 a.m. to 6:00 p.m.:
5-CNAs; 1-CNA (6:00 a.m. to 2:00 p.m.); 1-CNA (7:00 a.m. - 3:00 p.m.); Blank x2 for Whirlpool; and Blank x1 for Restorative Aide.
Resident #4
Review of the Clinical Record for Resident #4 revealed he was admitted to the facility on [DATE] and had diagnoses, which included, Parkinson's Disease; Moderate Protein-Calorie Malnutrition; History of Falling; Extrapyramidal and Movement Disorder; and Orthostatic Hypotension.
Review of the Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 01/11/2023 for Resident #4 revealed he was assessed to have a Brief Interview for Mental Status (BIMS) of 14, which indicated he was cognitively intact. Further review revealed he required extensive assistance of two staff members for transfers and personal hygiene, extensive assistance of one staff member for dressing, and was totally dependent of one staff member for bathing.
Review of the Bath Schedule provided by the facility revealed Resident #4 was to receive baths twice weekly on Wednesdays and Saturdays.
Review of the Bath Documentation for Resident #4 from January 2023 to February 2023 revealed he had not received a bath twice weekly the week of 01/29/2023 through 02/04/2023.
An observation and interview was conducted of Resident #4 on 02/14/2023 at 9:08 a.m. His hair appeared to be oily and looked unkempt. He was observed with facial hair on both sides of his face, a beard, and a mustache that all appeared unkempt. His mustache hair was long and extended past his upper lip. His fingernails were noted with a black and brown substance under them. He confirmed he did not wish to have facial hair but stated he could not shave himself and needed a staff member to shave him. He also confirmed there had not been a staff member available to shave him. He confirmed he needed his nails cleaned and trimmed. He confirmed he did not get a bath on set days but his preference would be to receive daily baths. He stated a lot of times, the staff did not have time to bring him to the shower room. He stated in those instances, his option was to receive a bed bath or no bath so he would choose a bed bath.
Resident #5
Review of the Clinical Record for Resident #5 revealed she was admitted to the facility on [DATE] and had diagnoses, which included, Mild Protein-Calorie Malnutrition; Anxiety; Presence of Right Artificial Hip Joint; History of Falling; Personal History of COVID-19; Unspecified Dementia; and Other Lack of Coordination.
Review of the Significant Change MDS with an ARD of 11/15/2022 for Resident #5 revealed she was assessed to have a BIMS of 15, which indicated she was cognitively intact. Further review revealed she required extensive assistance of two staff members for bed mobility and one staff member physical assistance for bathing.
Review of the Bath Schedule provided by the facility revealed Resident #5 was to receive baths twice weekly on Mondays and Thursdays.
Review of the Bath Documentation for Resident #5 for the months of January 2023 to February 2023 revealed she had not received a bath twice weekly the week of 01/15/2023 through 01/21/2023 nor 01/22/2023 through 01/28/2023. Further review revealed Resident #5 had not received a bath from 01/14/2023 until 01/28/2023.
An interview was conducted with Resident #5 on 02/13/2023 at 1:42 p.m. She stated she would like to get a bed bath every other day while she was on isolation. She stated when she was not on isolation, she would prefer to go to the shower room. She stated it had been a long time since she was able to go to the shower room because she required two staff members to transfer her to the shower chair and there were not enough staff available for her transfer. She confirmed it had been about a week since she had any kind of bath. She also confirmed she was not receiving a bath twice a week.
An interview was conducted with S27DON on 02/14/2023 at 11:45 a.m. He confirmed Resident #4 had not been bathed twice weekly the week of 01/29/2023. He confirmed it was not documented Resident #5 had been bathed from 01/14/2023 until 01/28/2023 and from 02/07/2023 through 02/12/2023. He stated she should have been bathed at least three times during that period and her bath schedule was every Monday and Thursday.
An observation was conducted of morning huddle held with S2IDON, S3ADON, day shift nurses and CNAs at NS H on 02/08/2023 at 6:20 a.m. S2IDON announced a current Census of 102 with 1 resident out of the facility. S2IDON then announced the facility was short CNAs for today but would be attempting to locate fill ins by calling staff members who were currently off and/or pulling people from their assigned duties and putting them on the floor. S2IDON stated they would immediately be pulling one of the transportation drivers from taking people to appointments and putting them on the floor until they could locate other alternatives for direct care.
An interview was conducted with S50LPN on 02/13/2023 at 2:30 p.m. She confirmed the facility did not have enough staff to be able to bring each resident to the shower room for a bath or shower on their scheduled bath days. She stated they no longer had shower aide and there were barely any CNAs.
An interview was conducted with S49CNA on 02/14/2023 at 12:39 p.m. She stated today her assigned section was rooms 46 to 53. She stated her assignment included 10 residents that needed a bath during her shift per the facility's bath schedule. She confirmed with that number, she was not able to get each resident to the shower room, so she had to provide bed baths. She confirmed there were many times when there was not enough staff to give each resident showers/baths so they received bed baths instead. She further confirmed it had been impossible to complete all of her tasks, round on every resident every two hours, and bring each resident to the shower room.
An interview was conducted with S46CNA on 02/14/2023 at 1:00 p.m. She stated her current assignment was rooms 31 to 45. She confirmed there was not a shower aide and she was not able to complete all of her tasks during her shift because she had too many residents to take care of. She stated most days she did not get a lunch break. She confirmed it had not been possible to complete all of her tasks, feed dependent residents, round on every resident every two hours, and give baths. She stated today she had 10 residents that were scheduled to receive a bath. She stated there was no way she could get all of the baths done today. She confirmed there were many days she could not get baths done and had to tell the residents they had to wait until the following day to get their bath because she did not have time. She stated she had communicated the staffing concerns with administration and that S27DON was aware. She stated the staffing in the facility was unbelievable. She confirmed, at times, residents had not been fed timely because she had 3 residents to be fed and she could only feed one at a time.
An observation was conducted of S52CNA on 02/14/2023 at 1:48 p.m. She was observed exiting Resident #R24's room with a Hoyer Lift. Resident #R24's room was observed without another staff member present.
An interview was conducted with S52CNA on 02/14/2023 at 1:50 p.m. She confirmed she had used the Hoyer Lift to transfer Resident #R24 without the assistance of another staff member. She then confirmed she knew she was supposed to use two staff members for a Hoyer Lift transfer, but she had been on the hall by herself and could not find anyone to assist her. She also confirmed since the facility was so short staffed, she had frequently performed Hoyer Lift transfers independently. She stated she was assigned rooms 21-30 with two residents per room. She stated she had two residents that required feeding at each meal. She stated there was not enough direct care staff in the facility to allow her to perform all of her duties. She confirmed she had not been able to perform all of her baths per the bathing schedule because she did not have time. She stated at times she had to give residents a wipe off, but not a full bed bath.
An interview was conducted with S4CN on 02/14/2023 at 2:08 p.m. She confirmed she would expect all Hoyer Lift transfers to be conducted with the assistance of two staff members.
A telephone interview was conducted with S43LPN on 02/09/2023 at 3:40 p.m. She confirmed she had worked 6:00 p.m. to 6:00 a.m. last night and was assigned to NS H. She also confirmed there were only 4 CNAs in the facility for the night shift last night.
An interview was conducted with S5CNA on 02/09/2023 at 10:24 a.m. She confirmed she had been one of only 4 CNAs working the night shift on 02/08/2023 and was assigned to Hall C. She also confirmed she had tested positive for COVID-19 during her shift at 11:06 p.m. She then confirmed she had not left the facility immediately because she would not leave them short staffed; so, she stayed to work the remainder of her shift and left the facility around 6:00 a.m. on 02/09/2023.
An interview was conducted with S51CNA on 02/14/2023 at 1:50 p.m. She stated she was responsible for bathing/showering an average of 15 to 16 residents per shift and providing incontinent care for roughly 15 residents. She also stated she was responsible for feeding 3 residents all of their meals and providing them with fluids throughout her shift. She stated CNAs were also expected to round on all of their residents every 2 hours. She then confirmed it had been impossible for her to always get all of her tasks done during her shift due to the workload. She stated she had tried as best as she could, but stated a soiled incontinent resident may have to wait until bath time to be changed and then would only receive a really quick wipe down bed bath and change of their brief. She stated the nurses have tried to help when they could, but they had their own stuff to do which limited what they were available to help with.
An interview was conducted with S48CNA on 02/14/2023 at 1:50 p.m. She confirmed she normally worked as the Restorative Care Aide but had been pulled from her job duties to work the floor as a CNA on a more regular basis lately. She also confirmed she had been pulled to work the floor today because they were short CNAs. She then confirmed when she was pulled to work the floor, no one else performed her duties as the Restorative Care Aide, and she provided Restorative Aide services to 12 residents in the facility. She stated today she was responsible for rounding on all of her assigned residents every two hours, bathing/showering 16 or 17 residents, providing incontinent care for roughly 10 to 18 residents, feeding 3 residents for all of their meals and providing them with fluids throughout her shift. She confirmed it had been impossible for one person to get all of the tasks completed properly and thoroughly during one shift.
An interview was conducted with S1ADM on 02/14/2023 at 1:22 p.m. He confirmed the following daily staffing ratios for CNAs based on the current facility assessment: Day Shift (6: 00 a.m. - 6:00 p.m.) - 10 CNAs; Day/Afternoon Shift (4:00 p.m. - 6:00 p.m.) - 9 CNAs; and Night Shift (6:00 p.m. - 6:00 a.m.) - 9 CNAs. He stated the facility had multiple staff that worked the floor from 6:00 a.m. to 2:00 p.m. or 8:00 a.m. to 4:00 p.m. He stated he also had other direct care floor staff who worked 12 hour shifts from 6:00 a.m. to 6:00 p.m. and those would indicate the people listed as working the Evening Shift on the Staffing Pattern. He confirmed he was not aware the CNAs were unable to get their work done timely related to staffing concerns.
Jan 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
Report Alleged Abuse
(Tag F0609)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews, the facility failed to ensure alleged violations of sexual abuse were reported immediate...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews, the facility failed to ensure alleged violations of sexual abuse were reported immediately, but not later than 2 hours after the allegation was made, to the administrator and to other officials in accordance with State law for 1 (#R1) of 7 (#1, #2, #3, #4, #5, #R1, #R2) residents reviewed for abuse.
Findings:
A review of the facility's Abuse, Neglect, Exploitation and Misappropriation Policies revealed the following:
Policy: It is inherent in the nature and dignity of each resident at the center that he/she be afforded basic human rights, including the right to be free from abuse, neglect, mistreatment, exploitation and/or misappropriation of property.
Definitions: Sexual Abuse is nonconsensual sexual contact of any type with a resident. Sexual abuse includes but is not limited to:
-Unwanted intimate touching of any kind especially of breast or perineal area
Generally, sexual contact is nonconsensual if the resident either:
-Does not want the contact to occur
Procedure: Acts of abuse directed against residents are absolutely prohibited.
The Administration of the company recognizes that resident abuse can be committed by other residents, visitors, or volunteers.
Any employee or contracted service provider who witnesses or has knowledge of an act of abuse or an allegation of abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, to a resident, is obligated to report such information immediately, but no later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in seriously bodily injury, to the Administrator and to other officials in accordance with State Law.
A review of the clinical record for Resident #R1 revealed the resident was admitted to the facility on [DATE] and had diagnoses which included Acquired Absence of Right Leg Above Knee, Unspecified Dementia Unspecified Severity with Other Behavioral Disturbances, Persistent Mood (Affective) Disorder.
A review of the MDS with an ARD of 10/10/2022 revealed Resident #R1 was assessed by the facility to have a BIMS of 15 which indicated he was cognitively intact.
On 01/09/2023 at 2:00 p.m., an interview was conducted with Resident #R1. Resident #R1 stated he had been inappropriately touched. He stated Resident #R2 started to massage his left leg and she scratched his private area. He could not recall when the incident occurred. He stated everybody knew about it. He stated he reported the incident to S1Admin.
On 01/09/2023 at 3:25 p.m., an interview was conducted with S1Admin. S1Admin stated no allegations of inappropriate touching was brought to his attention regarding Resident #R1. S1Admin stated Resident #R1 asked if he could just talk to Resident #R2 and requested to be separated.
On 01/10/2023 at 10:36 p.m. an interview was conducted with Resident #R2. Resident #R2 stated Resident #R1 accused her of touching his privates. She denied touching Resident #R1 privates. She stated she recalled patting him on his knee in a non-sexual manner or intent. She stated S1Admin informed her of Resident #R1 request to be separated but no allegations were made aware to her at this time.
On 01/10/2023 at 11:04 a.m., an interview was conducted with S6LPN. S6LPN stated on 01/04/2023, Resident #R1 reported Resident #R2 was in his room and was patting him on his leg then grabbed his wiener so hard she scratched it. S6LPN asked Resident #R1 if he reported it to anyone else and he said, no, why should I, no one is going to do anything about it. S6LPN stated she did not report the allegation to anyone. S6LPN confirmed the allegation should have been reported to S1Admin.
On 01/11/2023 at 8:55 a.m., an interview was conducted with Resident #R1. He restated he felt he was inappropriately touched by Resident #R2. He stated Resident #R2 began to rub his leg, caressed further up his leg, grabbed and scratched his penis. He stated he did not want or encourage this action. Resident #R1 stated he could not recall what he reported to S1Admin.
On 01/11/2023 at 9:30 a.m., an interview was conducted with S1Admin. S1Admin stated Resident # R1 told him Resident #R2 touched his stump and he wished for Resident #R2 to not be around him anymore. S1Admin stated he asked the resident at this time if he felt this was an act of sexual harassment or inappropriate touching and resident said No. S1Admin stated he had no suspicions of sexual harassment or inappropriate touching at this time and an incident report nor a state mandated facility investigation report had been filed. S1Admin stated had the incident been reported as inappropriate or unwanted touching he would have immediately opened up an investigation. S1Admin stated he did talk with Resident #R2 as requested by Resident #R1. S1Admin stated Resident #R1 and Resident #R2 were separated to prevent any further contact between the individuals and no other incidents had been reported.
On 01/11/2023 at 9:45 a.m., an interview was conducted with S7LPN. S7LPN stated Resident #R1 reported to her that Resident #R2 came to his room and touched his private parts. She stated she did not document anything regarding the incident, but she verbally reported the allegations to S8LPN.
On 01/11/2023 at 10:00 a.m., an interview was conducted with S8LPN. S8LPN stated she was never made aware of any allegations of a resident inappropriately touching Resident #R1.
On 01/11/2023 at 10:40 a.m., an interview was conducted with S14DA. S14DA stated a couple of weeks ago Resident #R1 reported he was inappropriately touched by another resident. He stated he was not made aware of who touched him. He stated he did not report the allegations to anyone.
On 01/11/2023 at 11:10 a.m., an interview was conducted with S1Admin. S1Admin stated if allegations of inappropriate touching were brought forth to any staff's attention, the facility policy should have been followed and allegations reported to him immediately.
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 reviews and interviews, the facility failed to ensure a resident's comprehensive plan of care was implemented fo...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews and interviews, the facility failed to ensure a resident's comprehensive plan of care was implemented for 5 of 5 (#1, #2, #3, #4 and #5) residents reviewed. The facility failed to ensure vital signs were obtained according to the Physician's Orders for Residents #1, #2, #3, #4 & #5.
Findings:
Resident #1
Review of the clinical record for Resident #1 revealed the resident was admitted to the facility on [DATE]. The resident had diagnoses that included Essential Hypertension, Type II Diabetes Mellitus with Diabetic Neuropathy, Acute Myocardial Infarction, Dependence on Supplemental Oxygen, Hyperlipidemia, Benign Intracranial Hypertension, Acute Kidney failure, unspecified, Localized Edema, Hypokalemia, and Hypomagnesemia.
Review of the most recent MDS with and ARD of 11/08/2022 revealed Resident #1 was assessed by the facility to have a BIMS of 13 which indicated cognitively intact.
Review of Resident #1's most current care plan revealed the following:
Problem: I have potential for alteration in cardiac output due to Hypertension, History of MI.
Goal: I will remain free of complications related to hypertension.
Interventions: Give antihypertensive medications as ordered. Observe for side effects such as orthostatic hypotension and increased heart rate (tachycardia) and effectiveness. Observe/report and signs and symptoms of malignant hypertension: headache, visual problems, confusion, disorientation, lethargy, nausea, and vomiting, irritability, seizure activity, difficulty breathing (dyspnea).
Review of Resident #1's current Physician Orders revealed the following:
Order date 01/29/2022: Amlodipine Besylate tablet 5mg by mouth for Hypertension related to Essential (Primary) Hypertension
Order date 01/29/2022: Metoprolol Succinate 50mg tablet extended release 24 hour give one tablet by mouth for Hypertension related to Essential (Primary) Hypertension
Order date 02/11/2022: Triamterene-HCTZ 37.5-25mg tablet give one tablet by mouth for fluid retention and hypertension related to essential (primary) Hypertension; localized edema
Order date 01/29/2022: Vital signs every shift
Review of Resident #1's vital signs log dated 10/18/2022-01/10/2023 revealed missing vital signs on the following dates indicating physician's orders were not followed:
10/18/2022, 10/19/2022, 10/20/2022, 10/21/2022, 10/23/2022, 10/26/2022, 11/01/2022, 11/02/2022, 11/03/2022, 11/04/2022, 11/05/2022, 11/06/2022, 11/07/2022, 11/11/2022, 11/12/2022, 11/13/2022, 11/14/2022, 11/20/2022, 11/21/2022, 11/22/2022, 11/25/2022, 11/29/2022, 11/30/2022, 11/31/2022, 12/01/2022, 12/02/2022, 12/03/2022. 12/04/2022, 12/05/2022, 12/06/2022, 12/07/2022, 12/08/2022, 12/09/2022, 12/10/2022, 12/11/2022, 12/12/2022, 12/13/2022, 12/14/2022, 12/15/2022, 12/16/2022, 12/17/2022, 12/18/2022, 12/19/2022, 12/20/2022, 12/21/2022, 12/22/2022, 12/23/2022, 12/24/2022, 12/25/2022, 12/27/2022, 12/29/2022, 12/30/2022, 12/31/2022, 01/01/2023, 01/03/2023, 01/04/2023, 01/06/2023, 01/07/2023 and 01/09/2023.
Resident #2
Review of the clinical record for Resident #2 revealed the resident was admitted to the facility on [DATE]. The resident had diagnoses that included Paraplegia, Pressure Ulcer Stage 4 Sacrum, Anxiety, Neurogenic Bowel, Chronic Pain, Hypertension, GSW to low back and right leg in April 2021 resulting in Paraplegia, and Tachycardia.
A review of the MDS with an ARD of 12/09/2022, revealed Resident #2 was assessed by the facility to have a BIMS of 15, which indicated he was cognitively intact.
Review of Resident #2's most current care plan revealed the following:
Problem: Resident #2 has hypertension and tachycardia
Goal: Resident #2 will remain free from signs and symptoms of hypertension through the review date.
Interventions: Give medications as ordered. Observe for side effects such as orthostatic hypotension and increased heart rate and effectiveness.
Review of Resident #2's current Physician Orders dated revealed the following:
Order date: 11/11/2022 Vital signs every shift
Order date: 11/03/2022 Metoprolol Succinate 100mg Give one tablet by mouth two times a day related to essential hypertension
Review of Resident #2's Vital Sign log dated 11/01/2022-01/09/2023 revealed missing vital signs on the following dates indicating physician's orders were not followed:
11/06/2022, 11/05/2022, 11/09/2022, 11/10/2022, 11/11/2022, 11/13/2022, 11/14/2022, 11/15/2022, 11/16/2022, 11/17/2022, 11/18/2022, 11/19/2022, 11/20/2022, 11/21/2022, 11/22/2022, 11/24/2022 -12/01/2021, 12/02/2022, 12/03/2022, 12/04/2022. 12/05/2022, 12/06/2022, 12/07/2022, 12/08/2022, 12/09/2022, 12/10/2022, 12/11/2022, 12/12/2022, 12/13/2022, 12/14/2022, 12/15/2022, 12/16/2022, 12/17/2022, 12/18/2022, 12/19/2022, 12/20/2022, 12/21/2022, 12/22/2022, 12/23/2022, 12/24/2022 and 12/25/2022.
Resident #3
Review of the clinical record for Resident #3 revealed the resident was admitted to the facility on [DATE]. The resident had diagnoses which included Hemiplegia and Hemiparesis following Cerebral Infarction affection left non-dominant side, Type 2 Diabetic Mellitus with Hyperglycemia, Secondary Hypertension and Glaucoma.
Review of the most recent MDS with and ARD of 11/08/2022 revealed Resident #3 was assessed by the facility to have a BIMS of 15 which indicated the cognitively intact.
Review of Resident #3's most current care plan revealed the following:
Problem: I have Hypertension
Goal: I will remain free of complications related to hypertension.
Interventions: Give antihypertensive medications as ordered. Observe for side effects such as orthostatic hypotension and increased heart rate (tachycardia) and effectiveness. Observe/report and signs and symptoms of malignant hypertension: headache, visual problems, confusion, disorientation, lethargy, nausea, and vomiting, irritability, seizure activity, difficulty breathing (dyspnea). Report significant changes to the MD.
Review of Resident #3's current Physician Orders revealed the following:
Order date 05/13/2022: Lisinopril 2.5mg tablet give one tablet by mouth at bedtime related to Secondary Hypertension
01/19/2022 Vital signs every shift, Discontinue 01/10/2023 at 2:42 p.m.
Review of Resident #3's Vital Sign log dated 11/01/2022-01/09/2023 revealed missing vital signs on the following dates indicating physician's orders were not followed:
11/01/2022, 11/02/2022, 11/05/2022, 11/06/2022, 11/07/2022, 11/09/2022, 11/13/2022, 11/14/2022, 11/15/2022, 11/16/2022, 11/17/2022, 11/18/2022, 11/19/2022, 11/20/2022, 11/21/2022, 11/22/2022, 11/24/2022, 11/25/2022, 11/26/2022, 11/28/2022, 11/29/2022, 11/30/2022, 11/31/2022, 12/01/2022, 12/03/2022, 12/04/2022, 12/05/2022, 12/06/2022, 12/07/2022, 12/08/2022, 12/09/2022, 12/10/2022, 12/11/2022, 12/12/2022, 12/13/2022, 12/14/2022, 12/15/2022, 12/16/2022, 12/17/2022, 12/18/2022, 12/19/2022, 12/20/2022, 12/21/2022, 12/22/2022, 12/23/2022, 12/24/2022, 12/25/2022, 12/26/2022, 12/27/2022, 12/28/2022, 12/29/2022, 12/30/2022, 12/31/2022, 01/03/2023, 01/05/2023, 01/06/2023, 01/07/2023, 01/08/2023, 01/09/2023.
Resident #4
Review of the clinical record for Resident #4 revealed the resident was admitted to the facility on [DATE]. The resident had diagnosis that included Parkinson's disease, Essential (Primary) Hypertension.
Review of the most recent MDS with an ARD of 12/23/2022 revealed Resident #4 was assessed by the facility to have a BIMS of 12 which indicated mild cognitive impairment.
Review of Resident #4's most current care plan revealed the following:
Problem: Resident #4 has altered cardiovascular status related to Hypertension, Hyperlipidemia
Interventions: Monitor vital signs every shift, notify physician of significant abnormalities.
Review of Resident #4's current Physician Orders revealed the following:
Vital Signs: vital signs every shift
Start Date: 06/09/2022 Discontinued: 01/10/2023.
Review of Resident #4's Vital Sign log dated 11/01/2022-01/09/2023 revealed missing vital signs on the following dates indicating physician's orders were not followed:
11/01/2022, 11/03/2022, 11/04/2022, 11/05/2022, 11/06/2022, 11/07/2022, 11/08/2022, 11/12/2022, 11/18/2022, 11/18/2022, 11/19/2022, 11/20/2022, 11/23/2022, 11/24/2022, 11/25/2022, 11/26/2022, 11/27/2022, 11/28/2022, 11/29/2022, 11/30/2022, 12/01/2022, 12/02/2022, 12/03/2022, 12/04/2022, 12/05/2022, 12/06/2022, 12/07/2022, 12/08/2022, 12/09/2022, 12/10/2022, 12/11/2022, 12/12/2022, 12/13/2022, 12/14/2022, 12/15/2022, 12/16/2022, 12/17/2022, 12/18/2022, 12/19/2022, 12/20/2022, 12/22/2022, 12/23/2022, 12/24/2022, 12/25/2022, 12/26/2022, 12/27/2022, 12/28/2022, 12/29/2022, 12/30/2022, 12/31/2022, 01/01/2023, 01/03/2023, 01/04/2023, 01/05/2023, 01/06/2023, 01/07/2023, 01/08/2023, 01/09/2023.
Resident #5
Review of the clinical record for Resident #5 revealed the resident was admitted to the facility on [DATE]. The resident had diagnosis that included Essential (Primary) Hypertension, Hyperlipidemia, and Type 2 Diabetes Mellitus.
Review of the most recent MDS with and ARD of 11/08/2022 revealed Resident #5 was assessed by the facility to have a BIMS of 15 which indicated cognitively intact.
Review of Resident #5's current care plan revealed the following:
Problem: Resident #5 has altered cardiovascular status related to Hypertension, Hyperlipidemia
Interventions: monitor vital signs every shift
Review of Resident #5's current Physician Orders revealed the following:
Vital Signs: vital signs every shift
Start Date: 06/09/2022 Discontinued: 01/10/2023.
Review of Resident #5's Vital Sign log dated 11/01/2022-01/09/2023 revealed missing vital signs on the following dates indicating physician's orders were not followed:
11/23/2022, 11/24/2022, 11/25/2022, 11/26/2022, 11/27/2022, 11/28/2022, 11/29/2022, 11/30/2022, 12/01/2022, 12/02/2022, 12/03/2022, 12/04/2022, 12/05/2022, 12/06/2022, 12/07/2022, 12/08/2022, 12/09/2022, 12/10/2022, 12/11/2022, 12/12/2022, 12/13/2022, 12/14/2022, 12/15/2022, 12/16/2022, 12/17/2022, 12/18/2022, 12/19/2022, 12/20/2022, 12/22/2022, 12/23/2022, 12/24/2022, 12/25/2022, 12/26/2022, 12/27/2022, 12/28/2022, 12/29/2022, 12/30/2022, 12/31/2022, 01/01/2023, 01/03/2023, 01/04/2023, 01/05/2023, 01/06/2023, 01/07/2023, 01/08/2023, 01/09/2023.
On 01/10/2023 at 1:00 p.m., an interview was conducted with S2DON. She confirmed the Physician Orders for Residents #1, #2, #3, #4 and #5 as being vital signs every shift. She stated as the order was written she would expect vitals to be taken twice a day. She confirmed on the above dates, nursing staff did not obtain vital signs or follow the physician orders.
Nov 2022
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
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 reviews and interviews, the facility failed to inform the resident and resident's responsible party (RP) of a re...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews and interviews, the facility failed to inform the resident and resident's responsible party (RP) of a resident's change in condition related to abnormal lab report with new physician's orders for 1 (#1) of 5 (#1, #2, #3, #4, #5) total sampled residents reviewed for Lab Services. This deficient practice had the potential to affect any of the 91 resident's residing in the facility.
Findings:
Review of facility's policy titled: Laboratory, Diagnostic and X-Ray Revised dated 06/21/2021 revealed, in part:
Policy:
To provide guidance on ordering, obtaining, documenting, and reporting laboratory, diagnostic and x-ray results.
Procedure:
Document notification of the practitioner and resident/resident representative of results
Laboratory work, diagnostic testing and x-rays to be filed in the electronic medical record
Resident #1 admitted to the facility on [DATE]. Her diagnoses included, in part: Spinal Stenosis, Lumber region with Neurogenic Claudication, Functional Quadriplegia, Major Depressive Disorder, Recurrent, Essential Hypertension, Unspecified.
Review of Resident #1's lab results revealed a written physician order dated 07/12/2022 on the lab report for Macrobid 100mg 1 tablet by mouth BID for 10 days and K-Dur 40meq by mouth twice daily x 2 doses.
Review of Nurse's Notes dated 07/12/2022 revealed no documentation of the family representative or Resident #1 being notified of the new order for Macrobid for UTI or K-Dur.
On 11/01/2022 at 3:15 p.m., an interview was conducted with S2LPN. She stated the facility's process when a new medication is ordered or a change in resident's condition is noted, the nursing staff notified the resident representative and resident. She said they should document it in the nurse's notes. She verified there was no documentation that the resident representative or resident had been notified of Resident #1's change in condition or new order for Macrobid or K-Dur on 07/12/2022.
On 11/01/2022 at 3:30 p.m., an interview was conducted with S1DON. She verified the resident representative and resident should have been notified when Resident #1's changed medical condition was identified and a new medication ordered on 07/12/2022 for Macrobid and K-Dur. She verified the resident nor the resident representative was notified of these changes.
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
Medical Records
(Tag F0842)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to ensure all residents' medications were documented and maintained o...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to ensure all residents' medications were documented and maintained on the Medication Administration Record in accordance with accepted professional standards and practices for 1 (#1) of 5 (#1, #2, #3, #4, #5) sampled residents. There were 91 residents currently residing in the facility according to the facility census.
Findings:
Review of the facility's Policy & Procedure titled: Administering Medications revealed, in part:
Medications are administered in a safe and timely manner, and as prescribed.
Policy Interpretation and Implementation, in part:
21. If a drug is withheld, refused, or given at a time other than the scheduled time, the individual administering the medications shall initial and circle the MAR space provided for that drug and dose.
22. The individual administering the medication initials the resident's MAR on the appropriate line after giving each medication and before administering the next ones.
Resident #1 was admitted on [DATE]. Her diagnoses included, in part: Spinal Stenosis, Lumber region with Neurogenic Claudication, Functional Quadriplegia, Major Depressive Disorder, Recurrent, Essential Hypertension, Unspecified.
Review of Resident #1's Physician Orders revealed the following:
Cymbalta 20 mg capsule by mouth one time daily: start date 08/25/2022
Garlic tablet 1 tablet by mouth daily: start date 08/20/2022
Geritol complete w/ Vitamins tablet 1 tablet by mouth daily: start date 08/20/2022
Ginko Biloba 60mg tablet 1 tablet by mouth one time daily: start 08/20/2022
Lasix 20mg tablet 1tablet by mouth every other day: start date 11/10/2021
Magnesium Oxide 500mg tablet 1 tablet by mouth every evening: start date 10/31/2021
Multivitamin tablet 1 tablet by mouth once daily: start date 12/10/2021
Omega 3-6.9 oral capsule 1 capsule by mouth once daily: start date 08/20/2022
Oscal 500/200 D3 tablet 1 tablet by mouth once daily: start date 11/13/2021
Protonix 40 mg tablet 1 tablet by mouth every day: start date 05/27/2022
Vitamin D3 125mcg tablet 1 tablet by mouth once daily: start date 11/13/2021
Zinc 50mg tablet 1 tablet by mouth once daily: start date 08/20/2022
Systane solution 0.4-0.3% Instill 1 drop in both eyes twice a day for dry eyes: start date 02/22/2022
Voltaren gel 1% apply to knees, fingers, upper back BID for pain: start date 05/23/2022
Review of the August 2022 MAR revealed the following medications were not documented as administered:
Cymbalta 20 mg capsule by mouth one time daily: 08/25/2022 entry blank.
Garlic tab 1 tab by mouth daily: 08/22/2022 entry blank.
Geritol complete w/ Vitamins 1 tab by mouth daily: 08/22/2022 entry blank.
Ginko Biloba 60mg tab by mouth one time daily: 08/21/2022, 08/22/2022 entries blank.
Lasix 20mg tab 1tab by mouth every other day: 08/13/2022 entry blank.
Magnesium Oxide 500mg tab 1 tab by mouth every evening: 08/12/2022, 08/13/2022, 08/18/2022, 08/21/2022-08/23/2022 entries blank.
Multivitamin tab 1 tab by mouth once daily: 08/12/2022-08/13/2022, 08/18/2022, 08/22/2022 entries blank.
Omega 3-6.9 oral capsule by mouth once daily: 08/22/2022 entry blank.
Oscal 500/200 D3 1 tab by mouth once daily: 08/12/2022-08/14/2022, 08/18/2022, 08/21/2022-08/23/2022 entries blank.
Protonix 40 mg tab by mouth every day: 08/12/2022-08/14/2022, 08/18/2022, 08/22/2022 entries blank.
Vitamin D3 125mcg 1 tab by mouth once daily: 08/12/2022-08/14/2022, 08/18/2022, 08/21/2022-08/23/2022 entries blank.
Zinc 50mg tab 1 by mouth once daily: 08/22/2022 entry blank.
Systane solution 0.4-0.3% Instill 1 drop in both eyes twice a day for dry eyes: 08/12-08/14/2022, 08/18/2022, 08/21/2022 and 08/22/2022 entries blank.
Voltaren gel 1% apply to knees, fingers, upper back BID for pain: 08/12/2022-08/14/2022 AM & PM, 08/18/2022 AM & PM, 08/21/2022 AM & PM, 08/22/2022 AM & PM, 08/23/2022 PM dose entries blank.
Review of September 2022 MAR revealed the following medications were not documented as administered:
Garlic 1 tab by mouth daily: 09/05/2022, 09/09/2022, 09/11/2022, 09/15/2022, 09/19/2022, 09/23/2022-09/25/2022, 09/28/2022-09/29/2022 entries blank.
Geritol Complete w/ Iron 1 tab by mouth once daily: 09/05/2022, 09/09/2022, 09/11/2022, 09/15/2022, 09/19/2022, 09/23/2022-09/25/2022, 09/28/2022-09/29/2022 entries blank.
Ginko Biloba 1 tab by mouth once daily: 09/05/2022, 09/09/2022, 09/11/2022, 09/15/2022, 09/19/2022, 09/23/2022-09/25/2022, 09/28/2022-09/29/2022 entries blank.
Lasix 20mg tab by mouth every other day: 09/24/2022, 09/28/2022 entries blank.
Magnesium Oxide tab 500mg by mouth once daily: 09/05/2022, 09/09/2022, 09/11/2022, 09/15/2022, 09/19/2022, 09/23/2022-09/26/2022, 09/28/2022-09/29/2022 entries blank.
Multivitamin tab 1 by mouth once daily: 09/05/2022, 09/09/2022, 09/11/2022, 09/15/2022, 09/19/2022, 09/23/2022-09/25/2022, 09/28/2022-09/29/2022 entries blank.
Omega 3-6-9 capsule by mouth once daily: 09/05/2022, 09/09/2022, 09/11/2022, 09/15/2022, 09/19/2022, 09/23-09/25/2022, 09/28-09/29/2022 entries blank.
Oscal 500/200 D3 tab 1 tab by mouth once daily: 09/05/2022, 09/09/2022, 09/11/2022, 09/15/2022, 09/19/2022, 09/23-09/25/2022, 09/28-09/29/2022 entries blank.
Protonix 40mg tab 1 tab by mouth once daily: 09/05/2022, 09/09/2022, 09/11/2022, 09/15/2022, 09/19/2022, 09/23-09/25/2022, 09/28-09/29/2022 entries blank.
Vitamin D3 125mcg tab 1 tab by mouth once daily: 9/05/2022, 09/09/2022, 09/11/2022, 09/15/2022, 09/19/2022, 09/23-09/25/2022, 09/28-09/29/2022 entries blank.
Zinc 50mg tab 1 tab by mouth once daily: 09/05/2022, 09/09/2022, 09/11/2022, 09/15/2022, 09/19/2022, 09/23-09/25/2022, 09/28-09/29/2022 entries blank.
Systane solution 0.4-0.3% Instill 1 drop both eyes BID for dry eyes: 09/05/2022 AM& PM, 09/09/2022 AM&PM, 09/11/2022 AM& PM, 09/15/2022 AM&PM, 09/19/2022 AM&PM, 09/23-09/25/2022 AM&PM, 09/28-09/29/2022 AM&PM entries blank.
Voltaren gel 1% apply to knees, fingers, upper back BID for pain: 09/05/2022 AM& PM, 09/09/2022 AM&PM, 09/11/2022 AM& PM, 09/14/2022 PM, 09/15/2022 AM&PM, 09/19/2022 AM&PM, 09/23-09/25/2022 AM&PM, 09/28-09/29/2022 AM&PM entries blank.
Review of October 2022 MAR revealed the following medications were not documented as administered:
Protonix 40 mg tab 1 tab by mouth once daily: 10/4/2022, 10/7/2022, 10/9/2022, 10/12/2022, 10/18/2022, 10/21/2022, 10/22/2022, 10/31/2022 entries blank.
Vitamin D3 125mcg tab 1 tab by mouth once daily: 10/4/2022, 10/7/2022, 10/9/2022, 10/12/2022, 10/18/2022, 10/21/2022, 10/22/2022, 10/31/2022 entries blank.
Zinc 50mg tab 1 tab by mouth once daily: 10/4/2022, 10/7/2022, 10/9/2022, 10/12/2022, 10/18/2022, 10/21/2022, 10/22/2022, 10/31/2022 entries blank.
MVI tab 1 by mouth once daily: 10/4/2022, 10/7/2022, 10/9/2022, 10/12/2022, 10/18/2022, 10/21/2022, 10/22/2022 and 10/31/2022 entries blank.
Omega 3-6-9 capsule by mouth once daily: 10/4/2022, 10/7/2022, 10/9/2022, 10/12/2022, 10/18/2022, 10/21/2022, 10/22/2022 and 10/31/2022 entries blank.
Oscal 500/200 D3 tab 1 tab by mouth once daily: 10/4/2022, 10/7/2022, 10/9/2022, 10/12/2022, 10/18/2022, 10/21/2022, 10/22/2022 and 10/31/2022 entries blank.
Magnesium Oxide tab 500mg by mouth once daily: 10/4/2022,10/7/2022, 10/9/2022, 10/12/2022, 10/18/2022, 10/21/2022, 10/22/2022 and 10/31/2022 entries blank.
Lasix 20mg tab by mouth every other day:10/4/2022, 10/12/2022, 10/18/2022, and 10/22/2022 entries blank.
Ginko Biloba 1 tab by mouth once daily: 10/4/2022, 10/7/2022, 10/9/2022, 10/12/2022, 10/18/2022, 10/21/2022, 10/22/2022, and 10/31/2022 entries blank.
Garlic 1 tab by mouth daily: 10/4/2022, 10/7/2022, 10/9/2022, 10/12/2022, 10/18/2022, 10/21/2022, 10/22/2022, and 10/31/2022 entries blank.
Geritol Complete w/ Iron 1 tab by mouth once daily: 10/4/2022, 10/7/2022, 10/9/2022, 10/12/2022, 10/18/2022, 10/21/2022, 10/22/2022, and 10/31/2022 entries blank.
Systane Solution 0.4-0.3% - 1 drop in both eyes twice a day for dry eyes: 10/4/2022, 10/7/2022, 10/9/2022, 10/12/2022, 10/18/2022, 10/21/2022, 10/22/2022 and 10/31/2022 AM entries blank.
Voltaren gel 1% topical apply to knees-fingers-upper back BID for pain: 10/4/2022 AM & PM, 10/7/2022 AM, 10/9/2022 AM & PM, 10/12/2022 AM & PM, 10/18/2022 AM & PM, 10/21/2022 AM & PM, 10/22/2022 AM & PM, and 10/31/2022 AM entries blank.
Review of Nurses Notes from August to October 2022 revealed there was no documentation of Resident #1 refusing to take medications.
On 11/01/2022 at 1:50 p.m., an interview was conducted with S2LPN. She confirmed the facility's process for documentation of refusals of medications on MARs should be indicated by a #2 and nurses' initials in the entry box on the MAR and in the nurses' notes. She stated if a box on the MAR is blank, it meant the medication was either given, but not documented; omitted; or the nurse failed to document the refusal of the medication.
On 11/01/2022 at 1:55 p.m. an interview was conducted with S1DON. She confirmed the missing documentation as stated above on the August, September, and October 2022 MAR for Resident #1. She said licensed staff should always document if they administered the medication and/or if it was refused.
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
- "What changes have you made since the serious inspection findings?"
- "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
- • Multiple safety concerns identified: 5 life-threatening violation(s), 1 harm violation(s), $248,719 in fines, Payment denial on record. Review inspection reports carefully.
- • 43 deficiencies on record, including 5 critical (life-threatening) violations. These warrant careful review before choosing this facility.
- • $248,719 in fines. Extremely high, among the most fined facilities in Louisiana. Major compliance failures.
- • Grade F (0/100). Below average facility with significant concerns.
Bottom line: This facility has 5 Immediate Jeopardy findings. Serious concerns require careful evaluation.
✓ Report will be sent to your email
About This Facility
What is Fair City Health And Rehab's CMS Rating?
CMS assigns FAIR CITY HEALTH AND REHAB an overall rating of 1 out of 5 stars, which is considered much 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 Fair City Health And Rehab Staffed?
CMS rates FAIR CITY HEALTH AND REHAB's staffing level at 2 out of 5 stars, which is below average compared to other nursing homes. Staff turnover is 55%, which is 9 percentage points above the Louisiana average of 46%. High turnover can affect care consistency as new staff learn residents' individual needs. RN turnover specifically is 70%, which is notably high. RNs provide skilled clinical oversight, so turnover in this role can affect medical care quality.
What Have Inspectors Found at Fair City Health And Rehab?
State health inspectors documented 43 deficiencies at FAIR CITY HEALTH AND REHAB during 2022 to 2025. These included: 5 Immediate Jeopardy (the most serious level, indicating potential for serious harm or death), 1 that caused actual resident harm, 36 with potential for harm, and 1 minor or isolated issues. Immediate Jeopardy findings are rare and represent the most serious regulatory concerns. They require immediate corrective action.
Who Owns and Operates Fair City Health And Rehab?
FAIR CITY HEALTH AND REHAB is owned by a for-profit company. For-profit facilities operate as businesses with obligations to shareholders or private owners. The facility operates independently rather than as part of a larger chain. With 121 certified beds and approximately 90 residents (about 74% occupancy), it is a mid-sized facility located in FRANKLINTON, Louisiana.
How Does Fair City Health And Rehab Compare to Other Louisiana Nursing Homes?
Compared to the 100 nursing homes in Louisiana, FAIR CITY HEALTH AND REHAB's overall rating (1 stars) is below the state average of 2.4, staff turnover (55%) is near the state average of 46%, and health inspection rating (1 stars) is much below the national benchmark.
What Should Families Ask When Visiting Fair City Health And Rehab?
Based on this facility's data, families visiting should ask: "What changes have been made since the serious inspection findings, and how are you preventing similar issues?" "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?" These questions are particularly relevant given the facility's Immediate Jeopardy citations, the facility's high staff turnover rate, and the below-average staffing rating.
Is Fair City Health And Rehab Safe?
Based on CMS inspection data, FAIR CITY HEALTH AND REHAB has documented safety concerns. Inspectors have issued 5 Immediate Jeopardy citations (the most serious violation level indicating risk of serious injury or death). The facility has a 1-star overall rating and ranks #100 of 100 nursing homes in Louisiana. Families considering this facility should ask detailed questions about what corrective actions have been taken since these incidents.
Do Nurses at Fair City Health And Rehab Stick Around?
Staff turnover at FAIR CITY HEALTH AND REHAB is high. At 55%, the facility is 9 percentage points above the Louisiana average of 46%. Registered Nurse turnover is particularly concerning at 70%. RNs handle complex medical decisions and coordinate care — frequent RN changes can directly impact care quality. High turnover means new staff may not know residents' individual needs, medications, or preferences. It can also be disorienting for residents, especially those with dementia who rely on familiar faces. Families should ask: What is causing the turnover? What retention programs are in place? How do you ensure care continuity during staff transitions?
Was Fair City Health And Rehab Ever Fined?
FAIR CITY HEALTH AND REHAB has been fined $248,719 across 4 penalty actions. This is 7.0x the Louisiana average of $35,566. Fines at this level are uncommon and typically indicate a pattern of serious deficiencies, repeated violations, or failure to correct problems promptly. CMS reserves penalties of this magnitude for facilities that pose significant, documented risk to resident health or safety. Families should request specific documentation of what issues led to these fines and what systemic changes have been implemented.
Is Fair City Health And Rehab on Any Federal Watch List?
FAIR CITY HEALTH AND REHAB 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.