HIGHLAND PLACE REHAB AND NURSING CENTER
For profit - Corporation
227 Beds
WELLINGTON HEALTH CARE SERVICES
Data: November 2025
4 Immediate Jeopardy citations
Trust Grade
0/100
#208 of 264 in LA
Last Inspection: July 2025
Inspected within the last 6 months. Data reflects current conditions.
Overview
Highland Place Rehab and Nursing Center has received a Trust Grade of F, indicating significant concerns about its care and operations. It ranks #208 out of 264 facilities in Louisiana, placing it in the bottom half of the state, and #17 out of 22 in Caddo County, showing limited local competition for quality. Unfortunately, the facility is worsening, with issues increasing from 27 in 2024 to 30 in 2025. Staffing is a relative strength, with a turnover rate of 32%, which is better than the state average, and they have good RN coverage, surpassing 89% of Louisiana facilities. However, the facility has concerning fines totaling $373,587, indicating repeated compliance issues, and serious incidents include a resident being exposed to another resident's inappropriate behavior and another resident going missing for 18 hours due to inadequate supervision. Overall, while there are some positive aspects regarding staff retention, the numerous critical incidents and low trust grade raise significant concerns for potential residents and their families.
- Trust Score
- F
- In Louisiana
- #208/264
- Safety Record
- High Risk
- Inspections
- Getting Worse
- Staff Stability ○ Average
- 32% turnover. Near Louisiana's 48% average. Typical for the industry.
- Penalties ✓ Good
- $373,587 in fines. Lower than most Louisiana facilities. Relatively clean record.
- Skilled Nurses ⚠ Watch
- Each resident gets only 18 minutes of Registered Nurse (RN) attention daily — below average for Louisiana. Fewer RN minutes means fewer trained eyes watching for problems.
- Violations ⚠ Watch
- 74 deficiencies on record. Higher than average. Multiple issues found across inspections.
0/100
Bottom 22%
Review needed
27 → 30 violations
★☆☆☆☆
1.0
Overall Rating
★☆☆☆☆
1.0
Staff Levels
★★☆☆☆
2.0
Care Quality
★☆☆☆☆
1.0
Inspection Score
↔
Stable
2024: 27 issues
2025: 30 issues
The Good
-
Full Sprinkler Coverage · Fire safety systems throughout facility
-
No fines on record
-
Staff turnover below average (32%)
16 points below Louisiana average of 48%
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: 32%
14pts below Louisiana avg (46%)
Typical for the industry
Federal Fines: $373,587
Well above median ($33,413)
Significant penalties indicating serious issues
Chain: WELLINGTON HEALTH CARE SERVICES
Part of a multi-facility chain
Ask about local staffing decisions and management
The Ugly 74 deficiencies on record
4 life-threatening 1 actual harm
Jul 2025
20 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0577
(Tag F0577)
Could have caused harm · This affected 1 resident
Based of observations and interview the facility failed to have the most recent annual survey results of the facility posted in a place readily accessible to the residents, family members or anyone to...
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Based of observations and interview the facility failed to have the most recent annual survey results of the facility posted in a place readily accessible to the residents, family members or anyone to review. Findings:During an observation on 07/21/2025 at 11:30 a.m., review of the survey results binder near the front door failed to reveal the annual survey from 2024.During an interview on 07/21/2025 at 12:05 p.m. S1 Administrator acknowledged that the previous years' annual survey results were not in the survey binder and should have been.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0583
(Tag F0583)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations and interviews the facility failed to accommodate 1 (#165) out of 1 resident reviewed for personal privacy...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations and interviews the facility failed to accommodate 1 (#165) out of 1 resident reviewed for personal privacy. The facility failed to ensure Resident #165 had a privacy curtain in a shared room. Findings:Observation on 07/21/2025 at 10:00 a.m. of Resident #165's room revealed was in a shared with a roommate. Further observation revealed Resident #165 did not have privacy curtain. During an interview on 07/21/2025 at 10:00 a.m. Resident #165 and visitor reported Resident #165 did not have a privacy curtain.Review of Resident #165's face sheet revealed an admission date of 01/07/2025 with the following diagnoses bipolar disorder, current episode depressed and altered mental status. Review of Resident #165's Quarterly MDS (Minimum Data Sets) assessment dated [DATE] revealed a BIMS (Brief Interview of Mental Status) score of 10 indicating moderately impaired cognition. During an interview on 07/23/2025 at 11:30 a.m. S19 CNA (Certified Nurse Assistant) observed Resident #165's room and confirmed there was no privacy curtain around bed A.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0744
(Tag F0744)
Could have caused harm · This affected 1 resident
Based on record reviews and interview the facility failed to develop an individualized person centered care plan for 1 (#14) of 2 (#5, #14) residents with measurable goals and appropriate intervention...
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Based on record reviews and interview the facility failed to develop an individualized person centered care plan for 1 (#14) of 2 (#5, #14) residents with measurable goals and appropriate interventions to address the care and treatment for a resident with dementia. Findings: Review of Resident #14's face sheet revealed an initial admission date of 12/15/2023 and a re-entry admission date of 02/10/2025 with diagnosis of dementia. Review of Resident #14's July 2025 Physician Orders revealed an order dated 05/10/2024: Memantine HCl (hydrochloride) oral tablet 5 MG (milligram); Give 1 tablet by mouth two times a day related to dementia and anxiety. Review of Resident #14's Care Plan failed to reveal a focus of dementia with measurable goals and appropriate interventions. During an interview on 07/23/2025 at 3:00 p.m. S3 MDS (Minimum Data Sets) Nurse confirmed Resident #14's care plan did not include a focus of dementia with measurable goals and appropriate interventions.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Room Equipment
(Tag F0908)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews, observation, and interviews the facility failed to maintain electrical equipment in safe operating cond...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews, observation, and interviews the facility failed to maintain electrical equipment in safe operating condition for 1 (#35) of 11 (#35, #50, #56, #68, #88, #91, #110, #128, #158, #179, #189) residents reviewed for environment. The facility failed to ensure that Resident #35's bed control was properly maintained and in safe working order. Findings:Review of Resident #35's medical record revealed, in part, a readmission date of 06/02/2025 with diagnoses including, but not limited to chronic respiratory failure with hypoxia and chronic obstructive pulmonary disease (COPD). Review of Resident #35's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview of Mental Status (BIMS) score of 15 which indicated Resident #35's cognition was intact. An observation on 07/21/2025 at 8:14 a.m. revealed Resident #35's bed remote had exposed wires. During an interview on 07/21/2025 3:28 p.m., S28Maintenance confirmed Resident #35's bed control had exposed wires. During an interview on 07/21/2025 at 3:35 p.m., S20Director of Nursing (DON) confirmed Resident #35's bed control had exposed wires and should not have.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0552
(Tag F0552)
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 1 (#165) of 5 (#5, #7, #14, #158, and #165) residents or re...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews and interviews the facility failed to ensure 1 (#165) of 5 (#5, #7, #14, #158, and #165) residents or resident's representatives reviewed for unnecessary medications were informed of risk and benefits, treatment alternatives or other options of psychotropic medications prior to administration. Findings: Review of facility's Psychotropic Medication Use and Chemical Restraints Policy dated 06/2025 revealed, in part:Purpose .This policy promotes safe, appropriate, and individualized use of psychotropic medications in nursing home residents.Policy StatementIt is the policy of this facility to prohibit the use of psychotropic medications as chemical restraints for staff convenience or disciplinary purposes. Psychotropic drugs will only be used: To treat a specific, documented condition diagnosed by a licensed practitioner, and As part of a comprehensive, person-centered care plan. Psychotropic Medication: Any drug that affects brain activity associated with mental processes and behavior. This includes but is not limited to Antipsychotics, Antidepressants, Anxiolytics (anti-anxiety agents) and Hypnotics (sedatives). The prescribing practitioner must document the resident's diagnosis or condition, risks and benefits discussed with the resident or representative, and non-pharmacological alternatives attempted.Informed ConsentObtain informed consent from the resident or legal representative.Prior to administration: Provide written and verbal education on medication purpose, potential benefits and risks, and alternatives (including non-drug interventions) Document consent in the medical record.Prohibited UsesPsychotropic medications must not be used: Without informed consent Review of Resident #165's face sheet revealed an admission date of 01/07/2025 with the following diagnoses but not limited to bipolar disorder, current episode depressed, severe with psychotic features, major depressive disorder, and altered mental status. Review of Resident #165's July 2025 Physician Orders revealed: 06/19/2025: Trazadone HCl (hydrochloride) Oral Tablet 50 MG (milligram); Give 0.5 tablet by mouth at bedtime for insomnia 06/18/2025: Cymbalta Oral Capsule Delayed Release Particles 60 MG; Give 1 capsule by mouth two times a day for major depressive disorder06/07/2025: Buspirone HCl Oral Tablet 10 MG; Give 1 tablet by mouth two times a day for generalized anxiety disorder05/27/2025: Mirtazapine Oral Tablet 30 MG; Give 1 tablet by mouth at bedtime related to major depressive disorder 03/31/2025: Anti-anxiety Medication use: Observe resident closely for significant side effect monitoring every shift 01/07/2025: Psych meds: monitor behaviors: physical aggression, yelling, cursing, biting, kicking, scratching, resisting care, exit seeking behavior or other behaviors every shift. 01/7/2025: EPS (Extrapyramidal symptoms): Monitor for EPS every shift. 01/7/2025: Psych meds: monitor side effects every shift. 01/8/2025: Hydroxyzine HCl Oral Tablet 25 MG; Give 1 tablet by mouth every 8 hours as needed for itchingReview of Resident #165's Quarterly MDS (Minimum Data Sets) assessment dated [DATE] revealed a BIMS (Brief Interview of Mental Status) of 10 indicating moderate impaired cognition. Review of Resident #165's MDS dated [DATE] revealed little interest or pleasure and poor appetite or overeating in doing things for 7-11 days of the look back period (over the last 2 weeks), feeling down, depressed, or hopeless for 2-6 days of look back period (over the last 2 weeks). Further review of Resident #165's MDS dated [DATE] revealed verbal behavioral symptoms directed toward others occurred for 1 to 3 days and other behavioral symptoms not directed toward others occurred 1 to 3 days for the past 2 weeks of the look back period. Review of Resident #165's MDS dated [DATE] Medications section revealed Resident #165 received during the last 2 weeks of the look back period revealed Antidepressant, Anticoagulant, Antibiotic, Hypoglycemic (including insulin), Anticonvulsant, and Antipsychotic medications during the last 2 weeks of look back period. Review of Resident #165's Care Plan revealed resident uses antidepressant medication related to insomnia, depression with interventions to educate the resident/family/caregivers about risks, benefits and the side effects and/or toxic symptoms of anti-depressant drugs being given, give antidepressant medications ordered by physician. Monitor/document side effects and effectiveness.Review of Resident #165's EHR (Electronic Health Record) failed to reveal informed consents were obtained before administration of psychotropic medications. During an interview on 07/24/2025 at 9:00 a.m. S1 Administrator presented the facility policy and confirmed informed consents were not obtained before administration of psychotropic medications.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0565
(Tag F0565)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews, observations and interviews the facility failed to act promptly to concerns presented in the resident c...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews, observations and interviews the facility failed to act promptly to concerns presented in the resident council meetings. The deficient practice affected 4 (#37, #139, #170, #178) of 7 (#37, #45, #139, #170, #173, #174, #178) residents interviewed for resident care and life in the facility. The deficient practice had the potential to affect the total census of 176 residents in the facility. Findings:Review of the facility's grievance policy with a revision date of 6/2025 revealed:INTENT: It is the policy of the facility to allow the resident and or legal representative to voice a grievance in such a manner to acknowledge and respect resident rights.PROCEDURE:1. The resident has the right to voice grievances to the facility or other agency or entity that hears grievances without discrimination or reprisal and without fear of discrimination or reprisal. Such grievances include those with respect to care and treatment which has been furnished as well as that which has not been furnished, the behavior of staff and of other residents, and other concerns regarding their LTC (Long Term Care) facility stay.2. The resident has the right to and the facility will make prompt efforts by the facility to resolve grievances the resident may have, in accordance with this paragraph.4. The designated professional will maintain the facility Grievance Program.5. All residents, staff, and visitors will have access to the professional designated to manage the Grievance Program, Grievance Officer. 8. The facility will establish a grievance policy to ensure the prompt resolution of all grievances regarding the residents' rights.9. Upon request, the facility will give a copy of the grievance policy to the resident. The grievance policy must include:a. Notifying resident individually or through postings in prominent locations throughout the facility of the right to file grievances orally (meaning spoken) or in writing; the right to file grievances anonymously; the contact information of the grievance official with whom a grievance can be filed, that is, his or her name, business address (mailing and email) and business phone number, a reasonable expected time frame for completing the review of the grievance, the right to obtain a written decision regarding his or her grievance, and the contact information of independent entities with whom grievances may be filed, that is, the pertinent State agency, Quality Improvement Organization, State Survey Agency and State Long-Term Care Ombudsman program or protection and advocacy system; b. Identifying a Grievance Official who is responsible for overseeing the grievance process, receiving and tracking grievances through to their conclusions, leading any necessary investigations by the facility, maintaining the confidentiality of all information associated with grievances, for example, the identity of the resident for those grievances submitted anonymously, issuing written grievance decisions to the resident; and coordinating with state and federal agencies as necessary in light of specific allegations;c. As necessary, taking immediate action to prevent further potential violations of any resident right while the alleged violation is being investigated;d. Consistent with 5483.12(c)(1), immediately reporting all alleged violations involving neglect, abuse, including injuries of unknown source, and/or misappropriation of resident property, by anyone furnishing services on behalf of the provider, to the administrator of the provider, and as required by State law;e. Ensuring that all written grievance decisions include the date the grievance was received, a summary statement of the resident's grievance, the steps taken to investigate the grievance, a summary of the pertinent findings or conclusions regarding the resident's concerns(s), a statement as to whether the grievance was confirmed or not confirmed, any corrective action taken or to be taken by the facility as a result of the grievance, and the date the written decision was issued;f. Taking appropriate corrective action in accordance with State law if the alleged violation of the residents' rights is confirmed by the facility or if an outside entity having jurisdiction, such as the State Survey Agency, Quality Improvement Organization, or local law enforcement agency confirms a violation for any of these residents' rights within its area of responsibility.Review of the Resident Council Meeting Minutes held on [DATE], [DATE], [DATE], and [DATE] revealed discussions of missing clothes among the residents with no resolution.During an interview on [DATE] at 2:12 p.m. Resident #178 reported missing items such as missing clothes to the facility and no one will do anything. Review of Resident #178's record revealed a Quarterly MDS dated [DATE] with a BIMS score of 12 indicating moderate cognition.During an interview on [DATE] at 2:13 p.m. Resident #139 reported hair grease going missing to the nurses and CNAs (Certified Nursing Assistant) and nothing gets done. Resident #139 further reported it does not do any good to report things missing because nothing gets done about it and there is no resolution and no replacements.nothing. Resident #139 further reported she will see other resident's wearing her clothes and she can't just go take it off of them. Resident #139 reported pants and shirts missing in the last 6 months and no one does anything about it. Resident #139 reported feeling aggravated. Review of Resident #139's record revealed a Quarterly MDS dated [DATE] with a BIMS score of 12 indicating moderate cognition.During an interview on [DATE] at 2:14 p.m. Resident #37 reported underwear missing within the last 2 months and they were never replaced. Resident #37 reported the missing items to S26 Social Service and S25 Laundry Supervisor.Review of Resident #37's record revealed a Quarterly MDS (Minimum Data Sets) dated [DATE] with a BIMS (Brief Interview of Mental Status) score of 15 indicating intact cognitionDuring an interview on [DATE] at 2:15 p.m. Resident #170 reported laundry goes missing all the time. Resident #170 further reported within the last 3 months he reported his laundry missing to CNAs and the nursing staff and the facility will not resolve the issue. Review of Resident #170's record revealed a Quarterly MDS dated [DATE] with a BIMS score of 15 indicating intact cognition. During an interview on [DATE] at 2:21 p.m. S27 Housekeeping reported the laundry was horrible and unorganized, residents clothing items go missing all the time. S27 House Keeping has observed CNAs gather laundry from residents' rooms and take them to the laundry area. S27 Housekeeping reported the laundry was so unorganized and that was why residents' laundry was missing. An observation on [DATE] at 2:00 p.m. revealed at least 4 large unorganized racks of laundry and blankets and a barrel with large amounts of laundry piled up over the top. During an interview on [DATE] at 2:00 p.m. S25 Housekeeping and Laundry Supervisor reported items should be labeled before being sent to the laundry. S25 Laundry Supervisor reported if items were washed and not labeled, they were placed in the missing clothes section. S25 Housekeeping and Laundry Supervisor reported some resident families donate their deceased family member's clothes and they were also placed in the same pile as the missing clothes pile. S25 Housekeeping and Laundry Supervisor reported if a resident needed a shirt, they pulled from the missing clothes pile and a shirt would be picked out for them to wear. S25 Housekeeping and Laundry Supervisor confirmed he was not aware of Resident #37's missing underwear, Resident #139's, Resident #170's and Resident #178's missing any clothing. S25 Housekeeping and Laundry Supervisor reported there was not a list of missing clothing items which included a date the items went missing. S25 Housekeeping Laundry Supervisor reported the donated pile of clothes was mixed with the missing clothes pile. During an interview on [DATE] at 2:24 p.m. S26 Social Service reported the CNAs and nursing staff should label all clothing upon admit and as they receive personal items. S26 Social Service reported items should be found in a reasonable amount of time which is about 3 days. S26 reported if missing items are not found, a Grievance form should be filled out with missing items listed and the facility will replace the missing items. S26 Social Service was not aware of missing items from Resident #37, Resident #139, Resident #170, or Resident #178.
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
Safe Environment
(Tag F0584)
Could have caused harm · This affected multiple residents
Based on observations and interviews the facility failed to provide a safe, clean, comfortable and homelike environment for 4 (#50, #88, #91, #110) of 11 (#35, #50, #56, #68, #88, #91, #110, #128, #15...
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Based on observations and interviews the facility failed to provide a safe, clean, comfortable and homelike environment for 4 (#50, #88, #91, #110) of 11 (#35, #50, #56, #68, #88, #91, #110, #128, #158, #179 #189) residents reviewed for environment. The facility failed to: 1. provide a clean room and a closet door for Resident #110.2. provide linens that were in good repair for all residents. (This had the ability to affect 176 residents residing in the facility.)3. provide the required furnishings in each resident room. The facility failed to provided a chair for Resident #88 and #91.4. provide a clean uncluttered room for Resident #50, Resident #50's clothes were stored on the floor. Findings:
Resident #50
Review of Resident #50’s medical record revealed an admit date of 06/26/2025 with the following diagnoses, including in part: unspecified fracture of upper end of right humerus/subsequent encounter with routine healing, unsteadiness on feet, and cognitive communication deficit.
Observation on 07/21/2025 at 8:05 a.m. revealed Resident #50's clothing in a box on the floor next to the bed and on clothing on the bathroom floor.
During an interview on 07/21/2025 at 8:25 a.m. S6 CNA (Certified Nursing Assistant) acknowledged the clothes in the box and on the bathroom floor should not be there.
Resident #91
Review of Resident #91’s medical record revealed an admit date of 09/13/2023 with the following diagnoses, including in part: Hypertension, depression, respiratory failure, and nutrition malnutrition. Further observation revealed a Quarterly MDS (Minimum Data Set) dated 06/19/2025 with a BIMS (Brief Interview for Mental Status) score of 14 indicating intact cognition.
An observation on 07/23/2025 at 1:00 p.m. revealed Resident #91 shared a room with one other resident and had one metal fold out chair in her room labeled with her roommate’s name. Further observation failed to reveal Resident #91 had a chair to sit in or for visitors to sit in.
During an interview on 07/23/2025 at 1:00 p.m. Resident #91 reported when her daughter visited, she had to sit on the edge of Resident #91's bed during the visit because there was not a chair for her to sit in.
Resident #88
Observation on 07/21/2023 at 9:30 a.m. revealed Resident #88 was in a shared room with no chairs for residents or visitors to sit.
During an interview on 07/21/2023 at 9:30 a.m. Resident #88 acknowledged there were no chairs to sit in the resident shared room and reported sitting on the side of the bed when wanting to sit up. Resident #88 reported his mother stood up during a visit with him and his grandmother sat on the foot of his bed.
Review of Resident #88's face sheet revealed an admission date of 02/22/2023 with the following diagnoses but not limited to major depressive disorder, history of falling, pyogenic arthritis, polyneuropathy, contracture of left knee, and pain in left knee.
Review of Resident #88's Quarterly MDS (Minimum Data Sets) dated 05/15/2025 revealed a BIMS (Brief Interview of Mental Status) of 14 indicating cognitively intact.
Resident #110
Observation on 07/21/2025 at 8:30 a.m. revealed Resident #110's floor was sticky with dark brown colored dirt and residue in the corners and on the base boards of the room, further review revealed Resident #110's closet did not have a door in place.
Review of Resident #110's Quarterly MDS (Minimum Data Set) dated 05/22/2025 revealed Resident #110 was assessed to have a BIMS score of 8 indicating moderately impaired cognition.
During an interview on 07/21/2025 at 9:16 a.m. Resident #110 reported the closet did not have a door when he was admitted to the facility several months ago and he did not know when the floor was mopped last.
During an interview on 07/22/2025 at 2:45 p.m. S22 Maintenance Director confirmed Resident #110 should have had a closet door in place and Resident #110's floor should have been cleaned daily.
During an interview on 07/24/2025 at 3:00 p.m. S1 Administrator confirmed each resident should have had a chair in their room.
Observations on 07/22/2025 at 11:50 a.m. during a tour of the laundry completed with S25 Housekeeping and Laundry Supervisor revealed bed sheets, pillowcases are worn thin and discolored (yellowish and tan stains). Further observation of the facility’s blankets revealed they were in very poor condition thin, discolored, felt scratchy.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0628
(Tag F0628)
Could have caused harm · This affected multiple residents
Based on record review and interview the facility failed to provide the required documents to 1 (#110) of 1 (#110) resident and or resident representative who was transferred out of the facility for t...
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Based on record review and interview the facility failed to provide the required documents to 1 (#110) of 1 (#110) resident and or resident representative who was transferred out of the facility for treatment. The facility failed to provide Resident #110 a copy of the facility's bed hold policy when transferred out of the facility. Findings: Review of Resident #110's medical record revealed an initial admit date of 11/06/2025 and a re-admission date of 02/16/2025 with diagnoses of but not limited to hyperkalemia, unspecified dementia, unspecified severity without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety, chronic kidney disease, essential hypertension and osteoarthritis.Review of Resident #1's medical record revealed Resident #110 was transferred to a hospital for treatment of hyperkalemia on 01/16/2025 and 02/13/2025.Review of Resident #110's medical record failed to reveal any documentation of the bed hold policy being provided to Resident #110 or Resident #110's representative when transferred to a hospital for treatment on 01/16/2025 and 02/13/2025. During an interview on 07/23/2025 at 2:15 p.m. S1 Administrator confirmed the facility's bed hold policy had not been provided to Resident #110 or Resident #110's representative when transferred to the hospital for treatment on 01/16/2025 and 02/13/2025.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
MDS Data Transmission
(Tag F0640)
Could have caused harm · This affected multiple residents
Based on record review and interview, the facitiy failed to ensure resident assessments were encoded, transmitted and completed for 1 (#81) of 3 (#81, #130, #183) residents reviewed for resident asses...
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Based on record review and interview, the facitiy failed to ensure resident assessments were encoded, transmitted and completed for 1 (#81) of 3 (#81, #130, #183) residents reviewed for resident assessments.Findings: Review of Resident #81's medical records revealed an admit date of 02/05/2025 and discharge date of 03/14/2025 with the following diagnoses, including in part: heart failure unspecified and type 2 diabetes mellitus without complications. Review of Resdient #81's MDS (Minimal Data Set) Assessments failed to reveal a discharge assessemnt. During an interview on 07/23/2025 at 2:30 p.m. S3 MDS Nurse acknowledged Discharge MDS Assessment was not completed until today.
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 F0655
(Tag F0655)
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 develop and implement a baseline care plan for 2 (#110, #188) out...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews and interviews, the facility failed to develop and implement a baseline care plan for 2 (#110, #188) out of 63 total sampled residents reviewed. Findings:
Resident #110
Review of Resident #110’s medical record revealed an initial admit date of 11/06/2025 and a re-admission date of 02/16/2025 with diagnoses of but not limited to hyperkalemia, unspecified dementia, unspecified severity without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety, chronic kidney disease, essential hypertension and osteoarthritis.
Review of Resident #110's medical record failed to reveal a baseline care plan had been completed when Resident #110 was admitted on [DATE] and re-admitted on [DATE].
During an interview on 07/22/2025 at 1:00 p.m. S3 MDS (Minimum Data Set) Nurse confirmed a baseline care plan was not completed when Resident #110 was admitted on [DATE] and re-admitted on [DATE] and should have been.
Resident #188
Review of Resident #188’s medical record revealed an admit date of 07/11/2025 with the following diagnoses, including in part: malignant neoplasm of upper lobe/left bronchus or lung, acute and chronic respiratory failure with hypoxia, chronic obstructive pulmonary disease, and unspecified pleural effusion not elsewhere classified.
Review of Resident #188’s medical records failed to reveal the baseline plan of care was completed upon admission.
During an interview on 07/24/2025 at 2:30 p.m. S3 MDS Nurse acknowledged a baseline care plan was not developed for Resident #188 and should have been.
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
Comprehensive Care Plan
(Tag F0656)
Could have caused harm · This affected multiple residents
Based on record review and interview, the facility failed to provide services according to the written plan of care for 1 (#14) of 5 (#5, #7, #14, #158, and #165) reviewed for unnecessary medications....
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Based on record review and interview, the facility failed to provide services according to the written plan of care for 1 (#14) of 5 (#5, #7, #14, #158, and #165) reviewed for unnecessary medications. The facility failed to ensure Resident #14's lab were obtained as ordered by the physician. Findings: Review of Resident #14's face sheet revealed an initial admission date of 12/15/2023 and a re-entry admission date of 02/10/2025 with the following diagnoses, but not limited to schizoaffective disorder, bipolar type, dementia without behavioral disturbances, psychophysiological insomnia, and anxiety disorder. Review of Resident #14's July 2025 Physician Orders revealed an order dated 06/02/2025: biannual labs: CBC (complete blood count), CMP (comprehensive metabolic panel), hemoglobin A1C, TSH (thyroid stimulating hormone), lipid, B12, folate, Vitamin D, Magnesium, Thiamine and Iron panel with ferritin for June and December.Review of Resident #14's Quarterly MDS (Minimum Data Sets) dated 04/30/2025 revealed a BIMS (Brief Interview of Mental Status) score of 15 indicating cognitively intact. Further review of Resident #14's MDS review of medications received during the last 7 days of the look back period revealed administration of antipsychotic, antidepressant, antiplatelet, hypoglycemic and anticonvulsant. Review of Resident #14's EHR (Electronic Health Record) failed to reveal lab for TSH (thyroid stimulating hormone), lipid, B12, folate, Vitamin D, Magnesium, Thiamine and Iron panel with ferritin were obtained as ordered. During an interview on 07/22/2025 at 10:30 a.m. S1 Administrator confirmed lab for TSH (thyroid stimulating hormone), lipid, B12, folate, Vitamin D, Magnesium, Thiamine and Iron panel with ferritin were obtained as ordered.
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 record reviews, observations and interviews, the facility failed to ensure residents who were unable to complete their ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews, observations and interviews, the facility failed to ensure residents who were unable to complete their activities of daily living received the necessary services to maintain grooming and hygiene for 4 (#50, #68, #74, #187) out of 4 (#50, #68, #74, #187) residents reviewed for activities of daily living. The facility failed to:1. Ensure Resident #50 received baths, washed hair and toenails were trimmed,2. Ensure Resident #68 received baths, oral care and nail care,3. Ensure Resident #74 received proper peri-care for MASD (moisture-associated skin damage)4. Ensure Resident #187 received baths.
Findings:
Review of Facility's Activities of Daily Living (ADLs)/Maintain Abilities (undated) revealed: Procedure: 2. The facility will ensure a resident is given the appropriate amount of treatment and services to maintain or improve his or her ability to carry out the activities of daily living. 3. The facility will provide care and services for the following activities of daily living: a. hygiene - bathing, dressing, grooming, and oral care. 4. A resident who is unable to carry out activities of daily living will receive the necessary services to maintain good nutrition, grooming, and personal and oral hygiene .
Review of Facility's fingernails/Toenails, Care of Policy and Procedure dated 06/2025 revealed: Purpose: The purposes of this procedure are to clean the nail bed, to keep nails trimmed to prevent infections.
Review of Facility's Hair, Shampooing Policy and Procedure dated 06/2025 revealed Purpose: The purpose of this procedure is to clean the hair and scalp.
Review of the Facility’s Mouth Care Policy and Procedure dated 06/2025 revealed: Purpose: The purposes of this procedure are to keep the resident's lips and oral tissues moist, to cleanse and freshen the resident's mouth, and to prevent infections of the mouth.
Resident #50
Review of Resident #50’s medical record revealed an admit date of 06/26/2025 with the following diagnoses, including in part: unspecified fracture of upper end of right humerus/subsequent encounter with routine healing, polyneuropathy unspecified, unsteadiness on feet, and cognitive communication deficit.
Review of Resident #50’s MDS (Minimum Data Set) assessment dated [DATE] revealed functional status: impairment on one side upper extremity; eating/oral hygiene setup; toileting/ shower/bathe/upper and lower dressing/bed mobility/toilet transfer partial/moderate.
Review of shower schedule posted in nurse's station revealed: women shower days are Monday-Wednesday-Friday.
Observation on 07/21/2025 at 8:05 a.m. revealed Resident #50 sitting on side of bed with hair disheveled and toenails long and curled over on both feet.
During an interview on 07/21/2025 at 8:05 a.m. Resident #50 reported she has not been getting a bath.
During an interview on 07/23/2025 at 9:50 a.m. Resident #50 reported she has not gotten a bath today.
Observation on 07/23/2025 at 9:58 a.m. revealed Resident #50 with hair greasy and toenails long and curled.
During an interview on 07/23/2025 at 10:54 a.m. S1 Administrator confirmed Resident #50 did not have bathing added as a task for staff and there is no documentation that a bath or shower was received.
During an interview on 07/23/2025 at 1:45 p.m. S1 Administrator acknowledged Resident #50's toenails needed to be trimmed.
During an interview on 07/23/2025 at 2:15 p.m. S6 CNA (Certified Nursing Assistant) acknowledged resident needs a bath and toenails need trimming. S6 CNA confirmed Resident #50's hair is greasy.
Resident #68
Review of Resident #68’s medical record revealed an initial admit date of 06/30/2011 with a re-entry date of 05/12/2024 with the following diagnoses, including in part: Encounter for attention to tracheostomy, gastrostomy, anoxic brain damage, cerebral aneurysm, acquired absence of left and right leg above the knee, contracture of muscle, multiple sites.
Review of Resident #68’s MDS (Minimum Data Set) assessment dated [DATE] revealed functional abilities: Functional limitation in range of motion – impairment on both sides with upper and lower extremities. Further review revealed Resident #68 was dependent with oral hygiene, toileting, shower/bathe, and personal hygiene.
Review of Resident #68’s medical record revealed for the month of July 2025 CNA Task For oral hygiene: Failed to document oral care was done or coded was Not Applicable (-97) on the following dates:
Day shift: July 2nd-6th, 9th-12th, 14th, 16th, 17th, and 19th-23rd.
Evening shift: July 2nd, 3rd, 6th-8th, 12th, 13th, 14th, 16th-21st.
Night shift: July 1st, 3rd-8th, 11th-20th.Record review revealed for the month of July 2025 CNA Task For Shower on Tuesdays-Thursdays-Saturdays 11-7 shift failed to document as done on the following scheduled dates: July 2025: 1st, 5th, 17th and 19th. An observation on 07/21/2025 at 9:15 a.m. revealed debris build up on Resident #68's teeth and dirty nail beds.
During an observation on 07/22/2025 at 12:34 p.m. heavy build-up of debris was noted on top and bottom teeth of Resident #68’s teeth. Further observation with S9 CNA revealed Resident #68 had gold front top teeth, but the gold was barely visible due to the heavy build up on his teeth. Further observation revealed a thick light grayish build up behind his bottom front teeth. An observation revealed black and brown build-up under the nail beds of Resident #68. S9 CNA looked under the nail bed and retrieved dark brown debris out from under the left thumb nail with a gloved hand.
During an interview on 07/22/2025 at 12:34 p.m. S9 CNA could not find any oral hygiene supplies in Resident #68’s room and acknowledged there should be. S9 CNA reported further Resident #68 should get oral hygiene care three times a day and nails should be cleaned with bath. S9 CNA agreed Resident #68's had heavy build up on teeth and nail beds were dirty and was in need of ADL care.
Resident #74
Review of Resident #74’s medical record revealed an initial admit date of 02/24/2017 with a re-entry date of 01/22/2023 with the following diagnoses, including in part: Spastic diplegic cerebral palsy, type 2 diabetes, chronic pain syndrome, muscle wasting and atrophy – right and left upper arms and right and left lower legs.
Review of Resident #74’s physician orders dated 05/12/2025 revealed an order for: Sacrum (including buttocks) apply house barrier cream every shift every day until resolved for MASD (Moisture-associated skin damage).
During an observation on 07/22/2025 at 2:59 p.m. with S16 CNA revealed Resident #74 had bright red moist skin breakdown to the buttocks area with a large amount of caked on white/yellow/gray substance. Further observation revealed large white and yellowish flakes of the substance was in Resident #74’s brief.
During an interview on 07/22/2025 at 2:59 p.m. S16 CNA reported Resident #74 had skin breakdown for a while and a house barrier cream was applied to her buttocks area. S16 CNA further reported not being able to get the cream completely off and the house barrier cream was reapplied with peri-care or bowel movement.
During an interview on 07/22/2025 at 3:05 p.m. S8 Wound Care Nurse reported Resident #74 had MASD and house barrier cream was applied after every incontinent episode. Resident #74 should have the buttocks completely cleaned after her bath, her wound should be cleaned with gauze and wound cleanser.
During a phone interview on 07/23/2025 at 9:37 a.m. S18 Wound Care NP, reported when residents have MASD the house barrier cream should not be caked up on the resident’s buttocks. The area should be cleaned off after incontinent episodes and cream reapplied.
Resident #187
Review of resident #187 records revealed an admit date of 07/16/2025.
Review of resident #187’s records revealed diagnoses include hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, weakness, contractures of the right and left knee, muscle weakness, atrophy of the right and left arms, gangrene to all toes to right and left foot.
During an interview on 07/21/2025 at 11:00 a.m. resident #187 reported he had not had a bath since he was admitted to the facility 5 days ago. Resident #187 reported he had not been offered a bath.
During an interview on 07/23/2025at 2:15 p.m. S1 Administrator reported there was no Task documented including bath for resident #187 to reveal ADL (activity of daily living) care was provide by the facility’s CNAs (certified nursing assistant). S1 Administrator reported if a bath was provided for resident #187 it should had been documented on the Task form and it was not. S1 Administrator reported she was informed that the CNAs are to document on the Task form what ADL care they had provided for the resident.
During an interview on 0723/2025 at 2:20 p.m. resident #187 still reported he had not been given a bath. During an interview on 07/23/2025 at 2:40 p.m.S21 CNA Supervisor reported the Task form for ADL care should be completed at the end of each shift by the CNAs revealing what care was provided for the resident.
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
Quality of Care
(Tag F0684)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to ensure residents received care and services that are resident center...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to ensure residents received care and services that are resident centered, in accordance with professional standards of practice for 2 (#74, #110) of 63 sampled residents. The facility failed to: 1.provide a splint for Resident #74 as ordered.2.complete all admission lab test ordered Resident #110.3.revise/update Resident #110's plan of care to reflect a diagnosis of hyperkalemia.4.complete Resident #110's admission lab in a timely manner.
Findings:
Resident #74
Review of Resident #74’s medical record revealed an initial admit date of 02/24/2017 with a re-admission date of 01/22/2023 with the following diagnoses, in part: Spastic diplegic cerebral palsy, chronic pain syndrome, muscle wasting and atrophy, not elsewhere classified, left and right upper arms, and contracture, unspecified joint.
An observation on 07/21/2025 at 12:32 p.m. revealed one hand splint on the bed side table of Resident #74.
During an interview on 07/23/25 at 9:16 a.m. S31 COTA (Certified Occupational Therapy Assistant) Rehab Director reported Resident #74 was discharged from OT (Occupational Therapy) services with a left hand splint and restorative nursing to apply the splint. S31 COTA Rehab Director reported the left hand split should continue to be part of restorative, which does not stop unless OT was notified of an issue. S31 COTA Rehab Director, reported she had not been notified of Resident #74 not using her left hand splint and should have been.
An observation on 07/23/2025 at 10:40 a.m. revealed one hand splint on the bed side table. No hand splint was in Resident #74's left hand.
During an interview on 07/23/2025 at 11:37 a.m. S17 Restorative CNA (Certified Nursing Assistant) reported Resident #74 was not on the list to receive restorative service for hand splint placement. S17 Restorative CNA reviewed Resident #74’s record and confirmed Resident #74 was discharged from OT on 11/25/2024 and should have received restorative care for hand splint placement.
During an interview on 07/24/2025 at 9:32 a.m. S31 COTA Rehab Director confirmed Resident #74 was discharged in 11/2024 with the use of a left hand splint.
Resident #110
Review of Resident #110’s medical record revealed an initial admit date of 11/06/2025 and a re-admission date of 02/16/2025 with diagnoses of but not limited to hyperkalemia, unspecified dementia, unspecified severity without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety, chronic kidney disease, essential hypertension and osteoarthritis.
Review of Resident #110’s medical record revealed Resident #110 was transferred to a hospital on [DATE] and 02/13/2025 and returned to the facility with a diagnosis of hyperkalemia.
Review of Resident #110's Comprehensive Care Plan failed to reveal a problem and approach for hyperkalemia.
During an interview on 07/22/2025 at 1:00 p.m. S3 MDS (Minimum Data Set) Nurse confirmed Resident #110 failed to have a comprehensive plan of care initiated for the diagnosis of hyperkalemia.
Review of Resident #110's November 2024 physician's orders revealed the following orders:
Admit to Skilled Services 11/06/2024,
Admit lab: CBC (complete blood count), CMP(comprehensive metabolic panel, TSH (thyroid stimulating hormone), Hgb A1C (hemoglobin A1C), HIV (human immunodeficiency virus) , hepatitis C, vitamin D level, RPR (Rapid Plasma [NAME]), and a urinalysis with culture and sensitivity 11/07/2024,
Need admit labs 11/26/2024.
Review of Resident #110’ medical record failed to reveal any results for HIV, Hepatitis C and RPR. Further review revealed CBC, CMP, TSH, HgbAIC, and Vitamin D level were not done until 11/26/2024 and were ordered on 11/07/2024.
Review of Resident #110’s Nurse Practitioner progress notes dated 11/25/2025 revealed the following documentation: There is still limited information for admission labs. Administration and floor nurse made aware to draw admission labs in the morning. During an interview on 07/22/2025 at 3:30 p.m. S1 Administrator confirmed all lab tests ordered for Resident #110 when admitted were not completed as ordered. S1 Administrator further confirmed Resident #110’s admission labs that were completed were not done in a timely manner. Resident #110’s admission lab (partial completion) was completed on 11/26/2025 but was originally ordered on 11/07/2025.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Accident Prevention
(Tag F0689)
Could have caused harm · This affected multiple residents
Based on observation, interview and record review the facility failed to ensure a resident environment remains as free of accident hazards for 1 (#158) reviewed for accidents. The facility did not mai...
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Based on observation, interview and record review the facility failed to ensure a resident environment remains as free of accident hazards for 1 (#158) reviewed for accidents. The facility did not maintain resident #158's wheelchair in safe operating condition. Findings:Review of the Accident and Incident Prevention, Reporting, and ResponseAdministrative Policies (7/2025) revealed in part:Purpose: To ensure a safe environment for all residents by minimizing accidents hazards, providing adequate supervision and assistive devices, and implementing a proactive and systematic approach to preventing, investigating, and mitigating accidents and incidents in accordance with federal regulations, facility policies, and resident-centered care principles.Policy StatementThe facility is committed to:Maintaining a resident environment that is as fee as possible from accident hazards while meeting individual resident needs.Observation on 07/21/2025 at 11:36 a.m. revealed resident #158's wheelchair was in need of repair. Resident #158's wheelchair locks did not lock, the right wheel was loose and unstable and the wheelchair did not have footrest.During an interview on 07/22/2025 at 2:00 p.m. S20 DON reported when a wheelchair or some other equipment needs repair a work order is completed and given to Maintenance. S20 DON reported if the wheelchair needs parts, then they will contact the company to get parts. S20 DON they will get the resident in another wheelchair until the part come in.During an interview on 07/22/2025 at 2:30 p.m. S22 Maintenance Director reported of has been on the job for three months. S22 Maintenance Director reported the process for completing a work order and getting it to his department is by using TELS (The Equipment Lifecycle System) the workplace reporting system. S22 Maintenance Director reported all staff has excess to the TELS system. S22 Maintenance Director reported when they create a work order in the TELS systems it hits the telephone of the two guys that work under him, DON, Administrator, and Corporate letting maintenance know the location, priority and issues. S22 Maintenance Director reported they can even take pictures. Reviewed S22 Maintenance Director phone with him, he entered resident #158's name and room number and her name or room number never came up in the TELS system. S22 Maintenance Director reported a work order had not been completed.Review of resident #158 records revealed diagnoses that include morbid (severe) obesity due to excess calories, effusion right knee and muscle weakness. Review of resident #158's 5-day MDS (minimum data set) dated 05/29/2025 revealed functional ability, she uses a manual wheelchair for mobility.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0692
(Tag F0692)
Could have caused harm · This affected multiple residents
Based on record reviews and interviews, the facility failed to provide care and services to maintain acceptable parameters of nutritional status for 1 (#62) resident reviewed for nutrition. The facili...
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Based on record reviews and interviews, the facility failed to provide care and services to maintain acceptable parameters of nutritional status for 1 (#62) resident reviewed for nutrition. The facility failed to consult a Registered Dietician for Resident #62 diagnosed with a pressure ulcer.Findings:Review of Facility's Pressure Ulcer Treatment Policy and Procedure dated 06/2025 revealed: Purpose: The purpose of this procedure is to provide guidelines for the treatment of pressure ulcers to facilitate healing and to prevent further deterioration. 3. Consult Dietary as needed/ordered. Review of Resident #62's medical records revealed an admit date of 05/02/2025 with the following diagnoses, including in part: other ulcerative colitis without complications, paraplegia complete, other idiopathic peripheral autonomic neuropathy and pressure ulcer of sacral region, stage 4. Review of Resident #62's medical records failed to reveal Resident #62 receiving supplements for wound healing.Review of Resident #62's weights revealed on 05/02/2025, the resident weighed 181 lbs. (pounds). On 06/02/2025, the resident weighed 171 lbs. which is a -5.52% loss.Review of Resident #62's medical records failed to reveal a consult was completed for a Registered Dietician since admission.During an interview on 07/23/2025 at 12:55 p.m. S4 Registered Dietician reported she has not received a consult for Resident #62.During an interview on 07/23/2025 at 2:17 p.m. S8 WCN (Wound Care Nurse)/LPN (Licensed Practical Nurse) confirmed Resident #62 was admitted with a stage 4 pressure ulcer.S8 WCN/LPN acknowledged Resident #62 is not receiving supplements for wound healing and the Registered Dietician has not been consulted.During an interview on 07/24/2025 at 10:20 a.m. S2 CNO (Chief Nursing Officer) acknowledged a consult for Registered Dietician was not completed.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Respiratory Care
(Tag F0695)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observations and interview, the facility failed to provide residents necessary respiratory care and serv...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observations and interview, the facility failed to provide residents necessary respiratory care and services in accordance with accepted professional standards of practice for 5 (#2, #35, #109, #128, #188) out of 6 (#2, #35, #109, #128, #186 and #188) residents reviewed for respiratory. The facility failed to store hand held nebulizer equipment in a covered bag and change and date oxygen tubing and humidification bottles weekly.Findings:Procedure Guidelines: Oxygen Administration -3. [NAME] bottle with date and initials upon opening.4. Change prefilled humidifier when water level becomes low.5. Change oxygen cannulas and tubing every 7 days and date. Resident #2Review of Resident #2's face sheet revealed an initial admission date of 02/20/2024 with a re-entry date of 05/07/2024 with the following diagnoses chronic respiratory failure with hypoxia. Review of Resident #2's July 2025 Physician orders revealed dated 07/03/2025: oxygen at 2L (liters) via NC (nasal cannula), every 8 hours as needed for shortness of breath Review of Resident #2's Quarterly MDS (Minimum Data Sets) assessment dated [DATE] revealed a BIMS (Brief Interview of Mental Status) was not conducted as resident was rarely/never understood. Review of Resident #2's Care Plan failed to reveal focus with measurable goals and appropriate interventions related to Resident #2's diagnoses of chronic respiratory failure with hypoxia and use of oxygen. Observation of Resident #2's oxygen concentrator on 07/21/2025 at 10:00 a.m. revealed oxygen administered at 2L via NC. Further observation revealed Resident #2's oxygen tubing was not dated/labeled and humidification bottle was empty. During an interview on 07/21/2025 at 11:30 a.m. S23 LPN (Licensed Practical Nurse) confirmed Resident #2's oxygen tubing was not dated/labeled and humidification bottle was empty. S23 LPN reported Resident #2's oxygen tubing should have been dated, labeled and humidification bottle should have been replaced. Observation of Resident #2's oxygen concentrator on 07/23/2025 at 11:40 a.m. revealed oxygen administered at 2L via NC. Further observation revealed Resident #2's oxygen tubing was not dated/labeled and humidification bottle was empty. During an interview on 7/23/2025 at 11:40 a.m. S24 LPN confirmed Resident #2's oxygen tubing was not dated/labeled and humidification bottle was empty. S24 LPN reported Resident #2's oxygen tubing should be dated, labeled and humidification bottle should have been replaced. During an interview on 07/23/2025 at 3:00 p.m. S3 MDS Nurse reviewed Resident #2's care plan and confirmed the care plan did not include a focus with measureable goals and appropriate interventions related to diagnoses chronic respiratory failure with hypoxia and use of oxygen. Resident #35Review of Resident #35's medical record revealed in part, a readmission date of 06/02/2025 with diagnoses including, but not limited to, chronic respiratory failure with hypoxia and chronic obstructive pulmonary disease (COPD). Review of Resident #35's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview of Mental Status (BIMS) score of 15 which indicated Resident #35's cognition was intact. Review of Resident #35's physician orders revealed, in part, order dated 06/02/2025 for oxygen at 3 liters (L) continuously per mask or nasal cannula. An observation on 07/21/2025 at 8:14 a.m. revealed Resident #35 lying in bed with oxygen per nasal cannula at 3L. Further observation on 07/21/2025 at 8:14 a.m. revealed oxygen tubing was not dated. During an interview on 07/21/2025 at 12:30 p.m., S29 Licensed Practical Nurse (LPN) observed Resident #35's oxygen tubing and confirmed Resident #35's tubing was not dated and should have been. Resident #109Review of Resident #109's medical records revealed an admit date of 04/01/2025 with the following diagnoses, including in part: acute respiratory failure with hypoxia and chronic obstructive pulmonary disease unspecified. Review of Resident #109's Physician's orders revealed an order dated 05/14/2025 for Ipratropium-Albuterol Inhalation Solution 0.5-2.5 (3) mg (milligram/3 ml (milliliter); 3ml inhale orally every 6 hours as needed for wheezing and 3 ml inhale orally four times a day for shortness of breath. Further review revealed an order dated 04/01/2025 for oxygen at (2) liters per mask or nasal cannula continuously every shift and change and date all respiratory supplies and tubing . Observation on 07/21/2025 at 8:10 a.m. revealed Resident #109's humidifier via nasal cannula at 2 liters per minute undated. Further observation revealed a hand held nebulizer tubing and mouth piece lying on bed side table not stored in a bag and undated. During an interview on 07/21/2025 at 10:15 a.m. S7 LPN reported oxygen tubing, humidifier bottles and hand held nebulizer equipment should be changed weekly and dated. S7 LPN further acknowledged the hand held nebulizer tubing and mouth piece should be placed in a bag. Resident #128Review of Resident #128's medical records revealed an admit date of 07/03/2025 with the following diagnoses, including in part: combined systolic (congestive) and diastolic (congestive) heart failure, and chronic obstructive pulmonary disease unspecified. Review of Resident #128's Physician's orders dated 07/03/2024 for change and date all respiratory supplies and tubing weekly .every day shift every Tuesday and as needed and oxygen at (2) liters per nasal cannula continuously every shift. Observation on 07/21/2025 at 8:50 a.m. revealed Resident #128's hand held nebulizer tubing observed on bed side table undated and not stored in a covered bag. During an interview on 07/21/2025 at 10:15 a.m. S7 LPN reported hand held nebulizer tubing is changed weekly. S7 LPN acknowledged Resident #128's hand held nebulizer is undated and should be stored in a covered bag. Resident #188Review of Resident #188's medical record revealed an admit date of 07/11/2025 with the following diagnoses, including in part: malignant neoplasm of upper lobe/left bronchus or lung, acute and chronic respiratory failure with hypoxia, chronic obstructive pulmonary disease, and unspecified pleural effusion not elsewhere classified. Review of Resident #188's Physician's orders revealed an order dated 07/21/2025 for change and date all respiratory supplies and tubing weekly on Monday .one time a day every Monday. Further review revealed an order dated 07/12/2025 for oxygen at 2 liters per nasal cannula continuously every shift. Observation on 07/21/2025 at 8:40 a.m. revealed Resident #188 wearing continuous oxygen via nasal cannula at 2 liters per minute. Further observation failed to reveal the oxygen tubing and humidifier bottle dated. During an interview on 07/21/2025 at 10:15 a.m. S7 LPN reported oxygen tubing and humidifier bottles are changed weekly. S7 LPN acknowledged Resident #188's oxygen tubing and humidifier bottle were undated.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0825
(Tag F0825)
Could have caused harm · This affected multiple residents
Based on interviews and record review the facility failed to provide specialized rehabilitation services for 1 of 1 (#158) sample resident as required by the resident's plan of care. Resident #158 was...
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Based on interviews and record review the facility failed to provide specialized rehabilitation services for 1 of 1 (#158) sample resident as required by the resident's plan of care. Resident #158 was not provided restorative services. Findings:During an interview on 7/21/2025 at 11:18 a.m. resident #158 reported she had therapy for three days and she had not had any therapy since then. Resident #158 reported she was told by therapy she would be seen by Restorative, and she had not been seen.Review of resident 158's Physical Therapy Restorative Referral dated 05/27/2025 revealed restorative service was to start dated 06/05/2025 for six weeks.During an interview on 07/22/2025 at 1:30 p.m. S17 Restorative CNA (certified nursing assistant) reported they did not provide restorative services for resident #158. S17 Restorative CNA reported there is only two Restorative CNAs for the entire facility. S17 Restorative CNA reported they obtain the referrals for restorative services from physical therapy then they give the referral to their supervisor. S17 Restorative CNA reported their supervisor will schedule the resident for restorative services. S17 Restorative CNA reported resident #158 was never put on their schedule by their supervisor.Review of resident #158's records revealed diagnoses that include morbid (severe) obesity due to excess calories, effusion, right knee and muscle weakness. Review of resident #158's 5-day MDS (minimum data set) dated 05/29/2025 revealed a BIMS (brief interview for mental status) score of 15 which indicate cognitively intact. Functional abilities indicate she uses a manual wheelchair. Related to mobility resident #158 requires substantial/maximal assistance with rolling left to right, lying to sitting on the side of the bed. Dependent with sitting to stand, chair/bed-to-chair transfers and toilet transfers.Review of resident #158's Comprehensive Plan of Care revealed an ADL self-care performance deficit related to weakness. Resident requires fluctuating assist times 1-2 with ADL. Resident #158 requires two person assist with transfers.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Staffing Data
(Tag F0851)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews and interview, the facility failed to electronically submit accurate direct care staffing information ba...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews and interview, the facility failed to electronically submit accurate direct care staffing information based on payroll to Centers for Medicare and Medicaid Services (CMS) as required. Findings:Record review of the PBJ (Payroll Based Journal) Report for FY (Fiscal Year) Quarter 2 2025 (January 1 - March 31) revealed triggers for the following: One Star Staffing Rating and Excessively Low Weekend Staffing. Review of staffing pattern forms for weekends of FY 2025 quarter 2 ([DATE]- March 31) revealed the facility provided more hours than required and failed to reveal any days in which the facility did not provide enough hours. During an interview on 07/23/2025 at 4:35 p.m. S1Administrator reported corporate submitted the information for the PBJ and did not submit correct information. During an interview on 07/24/2025 at 8:55 a.m. S2Chief Nursing Officer reported she did not know why the information submitted by corporate to PBJ was not accurate.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected multiple residents
Based on record reviews, observations, and interviews the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment to he...
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Based on record reviews, observations, and interviews the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment to help prevent the development and transmission of communicable diseases and infections. This deficient practice had the potential to effect 176 residents residing at the facility at time of entrance on 07/21/2025 as reported by the Administrator. The facility failed to:1. maintain an up to date monthly tracking and trending for infection prevention and control, 2. ensure resident care equipment, dirty linens and briefs were handled in a sanitary manner. Findings:
Observations on 07/22/2025 at 11:50 a.m. during a tour of the laundry completed with S25 Housekeeping and Laundry Supervisor revealed bed sheets, pillowcases are worn thin and discolored (yellowish and tan stains). Further observation of the facility’s blankets revealed to be in very poor condition thin, discolored, felt scratchy.
During an interview on 07/23/2025 at 10:30 a.m. S20 DON (Director of Nursing) present the facility's infection control surveillance binder. Observation with the S20 DON revealed infection surveillance was not done which included, monthly trend and tracking of antibiotic therapy and treatment.
Review of Resident #50’s medical record revealed an admit date of 06/26/2025 with the following diagnoses, including in part: unspecified fracture of upper end of right humerus/subsequent encounter with routine healing, acute kidney failure unspecified and cognitive communication deficit.
Observation on 07/21/2025 at 8:05 a.m. revealed 2 bath basins and a bedpan on Resident #50's bathroom shower floor not stored in bags or labeled.
Observation on 07/22/2025 at 10:00 a.m. revealed 2 bath basins and 2 bedpans on Resident #50's bathroom shower floor not stored in bags or labeled.
Observation on 07/23/2025 at 9:58 a.m. revealed 2 bath basins and a bedpan on Resident #50's bathroom shower floor not stored in bags or labeled.
During an interview on 07/23/2025 at 9:58 a.m. S1 Administrator and S2 Chief Nursing Officer acknowledged 2 bath basins and 2 bedpans on the bathroom shower floor were not stored in bags and labeled and should be.
Observation on 07/21/2025 at 11:21 a.m. revealed S30 CNA (Certified Nurse Assistant) exit a resident room. Observation of shared resident room revealed dirty linen and briefs were on the floor. Further observation revealed S30 CNA return to resident room with a white trash bag.
During an interview on 07/21/2025 at 11:21 a.m. S30 CNA reported dirty linen and briefs should not have been on the floor. S30 CNA reported a clear trash bag should be used for dirty briefs and blue bags are used for dirty linen. S30 CNA reported leaving the room to retrieve a clear trash bag since there was not any trash bags in the trash can in the room.
During an interview on 07/23/2025 at 2:30 p.m. S21 CNA Supervisor confirmed dirty linens and briefs should not have been placed on the floor.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0883
(Tag F0883)
Could have caused harm · This affected multiple residents
Based on record review and interview the facility failed to maintain and follow policies and procedures for immunization for 4 (#55, #84, #87, #186) of 5 ( #55, #77, #84, #87 and #186) sampled residen...
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Based on record review and interview the facility failed to maintain and follow policies and procedures for immunization for 4 (#55, #84, #87, #186) of 5 ( #55, #77, #84, #87 and #186) sampled residents for influenza, pneumococcal disease and COVID-19. The facility failed to educate and offer residents and/or their representative immunizations of pneumonia, influenza and coronavirus disease (COVID-19), and failed to allow them to refuse and/or agree to either of the vaccines.Findings:Pneumonia Vaccine for Residents (Nursing Policy Manual 06/2025) revealed in part:Policy: Each resident is offered a pneumococcal immunization, unless the immunization is medically contraindicated or the resident has already been immunized.Pneumococcal Vaccine/Diseasea. Before offering the pneumococcal immunization, each resident or the resident's legal representative receives education regarding the benefits and potential side effects of the immunization.b. The resident or the resident's legal representative has the opportunity to refuse immunization.Influenza Vaccine for Residents (Nursing Policy Manual 06/2025) revealed in part:Policy: Each resident is offered an influenza immunization October 1 through March 31st annually, unless the immunization is medically contraindicated or the resident has already been immunized during this time period, (may give with consent as soon as available and up until pharmacy supply is depleted). Influenza.1. Before offering the influenza immunization, each resident or the resident's legal representative receives education regarding the benefits and potential side effects of the immunization.2. The resident or the resident's legal representatives has the opportunity to refuse immunizations.Coronavirus Disease (COVID-19) Vaccination of Residents (@2001 MED PASS Revised June 2022) revealed in part:Policy Statement: Each resident is offered the COVID-19 vaccine unless the immunization is medically contradicted or the resident has already been immunized.Policy Interpretation and Implementation1. Resident who are eligible to receive the COVID-19 vaccine are strongly encouraged to do so.2. The resident (or resident representative) has the opportunity to accept or refuse a COVID-19 vaccine, and to change his/her decision.During an interview on 07/23/2025 at 10:50 a.m. S1 Administrator reported immunizations are offered during the admission process and documentation should be in the admission records.Review of resident #55's admission records revealed an admission date of 05/01/2025 to this facility. Further review of admission records failed to reveal any documentation that indicated the residents and/or their representative had been educated or offered the pneumonia, influenza and/or coronavirus disease (COVID-19 immunizations).Review of resident #84's admission records revealed an admission date of 05/01/2025 to this facility. Further review of admission records failed to reveal any documentation that indicated the residents and/or their representative had been educated or offered the pneumonia, influenza and/or coronavirus disease (COVID-19 immunizations).Review of resident #87's admission records revealed an admission date of 05/01/2025 to this facility. Further review of admission records failed to reveal any documentation that indicated the residents and/or their representative had been educated or offered the pneumonia, influenza and/or coronavirus disease (COVID-19 immunizations).Review of resident #186's admission records revealed an admission date of 05/01/2025 to this facility. Further review of admission records failed to reveal any documentation that indicated the residents and/or their representative had been educated or offered the pneumonia, influenza and/or coronavirus disease (COVID-19 immunizations).
Apr 2025
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
Menu Adequacy
(Tag F0803)
Could have caused harm · This affected 1 resident
Based on observation and interviews, the facility failed to ensure resident's personal dietary choices were met for 1 (#2) out of 3 (#1, #2, #3) sampled residents. The facility prepared a lunch meal w...
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Based on observation and interviews, the facility failed to ensure resident's personal dietary choices were met for 1 (#2) out of 3 (#1, #2, #3) sampled residents. The facility prepared a lunch meal with Resident #2's dislikes.
Findings:
During an interview on 04/22/2025 at 8:15 a.m., S2CNA (Certified Nursing Assistant) reported Resident #2 only liked white meat chicken and did not like dark meat.
Observation of Resident #2's plated lunch meal tray on 04/22/2025 at 12:45 p.m. with S3Dietary Aid, revealed two baked chicken legs as the meat portion. Further observation revealed Resident #2's meal card preference was listed as wants white meat.
During an interview on 04/22/2025 at 12:45 p.m., S3Dietary Aid, acknowledged Resident #2's meal card had a preference listed for white meat and lunch meal was plated with dark meat.
During an interview on 04/22/2025 at 12:50 p.m., S4Dietary Manager acknowledged Resident #2's lunch meal had been plated with dark meat. S4Dietary Manager further acknowledged Resident #2's preference for white meat had not been honored and should have been.
Apr 2025
2 deficiencies
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
Quality of Care
(Tag F0684)
Could have caused harm · This affected multiple residents
Based on record reviews and interviews the facility failed to ensure 1 (#4) of 6 (#1, #2, #3, #4, #5, and #6) sampled residents received treatment and care in accordance with professional standards of...
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Based on record reviews and interviews the facility failed to ensure 1 (#4) of 6 (#1, #2, #3, #4, #5, and #6) sampled residents received treatment and care in accordance with professional standards of practice. The facility failed to ensure:
1. Resident #4's high blood glucose levels were rechecked as ordered after being administered sliding scale insulin for glucose levels greater than 400.
2. Resident #4's blood glucose levels were checked to determine if sliding scale insulin needed to be administered as ordered.
3. Resident #4's MD (medical doctor) was notified when Resident #4's finger stick glucose was greater than 250.
4. Resident #4's Lantus insulin was administered as ordered.
Findings:
Review of Administration of Medications policy with review date of November 15, 2022 revealed, in part:
Policy Statement
Standards: Medications shall be administered in a safe and timely manner, and as prescribed.
Procedure
3. Medications must be administered in accordance with the orders, including any required timeframe.
5. Licensed Nurse/CMT (certified medical technician) giving medication must follow the six rights to ensure safe medication administration.
-Each time you administer a medication, you need to be sure to have the:
1. Right individual
2. Right medication
3. Right dose
4. Right time
5. Right route
6. Right documentation .
10. The individual administering the medication must initial the resident's electronic medication administration on the appropriate line entry after giving each medication and before administering the next ones .
11. If a drug is withheld, refused, or given at a time other than the scheduled time, the individual administering the medication shall document in space provided for that drug and dose.
12. As required or indicated for a medication, the individual administering the medication will record in the resident's eMAR (electronic medication administration record):
-The date and time the medication was administered;
-The dosage;
-The route of administration;
-The injection site (if applicable);
-Any complaints or symptoms for which the drug was administered;
-Any results achieved and when those results were observed; and
-The signature and title of the person administering the drug.
Review of Resident #4's record revealed an admit date of 2/14/2025 and a discharge date of 03/14/2025 with diagnoses that included, in part, Type 2 diabetes mellitus with hyperglycemia.
1.
Review of Resident #4's physician orders revealed orders including:
-02/20/2025 (end date of 03/02/2025) Novolog Injection Solution 100 unit/ml (milliliter) (insulin aspart) - Inject as per sliding scale: if 201 - 250 = 3 units; 251 - 300 = 5 units; 301 - 350 = 7 units; 351 - 400 = 9 units, subcutaneously before meals and at bedtime for DM (diabetes mellitus). If FSBS (finger stick blood sugar) > 400 Give 11 units. Recheck in 3 hours; if still > than 400 obtain stat serum glucose and NOTIFY MD.
-03/02/2025 (end date of 03/06/2025) Novolog injection solution 100 unit/ml (insulin Aspart) - Inject as per sliding scale: if 201 - 250 = 3 units; 251 - 300 = 5 units; 301 - 350 = 7 units; 351 - 400 = 9 units, subcutaneously two times a day for DM. If FSBS > 400 Give 11 units. Recheck in 3 hours; if still > than 400 obtain stat serum glucose and NOTIFY MD.
-03/06/2025 (end date of 03/14/2025) Novolog injection solution 100 unit/ml (insulin aspart) - inject as per sliding scale: if 201 - 250 = 3 units; 251 - 300 = 5 units; 301 - 350 = 7 units; 351 - 400 = 9 units; 401 - 600 = 11 units. Recheck in 3 hours; if still > than 400 obtain stat serum glucose and NOTIFY MD, subcutaneously two times a day for DM.
Review of Resident #4's February and March 2025 eMAR revealed glucose checks greater than 400 on the following dates and times with insulin administered per sliding scale:
-02/26/2025 at 1130 = 434
-02/26/2025 at 1630 = 440
-02/28/2025 at 1630 = 403
-03/05/2025 at 0830 = 547
-03/06/2025 at 1700 = 407
-03/13/2025 at 1700 = 539
Further review of Resident #4's February and March 2025 eMAR and nursing notes failed to reveal any rechecks of Resident #4's glucose after 3 hours as ordered.
2.
Review of Resident #4's physician order revealed:
-02/20/2025 (end date of 03/02/2025) Novolog Injection Solution 100 unit/ml (insulin aspart) - Inject as per sliding scale: if 201 - 250 = 3 units; 251 - 300 = 5 units; 301 - 350 = 7 units; 351 - 400 = 9 units, subcutaneously before meals and at bedtime for DM If FSBS >400 Give 11 units. Recheck in 3hours; if still >than 400 obtain stat serum glucose and NOTIFY MD.
Review of Resident #4's February 2025 eMAR failed to reveal finger stick blood sugar was obtained to determine if sliding scale insulin was needed as ordered for before breakfast dose on 2/24/2025 and 2/25/2025.
3.
Review of Resident #4's physician orders revealed orders including:
-2/14/2025 (end date of 2/20/2025) Finger stick glucose every 6 hours. Less than < 70 or greater than > 250 notify MD.
-2/20/2025 (end date of 2/27/2025) Finger Stick Glucose AC and HS. Less than < 70 or greater than > 250 notify MD - before meals and at bedtime.
-2/27/2025 (end date of 3/14/2025) Finger Stick glucose twice daily. Less than < 70 or greater then > 250 notify MD.
Review of Resident #4's February and March 2025 eMARs revealed glucose checks greater than 250 on the following dates and times:
-02/15/2025 at 1800 = 301
-02/17/2025 at 1800 =266
-02/19/2025 at 1200 = 275
-02/19/2025 at 1800 = 361
-02/20/2025 at 1200 = 275
-02/20/2025 at 1800 = 388
-02/22/2025 at 1130 = 343
-02/22/2025 at 1630 = 343
-02/23/2025 at 0630 = 304
-02/23/2025 at 1130 = 314
-02/23/2024 at 1630 = 424
-02/23/2025 at 2100 = 283
-02/24/2025 at 1130 = 308
-02/25/2025 at 1130 = 386
-02/26/2025 at 0630 = 341
-02/26/2025 at 1130 = 469
-02/26/2025 at 1630 = 440
-02/26/2025 at 2100 = 301
-02/27/2025 at 1130 = 536
-02/27/2025 at 1630 = 399
-02/28/2025 at 1830 = 295
-03/01/2025 at 1830 = 334
-03/02/2024 at 0830 = 281
-03/02/2025 at 1830 = 591
-03/03/2024 at 0830 = 369
-03/03/2024 at 1830 = 339
-03/04/2025 at 0830 = 339
-03/04/2025 at 1830 = 290
-03/05/2025 at 0830 = 547
-03/06/2025 at 0830 = 400
-03/06/2025 at 1830 = 407
-03/07/2025 at 1830 = 293
-03/08/2025 at 1830 = 300
-03/10/2025 at 1830 = 302
-03/11/2025 at 0830 = 333
-03/11/2025 at 1830 = 333
-03/12/2025 at 0830 = 331
-03/12/2025 at 1830 = 331
-03/13/2025 at 1830 = 539
Further review of Resident #4's February and March 2025 eMARs and nursing notes failed to reveal MD had been notified that Resident #4's glucose was greater than 250 as ordered.
4.
Review of Resident #4's physician orders revealed:
-2/26/2025 (end date of 3/14/2025) Lantus subcutaneous solution 100unit/ml (insulin glargine) - inject 60 unit subcutaneously at bedtime for DM, do not mix with any other insulin and inject 25 unit subcutaneously in the morning for DM.
-2/20/2025 (end date of 2/26/2025) Lantus subcutaneous solution 100 unit/ml (insulin glargine) - Inject 60 unit subcutaneously at bedtime for DM do not mix with any other insulin and inject 15 unit subcutaneously in the morning for DM.
Review of Resident #4's February and March 2025 eMARs failed to reveal the morning dose of Lantus 15mg was administered on 02/24/2025 and 02/25/2025 and failed to reveal the morning dose of Lantus 25mg was administered on 3/12/2025.
During an interview on 4/7/2025 at 1:30 p.m. S1 DON (Director of Nursing) reviewed Resident #4's record and confirmed:
1. There was no evidence glucose levels had been rechecked after sliding scale insulin was administered for the following glucose levels greater than 400:
-02/26/2025 at 1130 = 434
-02/26/2025 at 1630 = 440
-02/28/2025 at 1630 = 403
-03/05/2025 at 0830 = 547
-03/06/2025 at 1700 = 407
-03/13/2025 at 1700 = 539
2. There was no evidence a finger stick blood glucose had been obtained the morning of 2/24/2025 and 2/25/2025 to determine if Novolin insulin needed to be administered.
3. There was no evidence Resident #4's MD had been notified when Resident #4's finger stick blood glucoses were greater than 250.
4. There was no evidence the morning dose of Lantus 15 units had been administered on 02/24/2025 and 02/25/2024 and no evidence the morning dose of Lantus 25 units had been administered on 3/12/2025.
S1 DON further reported each of these should have been documented if they were done.
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
Pressure Ulcer Prevention
(Tag F0686)
Could have caused harm · This affected multiple residents
Based on record review and interview the facility failed to ensure residents received necessary treatment and services, consistent with professional standards of practice to promote healing and preven...
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Based on record review and interview the facility failed to ensure residents received necessary treatment and services, consistent with professional standards of practice to promote healing and prevent the development of new pressure ulcers for 1 (#4) of 4 (#3, #4, #5, and #6) residents reviewed for pressure ulcers. The facility failed to perform wound care as recommended by S2 Wound NP (nurse practitioner) for Resident #4.
Findings:
Review of Resident #4's record revealed an admit date of 02/14/2025 and a discharge date of 03/14/2025 with diagnoses that included, in part, gluteal cleft pressure injury, type 2 diabetes mellitus with hyperglycemia, encounter for attention to gastrostomy, muscle weakness generalized, and nontraumatic intracerebral hemorrhage unspecified.
Review of Resident #4's physician orders revealed the following:
-02/18/2025 (end date of 03/12/2025) Gluteal cleft: Clean area with wound cleaner. Apply Venelex to wound bed. Cover with dry cover dressing every day and prn - every day shift for pressure injury and as needed for dressing dislodge/soiled.
-03/12/2025 (end date of 03/14/2025) Gluteal cleft: clean area with wound cleaner, apply medi-honey, calcium alginate to wound bed, cover with dry cover dressing every day and prn - every day shift for pressure injury order per S2 Wound NP wound care and as needed for dressing dislodge/soiled.
Review of Resident #4's physician progress note for date of service 03/01/2025 revealed, in part, NP and wound treatment team were managing a buttocks wound.
Review of S2 Wound NP progress note for Resident #4 with service date of 02/25/2025 revealed, in part, an unstageable gluteal cleft pressure injury wound was evaluated and treatment recommendations were to clean with wound cleanser, apply honey and dry dressing, and change 3 times per week and as need if dislodged, saturated, or soiled.
Review of February and March 2025 TAR (treatment administration record) revealed S2 Wound NP's 02/25/2025 gluteal cleft wound treatment recommendations were not started until 03/13/2025.
During an interview on 04/09/2025 at 7:52 a.m. S3 Treatment Nurse reviewed S2 Wound NP's 02/25/2025 progress note and reported she thought S2 Wound NP wanted her to continue the original order until out of the Venelex and confirmed that was not documented in the progress note and if it wasn't documented it wasn't done.
During a phone interview on 04/09/2025 at 8:25 a.m., with S3 Treatment Nurse present, S2 Wound NP reported the 02/25/2025 order and treatment should have been started sooner and as per S2 Wound NP's 02/25/2025 recommendation.
During an interview on 04/09/2025 at 8:38 a.m. S3 Treatment Nurse reported since it wasn't documented to continue the Venelex until done, S2 Wound NP's wound treatment recommendations should have been started when ordered and was not.
Feb 2025
1 deficiency
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
Grievances
(Tag F0585)
Could have caused harm · This affected multiple residents
Based on observations, interviews and record reviews the facility failed to ensure the facility's Grievance Policy was followed for 1 (#2) of 7 (#1, #2, #3, #4, #5, #6 and #7) sample residents. The fa...
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Based on observations, interviews and record reviews the facility failed to ensure the facility's Grievance Policy was followed for 1 (#2) of 7 (#1, #2, #3, #4, #5, #6 and #7) sample residents. The facility failed to resolve a grievance of resident #2's call light not being answered and failed to provide a completed review of the grievance in writing and/or verbal to resident #2 or his RP (responsible party).
Findings:
Review of the facility's Grievance/Complaint form revealed in part a resident, their representatives, interested family members or advocates may file a grievance or complaint with the facility without fear or threat of reprisal of any kind. Please fill out, date, and sign this report and submit it to any department manager. You will be provided with an oral and/or written report of the facility's findings as soon as possible.
Review of resident #2's grievance/complaint form dated 01/31/2025 revealed grievance was filed by resident #2's RP. Resident #2's RP documented in part, the incident occurred on 01/25/2025 and again on 01/31/2025 during the 7-3 and 3-11 shift. Resident #2's RP documented twice in the last week resident #2 waited too long for his call light to be answered when he needed to be changed. Days were Saturday afternoon and again today (Friday).
Review of resident #2's Annual MDS (minimum data set) dated 01/15/2025 revealed the following: Section C - Cognitive Patterns a BIMS (Brief Interview for Mental Status) summary score of 15 which indicated cognition is intact. Section GG - Functional Abilities revealed resident #2 had functional limitation in range of motion he had impairment on one side of upper and lower extremities. Section H Bladder and Bowel indicate resident #2 was always incontinent of the bladder and was frequently incontinent of his bowel.
Review of resident #2's Comprehensive Care Plan revealed the following problems with some of the interventions:
Limited physical mobility due to cardiopulmonary arrest. 05/10/2019 refuse to wear boots to feet to aid in foot drop. Some of the interventions are turn and reposition according to facility protocol. Be alert for, document, report to medical doctor as needed sign/symptom of immobility (contractures forming or worsening, thrombus formation, skin breakdown, fall-related injury). Mobility bars X2 to bed to assist with turning and repositioning. Provide gentle range of motion as tolerated with daily care. Provide supportive care, assistance with mobility as needed.
The resident is on diuretic therapy (specify medication) related to: edema, hypertension. Some interventions were administer medication as ordered. Labs as ordered. Many other medications may interact with antihypertensive to potentiate their effect (Levodopa, Nitrates). Monitor for Interactions/adverse consequences. May cause dizziness, postural hypotension, fatigue, and an increased risk for falls. Observe for possible side effects q-shift. Monitor for edema.
During an interview on 02/11/2025 at 3:30 p.m. resident #2's RP reported no one had gotten back with her regarding the grievance/complaint about resident #2's call light not being answered, about resident #2 being left wet and soiled for long periods of time. Resident #2's RP reported she had been a witness to him having to wait 2 to 3 hours for someone to come and change him.
During an interview on 02/13/2025 at 10:45 a.m. Resident #2 was alert and awake in bed. When surveyor entered resident #2's room, he asked was I a CNA (Certified Nursing Assistant) and reported no one had answered when he pushed the call light. Surveyor noted the call light was within reach. Surveyor asked resident #2 to press his call light again, he pressed his light. Surveyor waited in resident #2's room and no one answered the call light and no one came to his room. Resident #2's call light was beeping and the red light outside above his door was on. Resident #2 reported no one had talked to him about his call light or taking a long time to answer his call light
.
During an interview on 02/17/2025 at 2:01 p.m. S1 CNA reported you have to go in the resident's room to answer a call light. S1 CNA reported anyone can answer a call light.
During an interview on 02/11/2025 at 11:10 p.m. S2 CNA Supervisor reported resident #2's RP is the one that filed a grievance/complaint dated 01/31/2025 regarding resident #2's call light not being answered. S2 CNA Supervisor acknowledged she did not notify resident #2's RP in writing and/or verbal about the completed review of the grievance.
Feb 2025
6 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 interviews and record reviews the facility failed to protect the residents' right to be free from sexual abuse and psyc...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews the facility failed to protect the residents' right to be free from sexual abuse and psychosocial harm from another resident for 3 (Resident #1, #6, #7) of 7 (Resident #1, #2, #3, #4, #5, #6, and #7) sampled residents.
The deficient practice resulted in an Immediate Jeopardy on 12/27/2024 at approximately 2:38 a.m., when Resident #1 was approached at his bedside by Resident #2 with Resident #2's penis exposed playing with himself. Residents #6 and #7 resided in the shared resident room at the time of the event. Resident #1 was verbal and his cognition was intact. Resident #1 reported Resident #2 grabbed him by his upper arms and shoulders and he had to wrestle with Resident #2 to get away. Resident #1 reported Resident #2 asked him if he was gay and had his penis exposed, in his hand playing with it. The facility staff did not separate Resident #2 from the other residents in the shared room. Resident #2 remained in the shared room throughout the night and part of the following day with Residents #1, #6 and #7. S1 Administrator was made aware of the abuse on 12/27/2024 at approximately 8:00 a.m. when Resident #1 came to her office and reported Resident #2 had exposed himself.
S1 Administrator and S2 DON (Director of Nursing) were notified of the Immediate Jeopardy on 01/30/2025 at 2:45 p.m.
The Immediate Jeopardy was removed on 01/31/2025 at 12:15 p.m. The facility implemented an accepted Plan of Removal as confirmed through onsite observations, interviews and record reviews prior to the exit.
Findings:
Abuse Prevention Policy (dated 9/5/16 and reviewed 11/15/22)
Policy Statement:
Standards:
The resident has the right to be free from verbal, sexual, physical and mental abuse, corporal punishment and involuntary seclusion.
The resident has the right to be free from mistreatment, neglect and misappropriation of property.
Facility has a zero-tolerance Abuse Standard regarding all proven allegations of verbal, sexual, physical, and mental, neglect
Action
Prevention: The abuse coordinator in the facility is the administrator.
Reports of allegations or suspected abuse, neglect or exploitation including those involving taking photograph and video recording, using any type of equipment such as cameras, smart phones, and any other electronic devices of resident and his or her personal space on social media will be reported immediately to: Facility abuse coordinator, DON, State Agencies, Local Ombudsman office.
5. Protect:
Resident Protection after alleged Abuse, Neglect and Exploitation, taking, keep, share and distribute of unauthorized photograph of resident and his/her personal space in social media.
It is the responsibility of all staff to provide a safe environment for the residents. Resident care and treatments shall be monitored by all staff, on an ongoing basis, so that residents are free from abuse, neglect, or mistreatment. Care will be monitored so that the resident's care plan is followed.
Examples of ways to protect a resident from harm during an investigation of abuse, neglect and exploitation may include but not limited to:
a) Temporary (less than 24 hours) separation from other residents if a resident's behavior poses a threat of abuse or violence.
b) Temporary or permanent room or roommate change, where incompatibility creates the potential for abuse (follow change or room or roommate procedures)
e) Temporary one-on-one supervision of a resident
f) Engage a resident in diversionary activities
g) Reassignment of nursing staff duties
h) Time off for nursing staff
i) Involve clergy, social services and counselors, as appropriate
Resident #1
Resident #1 was re-admitted to the facility on [DATE] from a local hospital with diagnoses, which included in part, unspecified paraplegia, anxiety disorder, depression and post-traumatic stress disorder.
Review of Resident #1's most recent Quarterly MDS (Minimum Data Set) assessment dated [DATE] revealed in part, Resident #1 had a BIMS (Brief Interview of Mental Status) score of 15 indicating cognition was intact. Resident #1 was a paraplegic and used a wheelchair for mobility. Resident #1 required extensive assistance from 1-2 staff with bed mobility, transfers, and toileting.
Review of Resident #1's comprehensive care plan revealed Resident #1 was care planned for the use of anti-anxiety medications relate to anxiety disorder and PTSD (Post Traumatic Stress Disorder). Some of the interventions are to give anti-anxiety medications ordered by physician and monitor/document side effects and effectiveness.
Resident #1 was subject to an unwanted sexual advancement from resident #2. Residents #6 and #7 resided in the shared resident room at the time of the event and were not protected.
Review of 2 videos from Resident #1's personal cell phone revealed:
First video (dated 12/27/2024) with a start time of 2:38 a.m. - lasting 40 seconds:
Resident #2 was standing at Resident #1's bedside facing Resident #1 while Resident #1 was lying in bed. Resident #2 was wearing a light blue denim button shirt unbuttoned with a black shirt underneath; black pants; red/black checkered underwear; underwear and pants pulled below his genitals; genitals fully exposed; Resident #2's right hand was on his own genitals. Resident #2's face fully visible in video.
Resident #1 can be heard stating: Get the f--- away from me; gone cuz gone.
Second video (dated 12/27/2024) moments after the first video lasting 1 min, 32 seconds:
Resident #1 can be heard stating: Get your b -- ch a-- back; Get away [NAME] a--; Drop that sh--, drop that b--ch.
Can hear a female voice (presumably staff) approach Resident #1 and then Resident #1 was heard saying: I didn't see him at first, I was looking at my phone, he snuck up on me; Tell her what you did; b--ch a-- tried to grab me; b--ch a-- was playing with his dick; he was standing over me asking if I'm crippled; right there by my bed looking at my phone; I was sitting on my bed and he tried to grab me because I'm crippled.
At the end of the first video and throughout second video, the video was unsteady as Resident #1 was transferring himself from his bed to his wheelchair trying to move away from Resident #2.
Review of Resident #2's admission photograph revealed the same clothing and face of Resident #2 in the video.
Review of the Behavior Note dated 12/27/2024 at 3:09 a.m. by S5 RN (Registered Nurse) documented Resident #1 in hallway swinging his wheelchair arms at his roommate, Resident #2, saying, Tell them what you did B____ a___ n____! Tell them what you did. This nurse re-directed resident to calm down and go outside to get some air.
Resident #2
Review of Resident #2's medical record revealed an admit date of 12/26/2024 and a discharge date of 12/27/2024 with the following diagnoses which included: Hypo-osmolality and hyponatremia (primary diagnosis); effusion, left wrist; chronic viral hepatitis C; cognitive communication deficit; and cannabis use, unspecified.
Review of Resident #2's MDS assessment dated [DATE] revealed a BIMS (Brief Interview for Mental Status) of 6 which indicated severe cognitive impairment. Further review revealed Resident #2 was independent with indoor mobility. Resident #2 was marked as not using any devices such as a wheelchair, lift, or walker.
Resident #6
Review of Resident #6's medical record revealed an admit date of 06/17/2014 with diagnoses which included: Stroke, hemiplegia unspecified and cerebral vascular disease.
Review of Resident #6's Quarterly MDS assessment dated [DATE] revealed a BIMS of 14 which indicated intact cognition and used a wheelchair for mobility.
Resident #7
Review of Resident #7's medical record revealed an admit date of 08/22/2024 with diagnoses which included: chronic obstructive pulmonary disease, syncope, type 2 diabetes, and heart failure.
Review of Resident #7's Quarterly MDS assessment dated [DATE] revealed a BIMS score of 14 which indicated cognition was intact. Further review revealed Resident #7 had no range of motion impairment for bilateral lower or upper extremities. Resident #7 was independent with activities of daily living.
Both Resident #6 and Resident #7 were interviewed on 01/30/2025 and denied knowledge of the incident on 12/27/2024.
During an interview on 01/28/2025 at 2:00 p.m. Resident #1 reported he had PTSD and staff did not even check on him after the incident. Resident #1 reported staff told him to go outside and get some fresh air. Resident #1 reported the staff called it an argument, staff did not believe him. Resident #1 reported S2 DON said he was exaggerating and the accused resident remained in their room until after 12:00 p.m. the next day. Resident #1 reported the incident occurred on 12/27/2024 in their shared resident room while 2 other residents were in the room.
During an interview on 01/28/2025 at 4:25 p.m. Resident #1 reported around 3:00 a.m. on 12/27/2024 one of his roommates, Resident #2, grabbed him by his upper arms and shoulders and he had to wrestle with him to get away. Resident #1 reported Resident #2 asked him if he was gay and had his penis exposed and in his hand playing with it. Resident #1 reported after the incident Resident #2 remained in the room with him. Resident #1 reported he was told to leave the room. Resident #1 reported he was not moved to another room until around noon on 12/27/2024 after his mother and his family came and moved his things to the first floor. Resident #1 reported the police attempted to interview him but he did not talk with them because he felt like no one cared. Resident #1 reported no one checked on him or asked if he was ok. Resident #1 reported it was like no one believed him.
During a phone interview on 01/28/2025 at 3:45 p.m., S5 RN reported she worked on the night of the incident with Resident #1 and Resident #2. S5 RN reported she did not see the incident but heard Resident #1 yelling. S5 RN reported Resident #2 was standing over Resident #1 when she entered the room. S5 RN further reported Resident #1 stated Resident #2 was exposing himself. Resident #2 had no previous behaviors that she was aware of. S5 RN reported no facility employee remained with Resident #2 after the incident and Resident #2 did not receive one-on-one care after the incident. S5 RN confirmed Resident #2 remained in the room with Residents #1, #6 and #7 after the allegation of the sexual abuse was made. S5 RN reported before she left at the end of her shift around 7:00 a.m. Resident #2 remained in the same room with Residents #1, #6 and #7.
During an interview on 01/28/2025 at 4:00 p.m., S6 ADON (Assistant Director of Nursing) reported she became aware of the incident around 3:00 a.m. on 12/27/2024 by S5 RN. S6 ADON reported when she checked on Resident #1 the morning of 12/27/2024, she saw Resident #1 coming out of the doorway of his room and Resident #2 was still in the room in the bed. S6 ADON reported Resident #2 did not say or do anything. S6 ADON reported Resident #2 was evaluated and sent to a local behavior hospital on [DATE]. S6 ADON reported she could not find documentation Resident #2 was placed with one-on-one monitoring after the incident. S6 ADON reported Resident #1 was still upset about Resident #2 exposing himself. S6 ADON reported Resident #1 was moved to the first floor around 12 noon on 12/27/2024.
During an interview on 01/29/2025 at 9:07 a.m. S2 DON reported he was out sick the week of 12/27/2024 when the incident occurred. S2 DON reported Resident #2 should have been placed with one-on-one care after the incident and that would have been found in Resident #2's notes or the shift report notes. S2 DON was unable to provide any documentation that Resident #2 was placed on one-on-one monitoring after the incident occurred.
During an interview on 01/29/2025 at 9:26 a.m. S1 Administrator reported on 12/27/2024 at 8:00 a.m. Resident #1 came to her office and reported Resident #2 had exposed himself to him during the early morning hours. S1 Administrator confirmed she was not notified of the incident until Resident #1 told her. S1 Administrator reported she should have been notified immediately and called S5 RN to find out the details about the incident with Resident #1 and Resident #2. S1 Administrator reported S5 RN got Resident #1 calmed down and Resident #2 was in bed and there were no issues. S1 Administrator confirmed Resident #1 and Resident #2 were in the same room with Resident #6 and Resident #7 until Resident #1 was moved later in the day on 12/27/2024.
During an interview on 01/29/2025 at 12:50 p.m., S1 Administrator confirmed the facility did not have documentation of Resident #2 receiving one-on-one supervision after the incident on 12/27/2024 involving Resident #1 and Resident #2.
During an interview on 01/29/2025 at 9:50 a.m. S7 SSD (Social Service Director) reported on 12/27/2024 she was instructed by S2 DON that she needed to do a trauma assessment for Resident #1. S7 SSD reported she was told very little about why the trauma assessment was needed. S7 SSD reported she was only made aware something had happened and she did not know what occurred. S7 SSD reported Resident #1 was emotional. S7 SSD reported Resident #1 was already being seen by their psych NP (Psychiatric Nurse Practitioner) for his diagnosis of PTSD.
Review of S9 Psych NP Follow-up evaluations notes dated 01/13/2025 revealed documentation of Resident #1's recent exacerbation of PTSD. Resident #1 reported recent exacerbation of PTSD symptoms after another resident at the facility reportedly exposed himself in front of him. Resident #1 reports that the other resident was lingering around him, causing his obsessive thoughts/anxiety. Resident #1 was now reporting hypervigilance and persistence of obsessive thoughts. Resident #1 also reported increase anxiety, currently taking clonazepam 0.5 mg (milligram) twice daily for anxiety treatment. Resident #1 stated increased depressive symptoms as well, currently taking Cymbalta 30 mg twice daily for depression/anxiety.
During an interview on 01/29/2025 at 3:45 p.m., S9 Psych NP reported he had seen Resident #1 a few times after the incident on 12/27/2024. S9 Psych NP reported Resident #1 had PTSD due to gunshot wounds. S9 Psych NP reported Resident #1 had shown exacerbation of his PTSD and he was working with Resident #1 trying to adjust his medications.
During an interview on 01/30/2025 at 10:30 a.m. S5 RN reported on 12/27/2024 she did not suspect abuse between Resident #1 and Resident #2 because she did not see it. S5 RN reported she placed a phone call to S6 ADON immediately after the incident because S6 ADON was on call for administration. S5 RN reported S6 ADON instructed her to separate them with no other instruction given. S5 RN reported she further informed S6 ADON that the situation had deescalated and both had calmed down. S5 RN reported she separated Resident #1 and Resident #2 by telling Resident #1 to go out and get some fresh air. S5 RN reported Resident #2 remained in the room along with the 2 other residents (Residents #6, and #7). S5 RN reported Resident #2 had an unsteady gait but could walk. S5 RN admitted telling Resident #1 that Resident #2 was probably using his urinal. When S5 RN was asked if Resident #2 went to the bathroom on his own, she verified Resident #2 was able to go to the bathroom on his own without assistance and he did not use a urinal. S5 RN further reported the other 2 residents, #6 and #7, remained in the room asleep during the incident and were unaware of the incident. S5 RN confirmed S6 ADON did not ask specific questions about the incident. S5 RN confirmed there was no other staff in the resident room when she left at the end of her shift at 7:00 a.m. S5 RN further reported at the end of her shift Resident #1 had returned to the shared resident room and was in his bed, Resident #2 was in his bed and the other 2 residents remained in bed.
The facility's Plan of Removal:
Resident #1 was the victim at the time of the event on 12/27/024 at 2:38 a.m. The perpetrator, Resident #2, was discharged from the center on 12/27/2024 at 6:08 p.m. Roommates, Resident #6 and Resident #7 had the potential to be affected since they were in the room at the time of the event and afterwards until the aggressor was discharged . To address the psychosocial/sexual abuse aspect of Resident #1, the Social Services Director completed Trauma Assessments on 12/27/2024, 12/30/2024, 01/02/2025 and 01/03/2025. The psychiatric nurse practitioner assessed Resident #1 on 12/30/2024 and 01/13/2025 to address psychiatric issues after the incident. Resident #1 will continue to see the psychiatric nurse practitioner on a monthly basis and as needed for any psychiatric concerns. Resident and staff interviews started 01/30/2025 and are in progress to identify any other residents who may have the potential to be affected.
1. Any allegation of abuse - the center must follow the abuse/neglect policy to protect residents, effective 01/30/2025.
2. If an abuse allegation is made, the abuse aggressor will be place on one-on-one with the behavior monitoring which will continue until cleared by a medical provider or until discharged , effective 01/20/2025.
3. The Administrator and DON are responsible for ensuring that all aspects of the abuse/neglect policy are carried out and that all components, such as one-on-one documentation and behavior monitoring, are implemented, effective 01/30/2025.
4. Administrator and Director of Nursing (DON) have been educated on abuse/neglect, the abuse/neglect policy to indicate reporting timeframes, and following all administration and reporting requirements for abuse/neglect and the follow-up of handling abuse/neglect allegations. This education occurred on 01/30/2025 by the RN, Chief Nursing Officer.
5. Residents #6 and #7 have had trauma assessments completed on 01/30/2025 by the Social Services Director.
Education started immediately on 01/30/2025 (see attached) to include 100% of staff and contract staff. This education will include the abuse/neglect policy with timeframes and will include initiation of the one-on-one with behavior monitoring form.
The mode of education will be verbal in person via staff meeting as well as a voice and text message communication blast.
The voice and text message blast communication were sent out by the Regional Administrator. The in-person staff meetings for education were/is being completed by the following staff members: RN, Director of Nursing; Associate Director of Nursing; and RN, Assistant Director of Nursing.
All education was initiated on 01/30/2025 and will continue daily until 100% is achieved. No one will work until education has been validated as received.
The Nursing Home Administrator or Designee will review all sign-in sheets/electronic documentation of text message communication blasts against the staff roster and contract staff roster on 01/30/2025. This will be continue until it is completed, no later than 02/03/2025. If any further staff are awaiting education, these staff will not work until their education completion has been validated.
All new hires will receive this education prior to working.
Ad hoc QAPI (Quality Assurance and Performance Improvement) was held on 01/31/2025 at 5:30 p.m. with Nursing Home Administrator, Director of Nursing, Management Nurses, Department Heads, Medical Director, and a floor staff licensed nurse and certified nursing assistant to discuss the systemic changes of facility practice.
Starting the week of 02/03/2025, the center social service director or designee will interview five residents weekly for four weeks to ask about abuse and follow up. The abuse interview monitoring process will continue after the initial four weeks monthly for three months. The results of these audits will be brought to the quality assurance/performance improvement committee to ensure all processes are followed and to ensure continued compliance. If it is determined that processes are not followed, the center will perform a 100% re-education of all staff and follow up directly with the responsible at the time of the incident.
Date Facility Asserts the Likelihood for Serious Harm to Any Recipient No Longer Exists: The IJ situation was removed at 12:15 p.m. on 01/31/2025.
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
Based on interviews and record reviews, the facility failed to be administered in a manner that enabled its resources to be used effectively and efficiently to attain or maintain the highest practicab...
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Based on interviews and record reviews, the facility failed to be administered in a manner that enabled its resources to be used effectively and efficiently to attain or maintain the highest practicable physical, mental and psychosocial well-being for 1 (Resident #1) of 7 (#1, #2, #3, #4, #4, #5, #6, and #7) residents.
The deficient practice resulted in an Immediate Jeopardy on 12/27/2024 at approximately 2:38 a.m., when Resident #1 was approached at his bedside by Resident #2 with Resident #2's penis exposed playing with himself. Residents #6 and #7 resided in the shared resident room at the time of the event. Resident #1 was verbal and his cognition was intact. Resident #1 reported Resident #2 grabbed him by his upper arms and shoulders and he had to wrestle with Resident #2 to get away. Resident #1 reported Resident #2 asked him if he was gay and had his penis exposed, in his hand playing with it. The facility staff did not separate Resident #2 from the other residents in the shared room. Resident #2 remained in the shared room throughout the night and part of the following day with Residents #1, #6 and #7. S1 Administrator was made aware of the abuse on 12/27/2024 at approximately 8:00 a.m. when Resident #1 came to her office and reported Resident #2 had exposed himself.
S1 Administrator and S2 DON (Director of Nursing) were notified of the Immediate Jeopardy on 01/30/2025m at 2:45 p.m.
The Immediate Jeopardy was removed on 01/31/2025 at 12:15 p.m. The facility implemented an accepted Plan of Removal as confirmed through onsite observations, interviews and record reviews prior to exit.
Findings:
Cross Reference F600
During a phone interview on 01/28/2025 at 3:45 p.m., S5 RN (Registered Nurse) reported no facility employee remained with Resident #2 after the incident on 12/27/2024 and Resident #2 did not receive one-on-one care after the incident. S5 RN confirmed Resident #2 remained in the room with Residents #1, #6 and #7 after the allegation of the sexual abuse was made. S5 RN reported before she left at the end of her shift around 7:00 a.m. Resident #2 remained in the same room with Residents #1, #6 and #7.
During an interview on 01/28/2025 at 4:00 p.m., S6 ADON (Assistant Director of Nursing) reported she became aware of the incident around 3:00 a.m. on 12/27/2024 by S5 RN. S6 ADON reported when she checked on Resident #1 the morning of 12/27/2024, she saw Resident #1 coming out of the doorway of his room and Resident #2 was still in the room in the bed. S6 ADON reported Resident #2 did not say or do anything. S6 ADON reported she could not find documentation Resident #2 was placed with one-on-one monitoring after the incident.
During an interview on 01/29/2025 at 9:07 a.m. S2 DON reported Resident #2 should have been placed with one-on-one care after the incident and that would have been found in Resident #2's notes or the shift report notes. S2 DON was unable to provide any documentation that Resident #2 was placed on one-on-one monitoring after the incident occurred.
During an interview on 01/30/2025 at 10:30 a.m. S5 RN confirmed there was no other staff in the resident room when she left at the end of her shift at 7:00 a.m. on 12/28/2024. S5 RN further reported at the end of her shift, Resident #1 had returned to the shared resident room and was in his bed, Resident #2 was in his bed and the other 2 residents remained in bed.
During an interview on 01/29/2025 at 9:26 a.m. S1 Administrator reported on 12/27/2024 at 8:00 a.m. Resident #1 came to her office and reported Resident #2 had exposed himself to him during the early morning hours. S1 Administrator confirmed she was not notified of the incident until Resident #1 told her. S1 Administrator reported she should have been notified immediately and called S5 RN to find out the details about the incident with Resident #1 and Resident #2. S1 Administrator confirmed Resident #1 and Resident #2 were in the same room with Resident #6 and Resident #7 until Resident #1 was moved later in the day on 12/27/2024.
During an interview on 01/29/2025 at 12:50 p.m., S1 Administrator confirmed the facility did not have documentation of Resident #2 receiving one-on-one supervision after the incident on 12/27/2024 involving Resident #1 and Resident #2.
During an interview on 01/30/2025 at 9:56 a.m. S2 DON reported he was responsible for overseeing all staff are trained on the abuse/neglect policy including recognizing signs, investigations, protection, and reporting procedures.
During an interview on 01/30/2025 at 9:56 a.m. S1 Administrator acknowledged she was responsible for providing oversite of the facility's abuse/neglect policy including reporting timeframes, one on one monitoring and making sure staff was educated on the necessary steps to ensure the safety and well-being of all resident.
The facility's Plan of Removal:
Resident #1 was the victim at the time of the event on 12/27/024 at 2:38 a.m. The perpetrator, Resident #2, was discharged from the center on 12/27/2024 at 6:08 p.m. Roommates, Resident #6 and Resident #7 had the potential to be affected since they were in the room at the time of the event and afterwards until the aggressor was discharged . Resident and staff interviews started 01/30/2025 and are in progress to identify any other residents who may have the potential to be affected.
1. Any allegation of abuse - the center must follow the abuse/neglect policy to protect residents, effective 01/30/2025.
2. If an abuse allegation is made, the abuse aggressor will be place on one-on-one with the behavior monitoring which will continue until cleared by a medical provider or until discharged , effective 01/20/2025.
3. The Administrator and DON are responsible for ensuring that all aspects of the abuse/neglect policy are carried out and that all components, such as one-on-one documentation and behavior monitoring, are implemented, effective 01/30/2025.
4. Administrator and Director of Nursing (DON) have been educated on abuse/neglect, the abuse/neglect policy to indicate reporting timeframes, and following all administration and reporting requirements for abuse/neglect and the follow-up of handling abuse/neglect allegations. This education occurred on 01/30/2025 by the RN, Chief Nursing Officer.
5. Residents #6 and #7 have had trauma assessments completed on 01/30/2025 by the Social Services Director.
Education started immediately on 01/30/2025 (see attached) to include 100% of staff and contract staff. This education will include the abuse/neglect policy with timeframes and will include initiation of the one-on-one with behavior monitoring form.
The mode of education will be verbal in person via staff meeting as well as a voice and text message communication blast.
The voice and text message blast communication were sent out by the Regional Administrator. The in-person staff meetings for education were/is being completed by the following staff members: RN, Director of Nursing; Associate Director of Nursing; and RN, Assistant Director of Nursing.
All education was initiated on 01/30/2025 and will continue daily until 100% is achieved. No one will work until this education has been validated as received.
All new hires will receive this education prior to working.
Ad hoc QAPI (Quality Assurance and Performance Improvement) was held on 01/31/2025 at 5:30 p.m. with Nursing Home Administrator, Director of Nursing, Management Nurses, Department Heads, Medical Director, and a floor staff licensed nurse and certified nursing assistant to discuss the systemic changes of facility practice.
Starting the week of 02/03/2025, the center social service director or designee will interview five residents weekly for four weeks to ask about abuse and follow up. The abuse interview monitoring process will continue after the initial four weeks monthly for three months. The results of these audits will be brought to the quality assurance/performance improvement committee to ensure all processes are followed and to ensure continued compliance. If it is determined that processes are not followed, the center will perform a 100% re-education of all staff and follow up directly with the responsible at the time of the incident.
Administrative oversight of the process will be completed by the Nursing Home Administrator and the Director of Nursing. As of 01/30/2025 and ongoing, the Regional Director Clinical Operations will provide oversight of the Nursing Home Administrator and Director of Nursing administrative oversight by reviewing and providing feedback on allegations of abuse and providing further supervision and training as needed.
Date Facility Asserts the Likelihood for Serious Harm to Any Recipient No Longer Exists: 01/30/2025.
SERIOUS
(G)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Actual Harm - a resident was hurt due to facility failures
Deficiency F0697
(Tag F0697)
A resident was harmed · 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 pain management was provided to a resident who required suc...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to ensure pain management was provided to a resident who required such services, consistent with professional standards of practice for 1 (#4) of 5 (#1, #2, #3, #4, and #5) sampled residents reviewed for pain. The facility failed to ensure Resident #4, who reported pain after a post-surgery wound, received medication or interventions to alleviate pain.
The deficient practice resulted in an actual harm for Resident #4 on 01/10/2025 at approximately 6:00 p.m. when Resident #4 requested pain medication for her post-surgical wound. Resident #4 requested Tylenol on the evening shift from S3 LPN (Licensed Practical Nurse). S3 LPN told Resident #4 she could not give her anything for pain. Resident #4 called 911 as a result of not getting pain medication. Resident #4 was eventually admitted to the hospital ER (Emergency Room) for acute pain on 01/10/2024 where she received 2 doses of Dilaudid for acute pain.
Findings:
Pain Policy: Pain management Program dated 04/2022.
Policy: The facility shall provide adequate management of pain to ensure that residents attain or maintain the highest practicable physical, mental, and psychosocial well-being.
Procedure:
1. Evaluate the resident for pain upon admission, to include prior use of pain medication
2. Behavioral signs and symptoms that may suggest the presence of pain include but are not limited to:
d. Resisting care, striking out.
f. Fidgeting, increased or recurring restlessness.
g. Facial expressions: grimacing, frowning, fear, grinding of teeth
h. Change in behavior: depressed mood, decreased participation in usual activities of daily living
k. Sighing, groaning, crying, breathing heavily
3. Assessment and evaluation by the appropriate members of the interdisciplinary team may include:
a. Asking the patient to rate the intensity of his/her pain using a numerical scale or a verbal or visual descriptor that is appropriate and preferred by the resident.
h. Current prescribed pain medications, dosages and frequency
7. Non-pharmacological pain management interventions include but are not limited to:
a. Adjusting room temp
b. Smoothing linens
c. Turning and repositioning to comfortable position
d. Loosen any constrictive bandage or device
e. Apply splinting (e.g., pillow or folded blanket)
f. Physical modalities (e.g., cold compress, warm shower or bath)
g. Exercises to address stiffness
h. Cognitive/behavioral interventions (e.g., music, diversions, pain education)
Review of facility policy dated 04/2022 and titled Pain Management Program, revealed the policy did not address the administration of pain medication, as ordered.
Review of the Resident #4's medical record revealed an admitted date of 01/09/2025, with diagnoses that included, in part: Encounter for orthopedic aftercare flowing surgical amputation; acquires absence of other right toe(s); acute osteomyelitis, right ankle and foot; severe sepsis without septic shock; encounter for surgical aftercare following surgery on the circulatory system; atherosclerosis of native arteries of extremities with gangrene, right leg; peripheral vascular disease; and malignant neoplasm of endometrium.
Review of Resident #4's Medicare 5 day MDS (Minimum Data Set) assessment dated [DATE] revealed a BIMS (Brief Interview of Mental Status) score of 15 indicating intact cognition.
Review of the Discharge MDS assessment dated [DATE] revealed Resident #4 was independent with eating, toileting hygiene and shower/bathing.
Review of Resident #4's admission pain assessment on 01/09/2025 revealed resident was marked as having mild pain in the last 5 days.
Review of the progress notes revealed, in part, on 01/10/2025 at 8:21 p.m. Resident #4 came to the nurses' station inquiring about pain medication which there was a problem with the medication prescription. Several attempts were made to correct the problems with no success.
Review of the progress notes revealed, in part, on 01/10/2025 at 8:50 p.m. Resident #4 was transferred to a local hospital per ambulance per stretcher.
Review of Resident #4's hospital medical records revealed an admit date of 01/10/2025 at 9:19 p.m. with acute pain and discharge date of 01/13/2025. Further review revealed Resident #4 received 2 doses of Dilaudid (pain medication) on 01/10/2025 after being admitted to the hospital. Resident #4 was discharged home from the hospital on [DATE].
During an interview on 01/30/2025 at 2:50 p.m. S3 LPN recalled she worked on 01/10/2025 on the 3P-11P shift and cared for Resident #4. S3 LPN reported Resident #4 knew the staff were working on getting her pain prescription filled. S3 LPN confirmed Resident #4 did ask for a pain pill and S3 LPN explained she didn't have anything for pain. S3 LPN reported she did not ask Resident #4 what her pain level was because she was trying to send her out to the hospital per Resident #4's request, but acknowledged Resident #4 was in pain. S3 LPN further reported she could have had Tylenol but Resident #4 did not ask for it (Tylenol). When asked if Resident #4 refused Tylenol, S3 LPN replied I guess you could say that. S3 LPN reviewed the January 2025 MAR (Medication Administration Record) and confirmed Resident #4 did not receive anything for pain during her 3P-11P shift on 01/10/2025. When the surveyor reviewed the January 2025 MAR with S3 LPN and asked why there was not a documented pain level on 01/10/2025 during her 3P-11P shift, S3 LPN reported Resident #4 was discharged before med pass time and that was why a pain assessment was not done on 01/10/2025 on the 3P-11P shift.
During a phone interview on 02/04/2025 at 12:20 p.m. Resident #4 reported she was admitted to the facility on [DATE]. She was not in great pain at the time of admit; but, she liked to keep her pain under control. Resident #4 reported she asked S3 LPN on 01/10/2025 at 6:00 p.m. for Tylenol. Resident #4 reported S3 LPN told her she could not get anything until orders were put in. Resident #4 reported she had pain at her surgical site from having metatarsals removed, and pain in her knees and her hips. Resident #4 reported, ultimately, she ended up with nothing for pain. Resident #4 reported S3 LPN triggered her and made her get irate when she told her she could not have anything for pain. Resident #4 reported feeling mad at the end. At this point, Resident #4 reported she was done with S3 LPN and called 911 to take her to the hospital. Resident #4 reported S3 LPN triggered her and it caused me to jump over the moon; she caused me to get irate. Resident #4 reported around 8:00 p.m. on 01/10/2025 the ambulance service picked her up from the facility and took her to the ER per her request because she had not received anything for pain and she was in pain. When the surveyor asked about Resident #4's pain level at the time she left the facility, on a scale of 0-10, Resident #4 reported her pain level was about a 6.
During an interview on 01/30/2025 at 3:10 p.m. S2 DON (Director of Nursing) acknowledged Resident #4 did not receive pain medication and should have received something for pain.
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 record reviews and interview, the facility failed to ensure an alleged violation of sexual abuse was reported immediate...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews and interview, the facility failed to ensure an alleged violation of sexual abuse was reported immediately to the facility's administrator and to the state agency within 2 hours after the allegations were made for 1 (#1) of 7 (#1, #2, #3, #4, #5, #6 and #7) sample residents.
Findings:
Review of the facility's Abuse Prevention Policy last reviewed date of 11/15/2022 revealed in part:
1. Prevention: The abuse coordinator in the facility is the administrator. Reports of allegations or suspected abuse, neglect .will be reported immediately to Facility Abuse Coordinator, Director of Nursing.
6. Report and Investigate: (e) Ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but no later than 2 hours after the allegation is made .to the administrator of the facility and to other officials (including to the State Agency .in accordance with state law).
Resident #1 was admitted to the facility on [DATE] with diagnoses, which included in part, unspecified paraplegia, anxiety disorder, depression and PTSD (post-traumatic stress disorder).
During an interview on 01/28/2025 at 4:25 p.m. Resident #1 reported around 3:00 a.m. on 12/27/2024 one of his roommates, Resident #2, grabbed him by his upper arms and shoulders and he had to wrestle with him to get away. Resident #1 reported Resident #2 asked him if he was gay and had his penis exposed and in his hand playing with it.
Review of 2 videos from Resident #1's personal cell phone revealed:
First video (dated 12/27/2024) with a start time of 2:38 a.m. - lasting 40 seconds:
Resident #2 was standing at Resident #1's bedside facing Resident #1 while Resident #1 was lying in bed. Resident #2 was wearing a light blue denim button shirt unbuttoned with a black shirt underneath; black pants; red/black checkered underwear; underwear and pants pulled below his genitals; genitals fully exposed; Resident #2's right hand was on his own genitals. Resident #2's face fully visible in video.
Resident #1 can be heard stating: Get the f--- away from me; gone cuz gone.
Second video (dated 12/27/2024) moments after the first video lasting 1 min, 32 seconds:
Resident #1 can be heard stating: Get your b -- ch a-- back; Get away [NAME] a--; Drop that sh--, drop that b--ch.
Can hear a female voice (presumably staff) approach Resident #1 and then Resident #1 was heard saying: I didn't see him at first, I was looking at my phone, he snuck up on me; Tell her what you did; b--ch a-- tried to grab me; b--ch a-- was playing with his dick; he was standing over me asking if I'm crippled; right there by my bed looking at my phone; I was sitting on my bed and he tried to grab me because I'm crippled.
During an interview on 01/28/2025 at 4:00 p.m., S6 ADON (Assistant Director of Nursing) reported she became aware of the incident around 3:00 a.m. on 12/27/2024 by S5 RN (Registered Nurse). S6 ADON acknowledged she did not report the incident that occurred on 12/27/2024 to the Administrator.
Review of the facility's incident investigation report revealed the incident occurred on 12/27/2024 at 2:38 a.m. and the incident was not entered until 12/27/2024 at 12:09 p.m.
During an interview on 01/29/2025 at 9:26 a.m. S1 Administrator reported she should have been notified immediately about the sexual abuse allegation with Resident #1 and Resident #2 and she was not. S1 Administrator confirmed she or S2 DON (Director of Nursing) were responsible for reporting the incident investigation report to the state agency when there was an allegation of abuse. S1 Administrator confirmed she did not enter the incident investigation report within the required time.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Investigate Abuse
(Tag F0610)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews the facility failed to thoroughly investigate an allegation of sexual abuse for 1 (#1) of ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews the facility failed to thoroughly investigate an allegation of sexual abuse for 1 (#1) of 7 (#1, #2, #3, #4, #5, #6 and #7) sample residents.
Findings:
Review of the facility's Abuse Prevention Policy (dated 9/5/16 and reviewed 11/15/22) revealed in part the following:
Policy Statement: Standards
The resident has the right to be free from verbal, sexual, physical and mental abuse, corporal punishment and involuntary seclusion.
The resident has the right to be free from mistreatment, neglect and misappropriation of property.
Facility has a zero-tolerance Abuse Standard regarding all proven allegations of verbal, sexual, physical, mental, neglect
Action
Prevention: The abuse coordinator in the facility is the administrator.
6. Report and Investigate: When suspicion of reports of abuse, neglect or exploitation occur, an investigation is immediately warranted.
Once the resident is cared for and initial reporting has occurred, an investigation should be conducted. Components of an investigation may include:
a) Interview with the involved resident, if possible, and document all responses. If resident is cognitively impaired, interview the resident several times to compare responses.
b) Interview all witnesses separately. Include roommates, residents in adjoining rooms, and staff members in the area and visitors in the area. Obtain witness statements, according to policy. All statements should be signed and dated by the person making the statement.
c) Document the entire investigation chronologically.
d) Notify the Local Ombudsman office to report the alleged abuse.
Review of Resident #1 records revealed an admission date of 12/23/2024 with diagnoses, which included in part, unspecified paraplegia, anxiety disorder, depression and post-traumatic stress disorder.
During an interview on 01/28/2025 at 4:25 p.m. Resident #1 reported around 3:00 a.m. on 12/27/2024 one of his roommates, Resident #2, grabbed him by his upper arms and shoulders and he had to wrestle with him to get away. Resident #1 reported Resident #2 asked him if he was gay and had his penis exposed and in his hand playing with it.
Review of 2 videos from Resident #1's personal cell phone revealed:
First video (dated 12/27/2024) with a start time of 2:38 a.m. - lasting 40 seconds:
Resident #2 was standing at Resident #1's bedside facing Resident #1 while Resident #1 was lying in bed. Resident #2 was wearing a light blue denim button shirt unbuttoned with a black shirt underneath; black pants; red/black checkered underwear; underwear and pants pulled below his genitals; genitals fully exposed; Resident #2's right hand was on his own genitals. Resident #2's face fully visible in video.
Resident #1 can be heard stating: Get the f--- away from me; gone cuz gone.
Second video (dated 12/27/2024) moments after the first video lasting 1 min, 32 seconds:
Resident #1 can be heard stating: Get your b -- ch a-- back; Get away [NAME] a--; Drop that sh--, drop that b--ch.
Can hear a female voice (presumably staff) approach Resident #1 and then Resident #1 was heard saying: I didn't see him at first, I was looking at my phone, he snuck up on me; Tell her what you did; b--ch a-- tried to grab me; b--ch a-- was playing with his dick; he was standing over me asking if I'm crippled; right there by my bed looking at my phone; I was sitting on my bed and he tried to grab me because I'm crippled.
During an interview on 01/30/2025 at 9:15 a.m., S3 Staffing Coordinator (as of 01/01/2025 worked in admissions) reviewed the staff schedule for 12/26/2024 to 12/27/2024 and confirmed 4 CNAs (certified nursing assistance), one RN (Registered Nurse) and one LPN (licensed Practical Nurse) worked 11 p.m.-7:00 a.m. on the second floor the night of the incident 12/26/2024 - 12/27/2024 with Resident #1 and Resident #2.
During an interview on 01/30/2025 at 9:56 a.m., S1 Administrator reported she only interviewed two employees about the incident on 12/27/2024 with Resident #1 and Resident #2. S1 Administrator acknowledged the two employees interviewed were not working on 12/27/2024. S1 Administrator confirmed that to perform a thorough investigation, all employees working on the second floor at the time of incident, should have been interviewed and they were not. S1 Administrator acknowledged a thorough investigation was not done.
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 reviews and interviews, the facility failed to ensure medical records were accurately documented for 1 (Resident...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews and interviews, the facility failed to ensure medical records were accurately documented for 1 (Resident #2) of 7 (Resident #1, #2, #3, #4, #5, #6, and #7) sampled residents. The facility failed to have documentation of a physician's discharge order.
Findings:
Review of Resident #2's record revealed an admit date of 12/26/2024 and a discharge date of 12/27/2024.
Review of Resident #2's medical record revealed the following diagnoses which included but not limited to: Pain in left wrist, chronic viral hepatitis C, cognitive communication deficit, cannabis use, unspecified.
Review of Resident #2's MDS (Minimum Data Set) revealed a BIMS (Brief Interview of Mental Status) of 06 indicated severe impaired cognition.
Review of Resident #2's physician orders failed to reveal a discharge order to the hospital on [DATE].
During an interview on 01/20/2025 at 3:20 p.m. S6 ADON (Assistant Director of Nursing) reported she could not locate the discharge order for Resident #2. S6 ADON reported she was responsible for taking the order and misplaced the verbal order from the physician. S6 ADON acknowledged there was not a system in place for taking verbal orders.
Dec 2024
1 deficiency
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
Resident Rights
(Tag F0550)
Could have caused harm · This affected multiple residents
Based on record reviews and interviews the facility failed to ensure residents had access to services outside the facility for 1 resident (#2) out of 3 residents (#2, #3, #4) reviewed for appointments...
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Based on record reviews and interviews the facility failed to ensure residents had access to services outside the facility for 1 resident (#2) out of 3 residents (#2, #3, #4) reviewed for appointments outside the facility.
Findings:
Review of the facility's Transportation to Appointments Policy dated April 2022 revealed in part:
Policy Interpretation and Implementation
1.
.Facility will provide transportation to and from appointments for all residents, unless resident prefers to provide their own transportation.
2.
Scheduled appointments for doctor's appointments, follow-ups, and referrals while residing in facility will be the responsibility of the Transportation Supervisor or designee.
3.
Documentation of refusals, missed appointments, and rescheduling of appointments will be completed by the floor nurse on duty in the chart or medical record; after receiving confirmation from the Transportation Supervisor.
4.
The Transportation Supervisor will also ensure all paperwork from appointments are handed to floor nurse and uploaded into medical records after scheduling follow up appointments.
6.
Inquiries concerning transportation should be referred to Transportation Supervisor and or designee.
Review of Resident #2's medical record revealed an admit date of 09/10/2024 with a re-admission date of 09/20/2024 with diagnoses that included colon cancer with metastatic cancer to bone. Resident #2 was discharged home per resident request on 11/23/2024.
Review of Resident #2's medical record revealed a ____ Chemotherapy Infusion's After Visit Summary report dated 10/18/2024 which included the following upcoming appointments:
-11/07/2024 at 7:00 a.m. non-fasting lab
-11/07/2024 at 8:00 a.m. established patient visit hematology oncology
-11/07/2024 at 9:00 a.m. infusion 90 minute chemotherapy infusion
Review of Resident #2's medical record revealed a ____ Emergency Department's After Visit Summary report dated 10/29/2024 which included the following upcoming appointments:
-11/07/2024 at 7:00 a.m. non-fasting lab
-11/07/2024 at 8:00 a.m. established patient visit hematology oncology
-11/07/2024 at 9:00 a.m. infusion 90 minute chemotherapy infusion
-11/07/2024 at 9:30 a.m. class hematology oncology
Review of facility records failed to reveal documentation Resident #2 was transported and attended his scheduled appointments on 11/07/2024.
Review of Resident #2's medical record revealed no documentation Resident #2 had refused to attend his scheduled appointments on 11/07/2024.
During an interview on 12/02/2024 at 1:10 p.m. S2 Director of Nursing (DON) reported S3 Certified Nursing Assistant (CNA) Supervisor was in charge of scheduling resident appointments and transportation of residents to/from scheduled resident appointments.
During an interview on 12/02/2024 at 3:30 p.m. S3 CNA Supervisor confirmed she was in charge of scheduling resident appointments and transportation of residents to/from scheduled resident appointments.
During an interview on 12/03/2024 at 4:45 p.m. S2 DON and S1 Administrator reviewed Resident #2's medical record and facility records and acknowledged there was no documentation Resident #2 was transported and attended his scheduled appointments on 11/07/2024.
During an interview on 12/04/2024 at 10:10 a.m. S3 CNA Supervisor reviewed Resident #2's medical record and facility records and acknowledged there was no documentation Resident #2 was transported and attended his scheduled appointments on 11/07/2024.
Oct 2024
2 deficiencies
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 F0657
(Tag F0657)
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 ensure the plan of care had been revised for 1 (#4) of 9 (#1, #2, #...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews the facility failed to ensure the plan of care had been revised for 1 (#4) of 9 (#1, #2, #3, #4, #5, #6, #7, #8, #9) sampled residents.
Findings:
Review of Resident #4's medical record revealed Resident #4 was admitted to the facility on [DATE] and had diagnoses that included, in part, fracture of shaft of left tibia, fracture of shaft of left fibula, traumatic subarachnoid and subdural hemorrhage, multiple fractures of ribs, left side, fracture of base of skull, fracture of unspecified thoracic vertebra, and fracture of unspecified lumbar vertebra.
Review of Resident #4's 07/20/2024 Quarterly MDS (minimum data set) revealed Resident #4 had a BIMS (Brief Interview of Mental Status) score of 15, indicating Resident #4 was cognitively intact. Further review of the 07/20/2024 quarterly MDS revealed Resident #4 did not have any functional limitation in ROM (range of motion) for upper or lower extremity.
Review of Resident #4's 07/20/2024 State Optional MDS revealed Resident #4 had a functional status of supervision and setup help only for bed mobility, transfer, eating and toilet use.
Review of Resident #4's care plan revealed Resident #4 was care planned for, in part:
Impaired Physical Mobility (initiated 04/18/2024) with interventions that included, in part, assist resident in performing movements/tasks, partial weight bearing for left lower leg and keep cam boot in place, and wear Miami J-Collar to neck at all times.
ADL (Activities of Daily Living) Self Care Performance Deficit (initiated 06/05/2024) with interventions that included, in part, Resident #4 requires 1-2 staff participation with toilet use, transfers, and bed mobility; provide Resident #4 with a sponge bath when a full bath or shower cannot be tolerated; Resident #4 requires 1 staff participation to dress; and wear Miami J-Collar to neck at all times.
During an interview on 10/02/2024 at 8:15 a.m. Resident #4 reported he was able to get out of bed, dress and bathe himself and was going out on pass by himself today to walk to a local gym.
During an interview on 10/03/2024 at 9:20 a.m. Resident #4 reported he had stopped using the Miami-J Collar and boot a while ago and was no longer receiving any therapy. Resident #4 further reported on arrival to the facility he was unable to walk outside.
During an interview on 10/3/2024 at 8:45am S3 MDS Director reviewed Resident #4's care plan and reported the care plan had not been updated and should have been. Further reported an MDS had been conducted in July 2024 and the care plan should have been updated.
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
Pressure Ulcer Prevention
(Tag F0686)
Could have caused harm · This affected multiple residents
Based on record reviews and interviews the facility failed to ensure a resident at risk for wounds received necessary treatment and services, consistent with professional standards of practice, to pro...
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Based on record reviews and interviews the facility failed to ensure a resident at risk for wounds received necessary treatment and services, consistent with professional standards of practice, to promote healing, to prevent infection, and to prevent wounds for 1 (#5) of 9 (#1, #2, #3, #4, #5, #6, #7, #8, and #9) sampled residents. The facility failed to ensure an accurate assessment was performed and the Medical Doctor (MD)/Nurse Practitioner (NP) was notifed of a current skin condition.
Findings:
Review of Resident #5's medical record revealed an admit date of 02/24/2021 with a re-entry date of 01/22/2023. Diagnoses, included in part, Spastic Diplegic Cerebral Palsy, Type 2 Diabetes, Neuromuscular Dysfunction of Bladder and Paralytic Syndrome, unspecified.
.
Review of Resident #5's Quarterly MDS (Minimum Data Set) dated 08/14/2024 revealed in part, Resident #5 had a BIMS (Brief Interview of Mental Status) score of 10, indicating moderately impaired cognition. Further review of Resident #5's MDS revealed Resident #5 was at risk for developing pressure ulcers and/or injuries and was totally dependent upon 2 staff for bed mobility and transfers.
Review of Resident #5's Comprehensive Care Plan revealed Resident #5 had been care planned for a potential impairment to skin integrity and/or pressure injury related to impaired mobility. Interventions included in part, to document location and size of skin injury and report abnormalities, maceration, blisters and pressure wounds to MD.
Review of Resident #5's Interdisciplinary Notes revealed the following in part:
09/14/2024 at 3:03 p.m.: 60 - 75% of Resident #5's buttock is pinkish/red in color. Appears to be stage I and II pressure ulcer. Contacted NP to notify. No answer. By: S4LPN (Licensed Practical Nurse).
10/02/2024 at 2:55 p.m.: (Late entry for 09/27/2024) No skin issues noted . By: S5Treatment Nurse.
10/02/2024 at 6:45 p.m.: MASD (Moisture Associated Skin Damage) noted to Resident #5's bilateral buttocks including sacrum and coccyx. Areas are blanchable with no breaks in the skin. By: S6Unit Manager.
During an interview on 10/02/2024 at 2:00 p.m., S5Treatment Nurse reported Resident #5 did not currently have a wound or any skin issues.
During an interview on 10/02/2024 at 3:30 p.m., S5Treatment Nurse reported she just re-assessed Resident #5's sacrum and did not see any skin issues.
During an interview on 10/02/2024 at 4:15 p.m., S6Unit Manager reported she assessed Resident #5's sacral area and her assessment revealed MASD to sacrum.
During an interview on 10/02/2024 at 4:30 p.m., S2DON (Director of Nursing) acknowledged MD should have been notified of Resident #5's skin assessment on 09/14/2024 and was not. S2DON acknowledged Resident #5's skin assessment by S5Treatment Nurse was not accurate and Resident #5's current skin condition of the sacrum could worsen rapidly.
During an interview on 10/03/2024 at 10:15 a.m., S6Unit Manager reported Resident #5 currently had a skin issue of MASD to the sacrum and the assessment by S5Treatment Nurse was inaccurate. S6Unit Manager acknowledged documenting no skin issues could result in no attention to Resident #5's sacral area and MASD could worsen into a wound.
Aug 2024
4 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
Based on record review and interviews, the facility failed to ensure resident's responsible party was notified when there was a change in condition for 1 (#2) out of 4 (#1, #2, #3, #4) sampled residen...
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Based on record review and interviews, the facility failed to ensure resident's responsible party was notified when there was a change in condition for 1 (#2) out of 4 (#1, #2, #3, #4) sampled residents. The facility failed to notify Resident #2's responsible party of an infection requiring antibiotic treatment.
Findings:
Review of Facility's Notification of Resident's Change in Condition (November 2019) revealed, in part:
Policy Statement: This facility will promptly notify the resident, his or her Attending Physician, and Responsible Party of changes in the patient's medical/mental condition and/or status (for example (e.g.), changes in level of care, billing/payments, resident rights, etc.). Procedure: Quality of Life - notification of changes - 4. Regardless of the resident's current mental or physical condition, the Nursing Supervisor/Charge Nurse will inform the resident, family, or responsibility party of any changes in his/her medical care or nursing treatments. 5. The Nurse Supervisor/Charge Nurse will record document the name of the responsible party that was notified of the change, date, time and response in electronic health record.
Review of Resident #2's medical records revealed an admit date of 04/15/2024 and discharge date of 07/06/2024.
Review of Resident #2's physician's orders revealed an order dated 06/22/2024 for Keflex Oral Capsule 500 mg (milligram). Give 500 mg via (by way of) PEG (Percutaneous Endoscopic Gastrostomy) - Tube three times a day - antibiotic for 7 days.
Review of Resident #2's medical record failed to reveal responsible party was notified of antibiotics ordered for a urinary tract infection on 06/22/2024.
During an interview on 08/27/2024 at 2:45 p.m. S2 LPN (Licensed Practical Nurse) acknowledged she made a progress note entry on 06/24/2024 for Resident #2's new order for Keflex 500 mg x 7 days and does not remember if she notified the family. S2 LPN reported it is the nurse's responsibility to notify the responsible party of any changes in the resident's condition.
During an interview on 08/28/2024 at 11:35 a.m. S1 DON (Director of Nursing) acknowledged Resident #2's responsible party should have been notified of antibiotics ordered for a urinary tract infection on 06/22/2024.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Incontinence Care
(Tag F0690)
Could have caused harm · This affected 1 resident
Based on record review, observation, and interview the facility failed to ensure residents with an indwelling catheter received appropriate care and services to prevent urinary tract infections to the...
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Based on record review, observation, and interview the facility failed to ensure residents with an indwelling catheter received appropriate care and services to prevent urinary tract infections to the extent possible for 1 (#4) of 4 (#1, #2, #3, #4) sampled residents.
Findings:
Review of policy and procedure reviewed/revised on 04/01/2018 titled Urinary Tract Infections (Catheter-Associated), Guidelines for Preventing revealed:
Purpose: The purpose of this procedure is to provide guidelines for the prevention of Catheter-Associated Urinary Tract Infections (CAUTIs).
Policy Interpretation and Implementation .Steps in the procedure The following CAUTI prevention strategies have been adopted and are to be followed by clinical staff: . 6. Maintain unobstructed urine flow .c. Keep drainage bag below the level of the bladder at all times. Do not place the drainage bag on the floor.
Review of Resident #3's medical records revealed an admit date of 04/01/2024 with the following diagnoses, including in part: acute respiratory failure with hypoxia, acute kidney failure unspecified, quadriplegia unspecified, encounter for fitting and adjustment of urinary device, encounter for attention to colostomy, other muscle spasm, and essential hypertension.
Review of Resident #3's Physician's Orders revealed an order dated 07/30/2024 for Suprapubic Cath (on admission) 18 FR (French)/cc (cubic centimeter). Insert ML (milliliter) sterile water in bulb. Use sterile catheter insertion tray and fig leaf urinary drain bag. Change monthly. Indwelling catheter assessment must be completed with each change - one time a day every 30 day(s) for change monthly.
Observation on 08/28/2024 at 11:45 a.m. revealed Resident #3's urinary catheter drainage bag was hanging from Resident #3's bedframe and the drain port tubing at the bottom of bag was touching the floor.
During an interview on 08/28/2024 at 11:50 a.m. S5 LPN (Licensed Practical Nurse) observed Resident #3's catheter bag and reported it was touching the floor and should not be.
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 F0700
(Tag F0700)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews, observations, and interviews, the facility failed to ensure received a written order from the physician...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews, observations, and interviews, the facility failed to ensure received a written order from the physician for and an informed consent for bed rails prior to installation for 1 (#2) out of 4 (#1, #2, #3, #4) sampled residents.
Findings:
Review of Facility's Bed Rail Policy (December 5, 2017) revealed, in part:
Policy Statement: It is the policy of this facility to identify and reduce safety risks and hazards commonly associated with bed rail use .The facility's priority is to ensure safe and appropriate bed rail use. It is the policy of this facility to prevent entrapment and other safety hazards associated with bed rail use .
Procedure: 1. Resident Assessment - e. facility has indicated documentation that the side rail is the least restrictive alternative for the least amount of time, f. the facility will document ongoing need for the use of a bed rail, .h. obtain informed consent, i. obtain physician order for medical symptom assessed for need for bed rail use, j. resident care plan will include use of bed rails
Review of Resident #2's medical records revealed an admit date of 04/15/2024 and discharge date of 07/06/2024 with the following diagnoses, including in part: acute respiratory failure with hypoxia, encounter for attention to gastrostomy, traumatic subdural hemorrhage without loss of consciousness/subsequent encounter, agitation or psychosis, tremors, and muscle spasms.
Review of Resident #2's MDS (Minimum Data Set) assessment dated [DATE] revealed resident is rarely/never understood; severely impaired cognitive skills.
Review of Resident #2's Bed Environment assessment dated [DATE] revealed - assist grab bar .is resident able to show you how they safely use the rail (s) - No.
Review of Resident #2's medical records failed to reveal an informed consent and physician's order for bed rail use.
During a telephone interview on 08/27/2024 at 2:20 p.m. S3 LPN (Licensed Practical Nurse) reported Resident #2 had grab bars in place on his bed.
During an interview on 08/27/2024 at 2:45 p.m. S2 LPN reported Resident #2 had mobility bars on his bed.
During an interview on 08/28/2024 at 11:35 a.m. S1 DON (Director of Nursing) acknowledged Resident #2 did not have an informed consent or a physician's order for a bed rail and should have.
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Comprehensive Care Plan
(Tag F0656)
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 develop and implement a comprehensive person-centered care plan f...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews and interviews, the facility failed to develop and implement a comprehensive person-centered care plan for each resident that includes measurable objectives to meet residents' medical, nursing, mental and psychosocial needs for 2 (#2, #4) of 4 (#1, #2, #3, #4) sampled residents. The facility failed to ensure:
1.) Resident #2's physician orders had been followed, and
2.) Resident #4's care plan had been revised with each of Resident #4's falls
Findings:
Resident #2
Review of Resident #2's medical records revealed an admit date of 04/15/2024 and discharge date of 07/06/2024 with the following diagnoses, including in part: acute respiratory failure with hypoxia, dysphagia/unspecified, encounter for attention to gastrostomy, and traumatic subdural hemorrhage without loss of consciousness/subsequent encounter.
Review of Resident #2's physician's orders revealed an order dated 06/22/2024 for Keflex Oral Capsule 500 mg (milligram). Give 500 mg via (by way of) PEG (Percutaneous Esophageal Gastrostomy) - tube three times a day - antibiotic for 7 days.
Review of Resident #2's June 2024 Medication Administration Record revealed Keflex 500 mg via PEG tube three times a day x 7 days was not administered on June 25th at 0600 and June 26th at 0600, 1400 and 2200.
Review of Resident #2's nurse's notes revealed the following entries:
- 06/24/2024 at 10:40 - received new orders from NP (Nurse Practitioner) for Keflex 500 mg PPT (per PEG tube) tid (three times a day) x 7 days .S2 LPN (Licensed Practical Nurse)
- 06/26/2024 at 12:02 - spoke with pharmacy worker. Writer to refax order for Keflex 500 mg via PEG tube.
During an interview on 08/28/2024 at 1:30 p.m. S4 Pharmacist reported Resident #2's Keflex 500 mg x 7 days was faxed on 06/26/2024 and sent to the facility the same day. S4 Pharmacist further reported no withdrawals of Keflex were taken out of the facility's automated medication dispensing system for Resident #2 on June 24th or June 25th.
During an interview on 08/28/2024 at 3:10 p.m. S1 DON (Director of Nursing) reported S2 LPN reported she did not wait for a return fax from the pharmacy on 06/24/2024 to determine if they received it. S1 DON further reported she spoke with a pharmacist at ____ and there was no activity on the facility's automated medication dispensing system on the dates of 06/24/2024 or 06/25/2024 for Resident #2 which would indicate he did not receive the antibiotic. S1 DON acknowledged there were missing doses of Keflex on June 25th at 0600 and June 26th at 0600, 1400 and 2200 and should not have been.
Resident #4
Review of Resident #4's medical records revealed an admit date of 05/21/2024 with the following diagnoses, including in part: acute respiratory failure with hypoxia, burns involving 10-19% of body surface with 0% to 9% third degree burns, personal history of traumatic brain injury, post-traumatic stress disorder unspecified, and bipolar disorder.
Review of Resident #4's 08/08/2024 Quarterly MDS (Minimum Data Set) assessment dated [DATE] revealed Resident #4 had a BIMS (Brief Interview Mental Status) of 15, indicating Resident #4 was cognitively intact. Further review of MDS revealed Resident #4 required extensive assistance with bed mobility and transfers and was totally dependent with toilet use.
Review of Incident Log revealed Resident #4 had falls on 06/29/2024, 07/12/2024, 08/18/2024, and 08/23/2024.
Review of Resident #4's comprehensive care plan failed to reveal Resident #4's care plan had been revised for Resident #4's 07/12/2024 and 08/23/2024 falls with interventions.
During an interview on 08/28/2024 at 3:52 p.m. S1 DON reviewed Resident #4's incident reports for falls and comprehensive care plan and acknowledged the care plan had not been revised for the 07/12/2024 and 08/23/2024 falls and should have been.
Aug 2024
1 deficiency
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 F0943
(Tag F0943)
Could have caused harm · This affected multiple residents
Based on record reviews and interview the facility failed to ensure required annual abuse and dementia training was completed for 1 direct care staff [S2 CNA (Certified Nursing Assistant)] out of 6 [S...
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Based on record reviews and interview the facility failed to ensure required annual abuse and dementia training was completed for 1 direct care staff [S2 CNA (Certified Nursing Assistant)] out of 6 [S2 CNA, S3 CNA, S4 CNA, S5 CNA, S6 LPN (Licensed Practical Nurse), S7 LPN] direct care staff personnel records reviewed.
Findings:
Review of the facility's Abuse Prevention Policy dated 09/15/2016 revealed in part:
4. Employee Training: All facility staff including contractors and volunteers will be educated on abuse, neglect, and exploitation . Annual education and training should be provided to all existing employees.
Review of S2 CNA's personnel record revealed a hire date of 09/25/2018. Further review of S2 CNA's personnel record revealed abuse and dementia training was last completed on 06/01/2023.
During an interview on 08/13/2024 at 4:36 p.m. S1 Staff Development reviewed S2 CNA's personnel record and acknowledged there was not documentation of required annual abuse and dementia training.
Jun 2024
16 deficiencies
CONCERN
(D)
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 interview the facility failed to ensure the MDS (Minimum Data Set) assessment accurately reflected t...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews and interview the facility failed to ensure the MDS (Minimum Data Set) assessment accurately reflected the resident's status for 1 (#178) of 2 (#178, #34) residents investigated for hospitalization.
Findings:
Review of Resident #178's record revealed a discharge date of 03/12/2024.
Review of Resident #178's progress note dated 03/12/2024 revealed resident #178 was discharged to another long term care facility.
Review of Resident #178's discharge MDS assessment dated [DATE] revealed Resident #178 was discharged to a short term general hospital.
During an interview on 06/05/2024 at S10 RN (Registered Nurse)/MDS Director reviewed Resident #178's record and acknowledged Resident #178 was discharged to another long term care facility. S10 RN/MDS Director further acknowledged Resident #178's discharge MDS assessment dated [DATE] indicated Resident #178 was discharged to the hospital and should have indicated Resident #178 was discharged to another long term care facility.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0558
(Tag F0558)
Could have caused harm · This affected multiple residents
Based on record reviews, observations and interviews, the facility failed to accommodate the needs of 2 (#39 and #67) of 5 (#21, #39, #51, #67, and #120) residents investigated for environment. The fa...
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Based on record reviews, observations and interviews, the facility failed to accommodate the needs of 2 (#39 and #67) of 5 (#21, #39, #51, #67, and #120) residents investigated for environment. The facility failed to ensure residents' call lights remained within reach.
Findings:
Review of Facility's Call Light, Answering procedure dated April 2022 revealed in part:
Purpose
The purpose of this procedure is to respond to the resident's requests and needs.
Key Procedural Points .
5. When the resident is in bed or confined to a chair be sure the call light is within easy reach of the resident .
Resident #39
During an interview on 06/03/2024 at 9:45 a.m., Resident #39 reported she did not have a call light.
Observation on 06/03/2024 at 9:45 a.m. failed to reveal Resident #39's call light within reach. Further observation revealed Resident #39's call light cord was connected to wall plug and the call light was on the ground between the wall and piece of furniture.
Observation on 06/04/2024 at 10:30 a.m. revealed Resident #39's call light cord was connected to teh wall plug wall and the call light was on the ground between the wall and piece of furniture.
During an interview on 06/05/2024 at 10:30 a.m. with S2 DON (Director of Nursing) present, Resident #39 reported she did not have a call light to call for assistance.
Observation on 06/05/2024 at 10:30 a.m. revealed Resident #39 in her room, sitting up in bed. Further observation revealed S2 DON located Resident #39's call light was on the ground wedged between the wall and a piece of furniture.
During an interview on 06/05/2024 at 10:30 a.m. S2 DON confirmed Resident #39's call light was not within Resident #39's reach and should have been.
Resident #67
Review of Resident #67's Care Plan revealed a problem of at risk for falls related to decreased mobility, history of falls with T11-12 compression fracture: Interventions included anticipate and meet resident's needs, attempt to keep resident's call light within reach, and encourage the resident to use call light for assistance as needed.
Observation on 06/03/24 at 9:40 a.m. revealed Resident #67's call light cord was wrapped around and wedged in the bed wheel at the foot of Resident #67's bed and was not in Resident #67's reach.
Observation on 06/04/2024 at 12:30 p.m. revealed Resident #67's call light cord was wrapped around and wedged in the bed wheel at the foot of Resident #67's bed and was not in Resident #67's reach.
During an interview on 06/04/2024 at 12:30 p.m. S2 DON acknowledged Resident #67's call light cord was wrapped around and wedged in the bed wheel at the foot of Resident #67's bed and was not in Resident #67's reach.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0565
(Tag F0565)
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 consider the views of the resident council group and act promptly ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews and interviews the facility failed to consider the views of the resident council group and act promptly to concerns related to laundry presented in the resident council meetings. The deficient practice had the potential to affect a total of 189 residents according to Long-Term Care Facility Application for Medicare and Medicaid dated 06/03/2024.
Findings:
Review of the resident council meeting notes from January 2024 through May 2024 revealed the following grievances related to laundry/ missing clothes:
01/22/2024:
Resident #62: missing her black blanket, activities gave her another one. Review of Resident #62's MDS dated [DATE] revealed a BIMS of 6 out of 15 indicating severely impaired cognition.
Resident #69: states his laundry is slow coming back sometimes a week. Review of Resident #69's MDS dated [DATE] revealed a BIMS of 15 out of 15 indicating cognitively intact.
Resident #13: states he is missing a gray shirt. Review of Resident #13's MDS dated [DATE] revealed a BIMS of 15 out of 15 indicating cognitively intact.
02/18/2024:
Resident #19: states he is still missing black jeans with gray patch. Review of Resident #19's MDS dated [DATE] revealed a BIMS of 15 out of 15 indicating cognitively intact.
Resident #58: missing cowboy shirt blue. Review of Resident #58's MDS dated [DATE] revealed a BIMS of 15 out of 15 indicating cognitively intact.
05/27/2024:
Resident #71: states her clothes are coming back from the laundry bleached. Review of Resident #71's MDS dated [DATE] revealed a BIMS of 13 out of 15 indicating cognitively intact.
Resident #149: states she is missing a black pajama shirt and one pair of camouflage pants. Review of Resident #149's MDS dated [DATE] revealed a BIMS of 15 out of 15 indicating cognitively intact.
Resident #113: missing three pair of sweat pants. Review of Resident #113's MDS dated [DATE] revealed a BIMS of 10 out of 15 indicating moderately impaired cognition.
Review of facility's Grievance/Complaint log for May 2024 revealed:
Resident #107: missing clothing. Grievance/ Complaint received on 05/23/2024-facility response on 06/06/2024 to request family to replace items and provide receipt for reimbursement
Resident #149: missing clothing. Grievance/ Complaint received on 05/27/2024-facility response on 05/29/2024 resident still not satisfied items have not been found, but did thank me for taking out time to look.
During an interview on 06/03/2024 at 2:00 P.M. during meeting of resident council group Resident #3 reported receiving other residents clothes back from the laundry. Resident #3 reported sometimes it may take up to a month to get your clothes back from laundry and then sometimes you still do not get your clothes back or you may get clothes that do not belong to you.
During an interview on 06/03/2024 at 2:00 P.M. during meeting of resident council group Resident #149 reported she had missing clothes in the past. Resident #149 described the clothes as a pajama shirt: black sleeve with a yellow face that she received for Christmas from her brother and a pair of camouflage pants. Resident #149 was unable to recall how long her clothes have been missing, but she reported she no longer sends her clothes to the facility laundry her family does her laundry.
During an interview on 06/03/2024 at 2:00 P.M. during meeting of resident council group Resident #9 reported she has seen other residents with her clothes on that were labeled with her name. Resident #9 reported she told the staff and followed the resident along with the staff to get her clothes back from the resident wearing her clothes. Resident #9 reported her family now does her laundry.
During an interview on 06/03/2024 at 2:30 P.M. S15 Activity Director reported the turn around time for clothes to be returned from the laundry was up to 3 days and after 5 days she would write up a grievance. S15 Activity Director reported when residents had issues she would log them into the grievance/ complaint log then turn it in to social services. S15 Activity Director reported S16 Housekeeping/ Laundry Supervisor looked out for reported missing clothes. S15 Activity Director reported if the missing clothes were not able to be found sometimes they were replaced; if staff had seen residents wearing clothes. S15 Activity Director reported she had heard of clothes from the laundry being given to wrong residents.
During an interview on 06/06/2024 at 10:30 A.M. S17 Social Services reported S16 Housekeeping/ Laundry Supervisor investigated missing clothing and if clothing was not found the facility wiould replace the clothing.
During an interview on 06/06/2024 at 2:30 P.M. S16 Housekeeping/ Laundry Supervisor reported the return of the residents clothes depend on many things, as laundry was liberal and there was no laundry schedule for hall or unit. S16 Housekeeping/ Laundry Supervisor reported sometimes residents did not have their names in their clothes or residents may have moved to another room/ floor and clothes are returned to previous room/ floor and this was a back and forth issue with returning resident's clothes.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Comprehensive Care Plan
(Tag F0656)
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 ensure a plan of care was developed and implemented for 2 (#25, 98)...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews the facility failed to ensure a plan of care was developed and implemented for 2 (#25, 98) of 2 residents reviewed for UTI (urinary tract infection). The facility failed to:
1. Develop a plan of care for 2 (#25, 98) residents diagnosed with urinary tract infection.
2. Administer medication as ordered for resident # 98.
Findings:
1.
Resident #25,
Review of resident #25's electronic health record revealed an admission date of 02/07/2023 and a diagnosis of but not limited to chronic congestive heart failure, primary hypertension, type 2 diabetes and Urinary Tract Infection.
Review of resident #25's MDS (minimum data set) revealed resident #25 had a BIMS (Brief Interview Mental Status) score of 12 indicating moderately impaired cognition.
Review of resident #25's lab results dated 05/29/2024 revealed resident #25 had cloudy yellow urine with a blood urea nitrogen level of 22 and a creatinine level of .56, a presumed UTI pending urine culture.
Review of resident #25's Physician's orders revealed an order for Keflex 500 mg give 1 mg (milligram) by mouth three times a day for 5 days dated 05/30/2024 for UTI (Urinary Tract Infection).
Review of resident #25's comprehensive plan of care failed to reveal a problem or approach related to resident #25's diagnosis of UTI.
During an interview on 06/05/2024 at 1:30 p.m. S8 LPN (licensed practical nurse)/MDS Nurse confirmed a plan of care for resident #25's diagnosis of UTI had not been developed and should have been.
Resident #98
Review of resident #98's electronic health record revealed an admit date of 11/22/2021 and a diagnosis of but not limited to UTI, generalized epilepsy, type 2 diabetes, cerebral infarction affecting right dominant side, essential hypertension, and Aphasia.
Review of resident #98's MDS dated [DATE] revealed resident #98 had a BIMS score of 9 indicating moderately impaired cognition.
Review of resident #98's Physicians Orders revealed an order for Macrobid Oral Capsule 100 mg give 1 capsule by mouth two times a day for UTI for 5 days.
Review of resident #98's comprehensive plan of care failed to reveal a problem or approaches related to resident #98's diagnosis of UTI.
During an interview on 06/05/2024 at 1:30 p.m. S8 LPN/MDS Nurse confirmed a plan of care for resident #98's diagnosis of UTI had not been developed and should have been.
2.
Review of resident #98's lab work dated 05/29/2024 revealed a result of leukocytosis and a high white blood cell count of 13.5 (range 4.6 to 10.2). Further review of resident #98's lab work revealed hand written order signed by the facility's nurse practitioner to Start Doxycycline 100 mg(milligrams) by mouth twice a day for 5 days, and add Acidophilus one tab by mouth daily for 30 days.
Review of resident #98's May 2024 and June 2024 Physicians Orders failed to reveal an order for Doxycycline 100 mg(milligrams) by mouth twice a day for 5 days, and Acidophilus one tab by mouth daily for 30 days.
Review of resident #98's May 2024 and June 2024 MAR (medication administration record) failed to reveal any documentation indicating doxycycline 100 mg and acidophilus had been administered to resident #98.
During an interview on 06/05/2024 at 3:30 p.m. S2 DON (Director of Nurses) confirmed the orders for doxycycline or acidophilus had not been put in resident #98's electronic health record and had not been administered to resident #98.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0657
(Tag F0657)
Could have caused harm · This affected multiple residents
Based on record reviews and interviews the facility failed to ensure the resident's plan of care was revised to meet the resident's needs for 1 resident (#159) out of 4 residents (#159, #7, #121, #161...
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Based on record reviews and interviews the facility failed to ensure the resident's plan of care was revised to meet the resident's needs for 1 resident (#159) out of 4 residents (#159, #7, #121, #161) investigated for weight loss.
Findings:
Review of Resident #159's record revealed an admit date of 02/02/2024 with a readmission date of 03/18/2024. Further review of Resident #159's record revealed Resident #159 was NPO (nothing by mouth) and was fed via enteral feedings through a PEG (percutaneous endoscopic gastrostomy) tube.
Review of Resident #159's weight log revealed on 02/02/2024, the resident weighed 112.6 lbs. (pounds). Further review of Resident #159's weight log revealed the following weights:
-on 02/23/2024 Resident #159 weighed 107.0 lbs.
-on 03/25/2024 Resident #159 weighed 106.1 lbs.
-on 04/02/2024 Resident #159 weighed 101.3 lbs.
-on 04/10/2024 Resident #159 weighed 99.4 lbs.
-on 05/08/2024 Resident #159 weighed 97.6 lbs. which indicated a -13.32 % (percent) loss from 02/02/2024.
Review of Resident #159's record failed to reveal Resident #159's care plan was revised to include a dietician consult to follow Resident #159's nutritional needs. Further review of Resident #159's record failed to reveal Resident #159's care plan was revised to include documentation that weekly weights were implemented to further monitor Resident #159 for weight loss.
During an interview on 06/05/2024 at 12:37 p.m. S2 DON (Director of Nursing) reported resident's weights were entered into the resident's weight log by the unit managers. S2 DON further reported residents with a weight loss of greater than 5% in 30 days, greater than 10% in 120 days, or any steady declining weight was reviewed and discussed in the monthly patient at risk meetings. S2 DON reported nurses implement weekly weights and consult the dietician on residents with weight loss. S2 DON reviewed Resident #159's weight loss and acknowledged that Resident #159 had a gradual weight loss in which the last weight on 05/08/2024 resulted in greater than 10% weight loss in the last 120 days. S2 DON further reviewed Resident #159's record and acknowledged the dietician had not been consulted and weekly weights had not been implemented to address Resident #159's weight loss.
CONCERN
(E)
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 record review, observations, and interviews the facility failed to ensure a resident who was unable to complete their a...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observations, and interviews the facility failed to ensure a resident who was unable to complete their activities of daily living received the necessary services to maintain grooming and hygiene for 6 (#25, #57, #98, #120, #141, #174) of 10 residents (#16, #25, #33, #57,#65, #98, #120, #141, #174) reviewed for Activities of Daily Living. The facility failed to ensure:
1. residents #25, #57, #98, and #141's fingernails were clean and trimmed.
2. resident #120's toenails were clean and trimmed.
3. resident #174 received scheduled bath/shower.
Findings:
Review of the facility's Nail Care (Finger and Toe) Policy dated 11/15/2024 revealed the following:
The purpose is to clean the nail bed, prevent infection and comfort the resident.
Practice Guidelines
Key points
1. Nails can be partially cleaned during bathing.
2. Nursing Assistants do not trim the nails of diabetic residents
3. Nail care includes daily cleaning and regular trimming
4. Stop and report any evidence of ingrown toes nails, infection, pain, or nails are too hard or thick to cut with ease.
1.
Resident #25
Review of resident #25's electronic health record revealed an admit date of 02/07/2023 with a diagnosis of but not limited to congestive heart failure, diabetes mellitus, lack of coordination, essential hypertension, communication deficit and atrophy of left upper arm.
Review of resident #25's MDS (Minimum Data Set) dated 04/12/2024 revealed a BIMS (brief interview mental status) of 12 indicating moderately impaired cognition.
Review of resident #25's comprehensive plan of care included in part; the resident has Diabetes Mellitus; Refer to podiatrist/foot care nurse to monitor/document foot care needs and to cut long nails.
Observation on 06/03/2024 at 2:25 p.m. revealed resident #25 fingernails were long and protruded past the nail beds on both hands.
During an interview on 06/03/2024 at 2:25 p.m. resident #25 stated, I need to get my nails cut, they grow back so fast, I used to try to cut them myself. When asked by surveyor if staff cut her nails, resident #25 stated, they never ask me to cut them.
During an interview on 06/04/2024 at 3:56 p.m. S11 LPN (licensed practical nurse) confirmed resident #25's fingernails were not trimmed and reported any CNA (certified nursing assistance) may trim nails, except for diabetics, diabetics must see the podiatrist.
Resident #57
Review of resident #57's electronic health record revealed an admit date of 06/21/2016 with a diagnosis of but not limited to Alzheimer's disease, contracture of muscle right hand, muscle wasting and atrophy in arms and lack of coordination.
Review of resident #57's comprehensive plan of care included in part the problem/risks and interventions for potential for ADL(activities of daily living) self-care performance deficit. Resident #57 requires fluctuating assistance with ADL's from extensive to total and requires the assistance of one staff with personal hygiene and oral care.
Observation on 06/03/2024 at 9:30 a.m. revealed resident #57 lying in bed with her fingers in her mouth. Further review revealed resident #57's fingernails long with black substance underneath and resident putting her fingers in her mouth.
Observation on 06/04/2024 at 12:15 p.m. with S2 DON (Director of Nursing) revealed resident #57 lying in bed with her fingers in her mouth. Further review revealed resident #57's fingernails long with black substance underneath and resident putting her fingers in her mouth.
During an interview on 06/04/2024 at 12:15 p.m. S2 DON confirmed resident #57's fingernails were long with a black substance underneath and should have cleaned and trimmed during resident #57's bath.
Resident #98
Review of resident #98's electronic health record revealed an admit date of 11/22/2021 and a diagnosis of but not limited to UTI (urinary tract infection), generalized epilepsy, type 2 diabetes, cerebral infarction affecting right dominant side, essential hypertension, and aphasia.
Review of resident #98's MDS (minimum data set) dated 11/22/2021 revealed resident #98 had a BIMS score of 9 indicating moderately impaired cognition.
Review of resident #98's comprehensive plan of care revealed resident #98 had a Self Care Performance Deficit related to hemiplegia and hemiparesis following a cerebral infarction affecting right dominant side with an approach of; Bathing check nail length and clean on bath day, report any changes or necessity for trimming to the nurse.
Observation on 06/03/2024 at 2:18 p.m. revealed resident #98 had long jagged fingernails on his right hand.
Observation on 06/04/2024 at 2:00 p.m. revealed resident #98 had long jagged fingernails on his right hand.
During an interview on 06/04/2024 at 3:15 p.m. S19 CNA (certified nursing assistant) reported I usually trim nails on bath days, resident #98's nails grow really fast and need frequent trimming.
During an interview on 06/04/2024 at 3:56 p.m. S11 LPN reported any CNA may trim nails, except for diabetics and confirmed resident #98's fingernails needed trimming.
Resident #141
Review of resident #141's electronic health record revealed and admit date of 09/13/2023 with a diagnosis of but not limited to major depressive disorder.
Review of resident #141's Quarterly MDS dated [DATE] revealed a BIMS of 14 indicating intact cognition.
Review of resident #141's comprehensive care plan revealed resident #141 had an ADL self-care performance deficit related to disease process. Resident #141 requires fluctuating assistance from extensive to total assistance with ADLS.
Observation on 06/03/2024 at 10:34 a.m. revealed resident #141 fingernails were long, uneven and jagged.
During an interview on 06/03/2024 at 10:34 a.m. resident #141 reported she liked her nails long but her left thumb nail was cracked across the nail bed and needed to be trimmed. Resident #141 reported her left thumb nail had been cracked across the nail bed for the last 3-4 days.
During an interview on 06/03/2024 at 12:30 p.m. S21 LPN confirmed resident #141's left thumb nail was cracked across the nail bed and should have been trimmed.
2.
Resident # 120
Review of resident #120's electronic health record revealed and admit date of 01/05/2023 with a diagnosis of but not limited to; displaced fracture of lateral condyle of left tibia, sequela, displaced Maisonneuve's fracture of left leg, sequela, unspecified injury at unspecified level of cervical spinal cord, sequela, 08/31/2023: complete rotator cuff tear or rupture of right shoulder, 09/01/2023: pain in the right shoulder, 01/09/2023: Muscle weakness, unsteadiness on feet, pain in left lower leg, pain in left knee, 06/02/2023: muscle wasting and atrophy, right upper arm & left upper arm, and lack of coordination.
Review of resident #120's Quarterly MDS dated [DATE] revealed resident #120 had a BIMS score of 15 indicating intact cognition.
Review of resident #120's comprehensive care plan revealed resident had an ADL (activities of daily living) self-care deficit requiring fluctuating assistance with ADL's from supervision to limited assist due to decreased mobility.
Observation on 06/03/2024 at 9:10 a.m. revealed resident #120's toe nails were thick, long and curved.
During an interview on 06/03/2024 at 11:18 a.m. resident #120 reported his toe nails had not been trimmed and they were so long they hurt.
Observation on 06/04/2024 at 3:20 p.m. with S7 CNA Supervisor revealed resident #120's toe nails were long and thick. S7 CNA Supervisor also confirmed resident #120 should have been seen by the podiatrist. S7 CNA Supervisor reported the last time she could recall resident #120 was seen by the podiatrist was about a year ago.
3.
Resident #174
Review of resident # 174's electronic health record revealed an admit date of 05/07/2024 with a diagnosis of but not limited unspecified fracture of lower end of left tibia, closed fracture with routine healing, unspecified dislocation of left knee, and pain in left leg.
Review of resident #174's admission MDS (Minimum Data Sets) dated 05/14/2024 revealed BIMS of 14 indicating intact cognition.
During an interview on 06/03/2024 at 11:02 a.m. resident #174 reported she scheduled to get a bath on the night shift, but her bath is often put off resulting in not receiving a bath. Resident #174 reported she would like to get a shower. Resident #174 further reported she had to wash herself off this morning in the bathroom sink before going to bingo.
Review of the printed resident shower schedule with S7 CNA (Certified Nurse Assistant) Supervisor revealed resident #174 was scheduled to receive a shower on Monday, Wednesday, and Friday on 11p.m. to 7a.m. shift.
Review of EHR (Electronic health Record) POC (Point of care) charting by CNAs (Certified Nurse Assistant) with S9 LPN (Licensed Practical Nurse) on 06/04/2024 at 4:00 p.m. failed to reveal resident # 174 had received a shower since admit.
During an interview on 06/04/2024 at 4:00 p.m. S9 LPN confirmed resident #174 was not set up in the EHR POC system to prompt a shower or bath to be done and should have been set up when resident #174 was admitted . S9 LPN further confirmed resident #174 had not been bathed or showered as scheduled.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Quality of Care
(Tag F0684)
Could have caused harm · This affected multiple residents
Based on observations, interviews and record reviews, the facility failed to ensure 1 (#139) resident out of 1 reviewed for edema received treatment and care in accordance with professional standards ...
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Based on observations, interviews and record reviews, the facility failed to ensure 1 (#139) resident out of 1 reviewed for edema received treatment and care in accordance with professional standards of practice by failing to follow physician orders for applying ted hose, monitoring for edema with use of diuretics (Lasix), and revision to care plan of edema with use of diuretics (Lasix).
Findings:
During an interview on 06/03/2024 at 11:45 A.M. Resident #139 reported he had a medical history of blood clots and cellulitis, and reported he was not sure if his edema was from the cellulitis since he has completed treatment of antibiotics and legs are still swollen or from history of blood clots. Resident #139 went on to report he should be wearing ted hose.
Observation on 06/03/2024 at 11:45 A.M. revealed Resident #139 had edema to bilateral lower extremities and failed to reveal Resident #139 had ted hose applied to lower extremities.
Observation on 6/5/2024 at 2:20 P.M. revealed Resident #139 had edema to bilateral lower extremities and failed to reveal Resident #139 had ted hose applied to lower extremities.
Review of Resident #139's medical diagnoses revealed the following diagnoses but not limited to embolism and thrombosis of unspecified deep veins of lower extremity (08/15/2023).
Review of Quarterly MDS (Minimum Data Sets) dated 05/22/2024 revealed a BIMS (Brief Interview of Mental Status) of 12 out of 15 indicating Resident #139 was cognitively intact.
Review of Resident #139's June 2024 physician orders revealed:
05/25/2024: Apply [NAME] hose during day only and remove at night; one time a day for DVT (deep vein thrombosis) risk reduction.
08/24/2023: Apixaban Oral Tablet 5 MG (milligram) (Apixaban); Give 1 tablet by mouth two times a day for DVT (deep vein thrombosis)
09/06/2023: Lasix Oral Tablet 40 MG (Furosemide); Give 1 tablet by mouth one time a day for CHF (congestive heart failure) with edema
Further review of Resident's #139's June 2024 EMAR (Electronic Medication Administration Record) failed to reveal Resident #139 was monitored for edema with use of diuretics.
Review of Resident #139 Comprehensive Care Plan failed to reveal problems and approaches addressing edema.
During an interview on 06/05/2024 at 2:20 P.M. S6 LPN (Licensed Practical Nurse) reported Resident #139 did have a physician order for ted hose and an order had been placed with medical supply company but have not arrived at the facility for Resident #139.
During an interview on 06/05/2024 at 2:20 P.M. S6 LPN reviewed Resident # 139's June 2024 physician orders and daily task to confirm monitoring of edema for diuretics was not included on the EMAR or daily task.
During an interview on 6/6/2024 at 1:40 P.M. S2 DON (Director of Nursing) reported a special order for thigh high ted hose was placed last week for Resident #139. S2 DON was unable to present surveyor with an invoice or documentation of ordering TED hose or follow up from corporate office or medical supply company.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Pressure Ulcer Prevention
(Tag F0686)
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 1 resident (#164) out of 3 residents (#164, #6, #94) invest...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews and interviews the facility failed to ensure 1 resident (#164) out of 3 residents (#164, #6, #94) investigated with pressure ulcers received necessary treatment and services consistent with professional standards of practice to promote healing and prevent infection. The facility failed to obtain and implement wound care treatment orders on Resident #164 upon readmissionn to the facility.
Findings:
Review of Resident #164's record revealed Resident #164 was admitted to the facility on [DATE] with a readmission on [DATE]. Resident #164's diagnoses included in part anoxic brain damage, cardiac arrest-cause unspecified, acute and chronic respiratory failure with hypoxia, sepsis-unspecified organism, chronic osteomyelitis with draining sinus-left radius and ulna, osteomyelitis-unspecified, bacterial infection-unspecified, bacteremia, carrier of methicillin resistant staphylococcus aureus, and severe hypoxic ischemic encephalopathy.
Review of Resident #164's record revealed an incomplete skin assessment on 05/30/2024. Further review of Resident #164's record revealed a skin assessment dated [DATE] with Resident #164 assessed to have a stage IV pressure ulcer to the sacrum, a stage II pressure ulcer pressure ulcer to the right arm, and a stage II pressure ulcer to the left foot.
Review of Resident #164's record failed to reveal wound care treatment orders were obtained and implemented on readmission to the faciliy on 05/30/2024. Further review of Resident #164's record revealed wound care treatment orders were not obtained and implemented until 06/03/2024.
During an interview on 06/05/2024 at 11:00 a.m. S14 RN (Registered Nurse)/Unit Manager reviewed Resident #164's record and acknowledged wound care care treatment orders were not obtained and implemented until 06/03/2024 after Resident #164's readmission on [DATE].
During an interview on 06/05/2024 at 12:18 p.m. S2 DON (Director of Nursing) reviewed Resident #164's record and acknowledged wound care treatment orders were not obtained and implemented until 06/03/2024 after Resident #164's readmission on [DATE].
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0692
(Tag F0692)
Could have caused harm · This affected multiple residents
Based on record reviews and interview, the facility failed to ensure:
1. Resident #85 received at least quarterly Registered Dietician assessments according to policy.
2. Monthly weights were document...
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Based on record reviews and interview, the facility failed to ensure:
1. Resident #85 received at least quarterly Registered Dietician assessments according to policy.
2. Monthly weights were documented in EHR (electronic health record) to ensure Resident #135 maintained a desired weight.
There were a total of 9 (#7, #21, #34, #52, #79, #85, #135, #159, #161) residents reviewed for nutrition.
Findings:
1.
Review of facility's Role of the Dietician policy dated April 2022 revealed in part,
1. Review all new admissions on each visit. (minimum of Monthly)
2. Review all tube feedings at least quarterly unless there is weight loss/gain, or pressure ulcer.
9. Review residents on dialysis quarterly and as needed.
Observation on 06/03/2024 at 9:00 a.m. revealed Resident #85 receiving Glucerna via feeding pump.
Review of Resident #85's medical record revealed diagnoses that include in part hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, encounter for attention to gastrostomy, and Type 2 diabetes mellitus.
Review of Resident #85's record revealed previous Registered Dietician (RD) Nutritional assessment completed 07/15/2021.
Review of Resident #85's Registered Dietician MINI assessment completed 06/06/2024.
Review of Resident #85's comprehensive care plan revealed resident has nutritional problem or potential nutritional problem related to dysphagia, Gastroesophageal reflux disease, hyperlipidemia, malnutrition, peg tube, and nothing by mouth.
During an interview on 06/06/2024 at 2:55 p.m. S22 RD reported the last Health Care RD Nutritional Assessment was completed on 03/21/2023 for Resident #85 but could not provide the documentation. S22 RD further reported she did not see the Resident on 06/06/2024 for the mini assessment, she only gathered the information from Resident #85's record.
During a telephone interview on 06/06/2024 at 3:30 p.m. S12 RDCO (Regional Director of Clinical Operations) reported the Registered Dietician should see all residents on admit or readmit, all residents that receive tube feeding, any resident with weight loss, any resident with wounds, and residents on dialysis or nutritional consult.
2.
Review of facility's weight management Policy dated 01/01/2023 revealed in part,
Intent: It is the policy of the facility to provide care and services related to weight management in accordance to State and Federal regulation.
Procedure:
2. All residents will be weighted on a monthly basis unless otherwise ordered by the physician or deemed necessary by the dietician and or the interdisciplinary team.
3. Monthly weights will be completed by the fifth of each month.
7. All weights will be documented in the resident's electronic medical record.
Review of Resident # 135's medical diagnoses revealed the following medical diagnoses but not limited to unspecified sequelae of unspecified cerebrovascular disease, traumatic subdural hemorrhage with loss of consciousness status unknown, nontraumatic intracerebral hemorrhage, intraventricular, aneurysm of unspecified site, dysphagia following other cerebrovascular disease, encounter for attention to gastrostomy
Review of Resident #135's June 2024 Physician Orders revealed:
08/01/2023: Enteral Feed; every shift Jevity 1.5 at 55 ml (milliliters)/HR (hour) per peg per pump continuously
08/01/2023: NPO (Nothing by mouth) diet
Review of Resident #135's Quarterly MDS (Minimum Data Sets) Swallowing/ Nutritional Status dated 05/17/2024 revealed:
Height: 72 inches
Weight: 164 pounds
Weight loss: no or unknown
51% or more in proportion of total calories the resident received through parenteral or tube feeding. 501 cc/day or more of average fluid intake per day by IV (intravenous) or tube feeding
Review of EHR (Electronic Health Record) revealed Resident # 135's last recorded weight was 164.4 pounds on March 1, 2024.
Review of Weight Binder with S7 CNA (Certified Nurse Assistant) Supervisor on 06/04/2024 at 3:40 P.M. revealed Resident #135's hand written weight dated May 7, 2024 was 158.9 pounds.
Review of Resident # 135's care plan revealed Resident has nutritional problems or potential nutritional problem related to NPO status, vitamin deficiency, SDH (subdural hematoma) with interventions monitor/record/report to physician as needed signs & symptoms of malnutrition: Emanication (Cachexia), muscle wasting, significant weight loss: 3 pounds in 1 week, more than 5% in 1 month, more than 7.5% in 3 months, more than 10% in 6 months, weights per facility policy
During an interview on 6/5/2024 at 2:10 P.M. S2 DON (Director of Nursing) reported weights should be obtained monthly and the weights should be recorded in the EHR by the unit manager. S2 DON reviewed Resident # 135's EHR and confirmed Resident # 135's weights were not recorded for the month of April 2024 and May 2024.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Tube Feeding
(Tag F0693)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews, observations and interview the facility failed to provide appropriate treatment and services for 2 (#85...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews, observations and interview the facility failed to provide appropriate treatment and services for 2 (#85 and #161) of 3 (#21, #85, and #161) residents reviewed for tube feeding. The facility failed to ensure the tube feeding container was appropriately labeled.
Findings:
Review of Facility's undated procedure with subject of Enteral Tube Feeding via Pump, revealed in part:
Intent:
It is the policy of the facility to provide enteral feeding as ordered by the physician via pump to ensure adequate nutrition for residents that are unable to maintain their nutrition orally.
Procedure .
3. Label the enteral feeding bag/bottle, to include the tubing, with the following information:
a. Resident's name and room #
b. Type of formula (if using bags)
c. Date and time formula is being hung
d. Rate of administration
Resident #85
Review of resident #85's medical record revealed an admit date of 06/13/2019 and a readmit date of 06/30/2021 with diagnoses that included in part hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, encounter for attention to gastrostomy, and Type 2 diabetes mellitus.
Review of registered Dietician assessment dated [DATE] revealed in part: Current diet: NPO (nothing by mouth); Enteral Feeding: Glucerna 1.2 at 55 ml (milliliter)/hr (hour) X 24 hrs/day.
Observation on 06/03/2024 at 06/03/2024 at 9:00 a.m. revealed Resident #85 was receiving Glucerna via feeding pump. Further observation revealed Resident #85's tube feeding formula label failed to include the time the feeding was hung.
Resident #161
Review of Resident #161's medical record revealed an admit date of 01/29/2024 and diagnoses which included, in part, hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, aphasia, dysphagia, severe protein-calorie malnutrition, body mass index 19.9 or less, and encounter for attention to gastrostomy.
Review of Resident #161's physician orders revealed, in part an order dated 03/20/2024 for Jevity 1.5 at 50 ml (milliliters)/hr. (hour) per peg, per pump continuously.
Observation on 06/03/2024 at 9:00 a.m. revealed Resident #161's tube feeding formula label failed to include the time the feeding was hung.
During an interview on 06/03/2024 at 9:50 a.m. S5 LPN (Licensed Practical Nurse) confirmed Resident #85 and Resident #161's tube feeding formula labels failed to include the time the feeding was hung and should have.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Respiratory Care
(Tag F0695)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews, observations, and interviews the facility failed to ensure residents who need respiratory care were pro...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews, observations, and interviews the facility failed to ensure residents who need respiratory care were provided care consistent with professional standards of practice for 4 (#79, #120, #136, #139) out of 5 (#79, #120, #136, #139, #164) residents reviewed for respiratory care.
The facility failed to ensure:
1. The oxygen concentrator and filter were clean and the nasal cannula was dated for Resident #79.
2. The respiratory supplies (oxygen mask and tubing for Resident ##139 and nebulizer mask and tubing for Resident #120, #136, and #139 were changed weekly, labeled with date and initials upon opening and stored in plastic bag between uses.
Findings:
Review of facility's Respiratory Therapy equipment policy dated April 2022 revealed in part:
This procedure may involve potential/direct exposure to blood, body fluids, infectious disease, air containments, and hazardous chemicals.
Purpose
The purpose of this procedure is to provide guidelines to help prevent nosocomial infections associated with respiratory therapy equipment, including ventilators, and to prevent transmission of infections to resident and staff.
Procedure Guidelines
Oxygen Administration:
3. [NAME] bottle with date and initials upon opening.
5. Change oxygen cannulas and tubing used PRN (as needed) in a plastic bag when not in use.
7. Wash filters from oxygen concentrators weekly. Rinse and squeeze dry.
Medication Nebulizers/Continuous Aerosol:
7. Store circuit in plastic bag, marked with date and resident's name, between uses
9. Discard administration set-up every 7 days. Date new tubing.
Resident #79
Resident #79's medical record revealed an admit date of 10/15/2018 with diagnoses that include but not limited to COPD (Chronic Obstructive Pulmonary Disease), multiple myeloma not having achieved remission, chronic diastolic (congestive) heart failure, chronic respiratory failure with hypoxia, anxiety disorder and dependence on renal dialysis.
Review of Resident #79's physician orders revealed in part:
04/23/2024: Change and date all respiratory supplies and tubing weekly. If oxygen concentrator is present, clean filter every day shift every Tuesday and as needed.
12/31/2020: Oxygen at (4) liters per nasal cannula while in room, every shift related to shortness of breath.
Observation on 06/03/2024 at 9:30 A.M. revealed Resident #79's oxygen concentrator and filter with a thick layer of dust covering the machine and Resident #79's oxygen tubing laying across the bedrail with no date.
Observation on 06/04/2024 at 11:50 A.M. revealed Resident #79's oxygen was in use via nasal cannula. Further observation revealed oxygen concentrator and filter with a thick layer of dust covering the machine and filter, oxygen tubing with no date.
During an interview on 06/04/2024 at 12:45 P.M. S2 DON (Director of Nursing) confirmed Resident #79's oxygen concentrator and filter should have been cleaned and the oxygen tubing should have been dated.
Resident #120
Review of Resident # 120's June 2024 physician orders revealed an order dated
05/10/2024: Ipratropium-Albuterol Inhalation solution 0.5-2.5 (3) mg (milligrams)/ 3ml (milliliters); 1 application inhale orally every 6 hours as needed for SOB (shortness of breath)
Observation on 06/03/2024 at 9:31 A.M. revealed Resident # 120's nebulizer and mask on the overbed table. Further observation revealed Resident # 120's nebulizer and mask was not labeled/ dated.
During an interview on 06/03/2024 at 12:40 P.M. S21 LPN (licensed practical nurse) confirmed Resident #120's nebulizer mask was not labeled/dated with the opening date and was not stored properly when not in use.
Resident #136
Review of Resident # 136's medical diagnoses revealed chronic respiratory failure with hypoxia (08/31/2023) and COPD (08/31/2023).
Review of Resident # 136's June 2024 Physician Orders revealed:
08/26/2023: Levalbuterol Hydrochloride Inhalation Nebulization solution 1.25 mg/3ml; 1 vial inhale orally via nebulizer three times a days for COPD/shortness of breath
Review of Resident #136's MDS (Minimum Data Set) dated 04/12/2024 revealed a BIMS (Brief Interview of Mental Status) of 15 out of 15 indicating cognitively intact.
Observation on 06/03/2024 at 10:00 A.M. revealed Resident #136's nebulizer and mask were in Resident # 136's bed. Observation revealed Resident #136's nebulizer was not in use. Further observation revealed Resident # 136's nebulizer mask was dated 05/15/2024 and was not stored in a plastic bag when not in use.
Observation on 06/03/2024 at 12:00 P.M. revealed Resident #136's nebulizer and mask was in Resident # 136's bed. Observation revealed Resident #136's nebulizer was not in use. Further observation revealed Resident # 136's nebulizer mask was dated 05/15/2024 and was not stored in a plastic bag when not in use.
Observation on 06/03/2024 at 12:35 P.M. with S21 LPN revealed Resident #136's nebulizer and mask was in Resident #136's bed. Further observation revealed Resident # 136's nebulizer mask was dated 05/15/2024 and was not stored in a plastic bag when not in use.
During an interview on 06/03/2024 at 12:35 P.M. S21 LPN confirmed Resident # 136's nebulizer, mask and tubing was not stored properly when not in use. S21 LPN reported Resident #136's mask and tubing should have been labeled when it was opened and stored in a plastic bag when not in use.
Resident #139
Review of Resident #139's medical diagnoses revealed 08/15/2023 revealed in part; acute embolism and thrombosis of unspecified deep veins of lower extremity, bilateral, chronic obstructive pulmonary disease, chronic respiratory failure with hypoxia, heart failure (11/09/2023), personal history of pulmonary embolism (08/15/2023)
Review of Resident #139's June 2024 physician orders revealed:
04/23/2024: oxygen at 2 liters per nasal cannula continuously; every shift
04/23/2024: change and date all respiratory supplies and tubing weekly.
09/26/2023: Ipratropium-Albuterol Inhalation Solution 0.5-2.5 (3) mg/3ml (Ipratropium-Albuterol); 1 dose inhale orally every 4 hours as needed for COPD
Review of Quarterly MDS dated [DATE] revealed a BIMS of 12 out 15 indicating moderately impaired cognition
Review of Resident #139's Care Plan revealed resident had COPD related to smoking, at risk for complications with interventions to give aerosol or bronchodilators, and give oxygen therapy as ordered by the physician.
Observation on 06/03/2024 at 9:30 A.M. revealed Resident # 139's oxygen tubing and humidifier bottle was not labeled and dated. Observation revealed Resident # 139's nebulizer mask was not in use. Further observation revealed Resident # 139's nebulizer mask was not dated, labeled or stored properly when not in use.
Observation on 06/03/2024 at 11:45 A.M. revealed Resident # 139's oxygen tubing and humidifier bottle was not labeled and dated. Observation revealed Resident # 139's nebulizer mask was not in use. Further observation revealed Resident # 139's nebulizer mask was not dated, labeled or stored properly when not in use.
Observation on 06/03/2024 at 12:40 P.M. with S21 LPN revealed Resident #139's oxygen humidifier bottle was not dated and oxygen mask was attached to the oxygen concentrator and placed over the oxygen humidifier bottle. Observation with S21 LPN revealed Resident #139's nebulizer on bedside table with mask not dated or stored in a plastic bag when not in use.
During an interview on 06/03/2024 at 12:40 P.M. S21 LPN confirmed Resident #139's oxygen humidifier bottle was not dated and should have been. S21 LPN confirmed Resident #139's oxygen and nebulizer mask should be stored in a plastic bag when not in use.
During an interview on 06/4/2024 at 12:10 P.M. S23 Respiratory Therapist reported respiratory supplies (humidifier bottles, tubing, mask) should be changed on the Sunday night shift. S23 Respiratory Therapist reported respiratory supplies and tubing should be signed, dated and initialed on the date it is changed.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0725
(Tag F0725)
Could have caused harm · This affected multiple residents
Based on record reviews and interview the facility failed to ensure there was a sufficient number of skilled licensed nurses, nurse aides, and other nursing personnel to provide care and respond to ea...
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Based on record reviews and interview the facility failed to ensure there was a sufficient number of skilled licensed nurses, nurse aides, and other nursing personnel to provide care and respond to each resident's basic needs. The facility failed to provide the minimum required staffing hours for 3 of 27 weekend days during FY (Fiscal Year) Quarter 1 2024.
Findings:
Review of the facility's PBJ (Payroll Based Journal) Staffing Data Report for FY Quarter 1 2024 (October 1 - December 31) revealed excessively low weekend staffing was triggered.
Review of the facility's Staffing Pattern forms for weekends from FY Quarter 1 2024 revealed the facility:
Provided 275.75 hours on 10/01/2023 and were required to provide 254.85 hours.
Provided 375.38 hours on 10/21/2023 and were required to provide 378.35 hours.
Provided 366.9 hours on 12/16/2023 and were required to provide 376 hours.
During an interview on 06/06/2024 at 5:35 p.m. S13 Interim Administrator/Regional MDS (Minimum Data Set) confirmed the facility did not provide the minimum required hours on 10/01/2023, 10/21/2023, 12/16/2023 and should have.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0757
(Tag F0757)
Could have caused harm · This affected multiple residents
Based on record review and interview, the facility failed to adequately monitor for 2 (# 27, #106) residents reviewed for unnecessary medications out of a total 6 (#27, #67, #72, #78, #106, #175) resi...
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Based on record review and interview, the facility failed to adequately monitor for 2 (# 27, #106) residents reviewed for unnecessary medications out of a total 6 (#27, #67, #72, #78, #106, #175) residents reviewed. The facility failed to adequately monitor residents #27 and #106 for edema while on a diuretic, and resident #27 for bleeding and bruising while on an anticoagulant.
Findings:
Resident #27
Review of Resident #27's current Physician orders revealed in part:
6/4/2024 Monitor for abnormal bleeding or bruising every shift if + (positive) notify medical doctor or Nurse Practioner.
12/1/2023 Lasix Oral Tablet 20 MG (milligram) (Furosemide) Give one tablet by mouth one time a day related to Peripheral Vascular Disease, Check for Edema.
10/27/2023 Eliquis Oral Tablet 2.5 MG (Apixaban) Give one tablet by mouth two times a day related to Peripheral Vascular Disease
Review of Resident #27's medical record failed to reveal monitoring for edema, bleeding and bruising.
During an interview on 06/06/2024 at 4:45 p.m. S9 LPN (Licensed Practical Nurse) reviewed Resident #27's medical record and acknowledged monitoring for bleeding and edema were not being done and should have been.
Resident #106
Review of Resident #106's current Physician orders revealed in part:
-5/12/23 Lasix Oral Tablet 20 mg (Furosemide) Give 1 tablet by mouth one time a day for edema with HTN (hypertension).
Review of Resident #106's medical record failed to reveal monitoring for edema.
During an interview on 06/06/2024 at 9:50 a.m. S11 LPN (Licensed Practical Nurse) reviewed Resident #106's record and reported Resident #106 was on the diuretic Lasix. S11 LPN further reviewed Resident #106's record and acknowledged there was not documentation of monitoring for edema with administration of a diuretic for Resident #106 and should have been.
During an interview on 06/06/2024 at 12:10 p.m. S2 DON (Director of Nursing) reviewed Resident #106's record and reported Resident #106 was on the diuretic Lasix. S2 DON further reviewed Resident #106's record and acknowledged there was not documentation of monitoring for edema with administration of a diuretic for Resident #106 and should have been.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0868
(Tag F0868)
Could have caused harm · This affected multiple residents
Based on record review and interview the facility failed to ensure the Quality Assessment and Assurance (QAA) Committee met at least quarterly. The failed practice had the potential to affect the 189 ...
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Based on record review and interview the facility failed to ensure the Quality Assessment and Assurance (QAA) Committee met at least quarterly. The failed practice had the potential to affect the 189 residents residing in the facility as documented by the facility's Long-Term Care Facility Application for Medicare and Medicaid form [CMS (Centers for Medicare and Medicaid Services)-671] dated 06/03/2024.
Findings:
Review of the QAA meeting information provided by the facility failed to reveal evidence of quarterly QAA meetings since the last annual survey on 06/08/2023.
During an interview on 06/06/2024 at 5:30 p.m. S1 Administrator and S12 Regional Director of Clinical Operations acknowledged they could not provide documentation of quarterly QAA meetings since the last annual survey on 06/08/2023.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected multiple residents
Based on observations, interviews, and record review the facility failed to:
1. Ensure staff practices were consistent with current infection control principles and practices to prevent cross contamin...
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Based on observations, interviews, and record review the facility failed to:
1. Ensure staff practices were consistent with current infection control principles and practices to prevent cross contamination by failing to ensure staff used appropriate PPE (Personal Protective Equipment) during resident care for 1 resident (#112) who was on contact isolation.
2. Ensure an infection prevention and control program was maintained by failing to provide written evidence of implemented infection control policies and procedures for surveillance of tracking and trending of infections in the facility.
This deificient practice had the potential to effect the total census was 189 according to the Long-Term Care Facility Application for Medicare and Medicaid Form dated 06/03/2024.
Findings:
1.
Review of the facility's contact isolation policy dated April 2022 revealed in part:
In addition to standard precautions, contact precautions must be implemented for resident's known or suspected to be infected with microorganisms that can be transmitted by direct contact with the resident or indirect contact with environment surfaces or patient-care items in the resident's environment
A. Place the resident in a private room
B. Gloves and hand hygiene
1. Wear gloves when entering the room
2. Remove gloves before exiting the room and wash hands
C. Gown.
1. In addition to wearing a gown as outlined under standard precautions, wear a gown when entering the room if you anticipate that your clothing will have substantial contact with the patient environmental surfaces, or items in the patient room ,or if the resident is incontinent, has diarrhea an ileostomy, a colostomy or wound drainage not contained by a dressing.
2. Remove the gown before leaving the resident' environment.
Review of Resident #112's medical record revealed in part:
05/21/2024 Nurse's Note: CNA (Certified Nursing Assistant) reported stool is loose and has a bad odor. Assessed and observed yellowish brown, loose stool with foul odor. MD (Medical Doctor)/nurse communication sent to NP (Nurse Practioner) communication book. Resident #112 placed on contact isolation until further notice.
05/27/2024 at 10:29 p.m. Nurse's Note: Resident was placed on contact isolation for possible C-Diff 05/22/2024. Remains on contact isolation for positive C-diff collected 05/24/2024.
Observation on 06/03/24 at 9:00 a.m. revealed resident #112 sitting up in geri chair watching television with doorway open. Further observation failed to reveal contact isolaton information was posted and clearly visible to staff for resident #112.
Observation on 06/03/2024 at 12:45 p.m. revealed S20 CNA feeding resident #112, without the use of appropriate PPE, gloves were the only PPE in use.
During an interview on 06/04/2024 at 12:05 p.m. S20 CNA confirmed resident #112 was on contact isolation and confirmed not wearing appropriate PPE for contact isolation when providing resident #112's care and treatment.
During an interview on 06/04/2024 at 12:45 p.m. S2 DON (Director of Nursing) confirmed resident #112 remained on contact isolation precautions for C-diff which required a gown, gloves, and shoe covers during resident care and a sign on the resident's door. S2 DON acknowledged S20 CNA did not follow the facility's policy for contact isolation by not wearing a gown when feeding resident #112's on 06/03/2024.
2.
Review of facility policy of Infection Control Monitoring revealed the following in part:
Policy: It is the policy of the Center to investigate the cause of infections (nosocomial and community and hospital acquired) and the manner of spread.
Record Keeping:
Records will be maintained and infectious trends or any identified problems or potential problems will be reported to the Administrator, Director of Nurses and the Quality Assurance Committee. Follow up action will be taken as necessary.
Procedure:
Action
1. The Charge Nurse must report all infections to the Infection Preventionist using the Infection Control Report Form/ the Infection Control Log.
4. The Infection Preventionist will complete the Infection Surveillance Form for each unit or add to the Infection Control Log. The original is maintained by the Infection Preventionist.
5. The Infection Preventionist will record data for the Monthly Infection Control Report including if infection was nosocomial or community' hospital acquired and summarized on the Infection Tracking Chart/ Log.
6. The Infection Preventionist will also use an Infection Control Trending Map of the Center to identify and trends/ specific organism.
7. The Infection Preventionist will write a brief summary each month to include the findings, trends, recommendations and plan of corrections.
8. The Infection Preventionist will make a monthly report of infections to the Director of Nursing Services and Administrator.
Review of facility's Infection Control binder failed to reveal monthly infection control tracking and trending had been completed for December 2023, February 2024, March 2024, April 2024, and May 2024.
During an interview on 06/06/2024 at 1:40 p.m. S2 DON/Infection Preventionist reviewed the facility's monthly infection control tracking and trending and confirmed monthly infection tracking and trending had not been completed for December 2023, February 2024, March 2024, April 2024, and May 2024 and should have been completed monthly.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0924
(Tag F0924)
Could have caused harm · This affected multiple residents
Based on observations and interviews the facility failed to ensure hallway hand rails were securely affixed to the walls. The facility failed to ensure hand rails were secure on 1 (Hall W) of 4 hallwa...
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Based on observations and interviews the facility failed to ensure hallway hand rails were securely affixed to the walls. The facility failed to ensure hand rails were secure on 1 (Hall W) of 4 hallways in the building. This had to potential to affect 31 residents residing on Hall W.
Findings:
Review of the facility's Physical Environment Policy and Procedure dated 01/01/2023 revealed:
It is the policy of the facility to provide care and services related to physical environment in accordance to State and Federal Regulation: The policy will include the Corridors have firmly secured handrails.
Observation on 06/04/2024 at 12:50 p.m. revealed on Hall W near the exit door, the hand rail did not have an end cap on it leaving a sharp edge exposed with a crack in the hand rail.
During an interview on 06/04/2024 at 2:00 p.m. S4 CNA reported the hand rail on Hall W near the exit door had been broken for a couple of months.
Observation on 06/04/2024 at 2:03 p.m. with S3 Maintenance Supervisor revealed on Hall W near the exit door, the hand rail did not have an end cap on it leaving a sharp edge exposed with a crack in the hand rail.
During an interview on 06/04/2024 at 2:05 p.m. S3 Maintenance Supervisor confirmed the hand rail near the exit door on Hall W should have been repaired.
Mar 2024
1 deficiency
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Notification of Changes
(Tag F0580)
Could have caused harm · This affected 1 resident
Based on record review and interview the facility failed to ensure a medical doctor or representative was notified after a resident had a fall in the facility for 2 (#1, #2) of 2 (#1, #2) residents re...
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Based on record review and interview the facility failed to ensure a medical doctor or representative was notified after a resident had a fall in the facility for 2 (#1, #2) of 2 (#1, #2) residents reviewed for falls.
Findings:
Resident #1
Record review of the facility's incident report dated 03/08/2024 failed to reveal a medical doctor or representative was notified of Resident #1's fall on 03/08/2024.
During an interview on 03/26/2024 at 12:30 p.m., S1 Administrator verified she could not find any documentation the NP (Nurse Practitioner) or MD (Medical Doctor) were notified of Resident #1's fall on 03/08/2024 and should have been notified.
Resident #2
Record review of the facility's incident report dated 03/09/2024 failed to reveal a medical doctor or representative was notified of Resident #2's fall on 03/09/2024.
During an interview on 03/26/2024 at 11:55 p.m., S1 Administrator verified she could not find any documentation the NP or MD were notified of Resident #2's fall on 03/09/2024 and should have been notified.
During a telephone interview on 03/26/24 at 12:10 p.m., S2 LPN (Licensed Practical Nurse) indicated she did not call the NP or MD to notify them of Resident #2's fall on 03/09/2024.
Mar 2024
2 deficiencies
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0725
(Tag F0725)
Could have caused harm · This affected 1 resident
Based on record review and interview, the facility failed to ensure there were a sufficient number of personnel to provide care and respond to each Resident's basic needs. The facility failed to provi...
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Based on record review and interview, the facility failed to ensure there were a sufficient number of personnel to provide care and respond to each Resident's basic needs. The facility failed to provide the minimum required staffing hours for 1 of 26 days reviewed during the month of February 2024.
Findings:
Review of the Facility's Staffing Pattern forms for February 4, 2024 to February 29, 2024 revealed the facility provided 384.57 hours on 02/24/2024 and were required to provide 397.15 hours.
During an interview on 03/06/2024 at 4:05 p.m. S1 Assistant Administrator confirmed the facility did not provide the minimum required hours on 02/24/2024.
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
Pressure Ulcer Prevention
(Tag F0686)
Could have caused harm · This affected multiple residents
Based on record review and interview, the Facility failed to ensure a resident with pressure ulcers received necessary treatment and services, consistent with professional standards of practice, to pr...
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Based on record review and interview, the Facility failed to ensure a resident with pressure ulcers received necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing for 1 (Resident #9) of 13 (Residents #1, #2, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, #13) sampled residents.
Findings:
Review of Resident #9's Physician orders for March 2024 revealed the following order: Sacrum: Apply house barrier, every shift, every day, until resolved. Every shift for pressure injury. Created date was 02/07/2024.
Review of Resident #9's comprehensive care plan revealed a plan with a focus of, Impaired skin integrity: Pressure injury noted to sacrum. Interventions: Notify Nurse Practitioner and/or Medical Doctor of decline noted to area being treated, skin checks to per company protocol, and treatment to area as ordered.
Review of Resident #9's TAR (treatment administration record) for February 2024 revealed the following:
7:00 a.m. to 3:00 p.m. shift - Treatment not completed on February 22nd, 24th, and 28th of 2024.
3:00 p.m. to 11:00 p.m. shift - Treatment was not completed on February 7th, 8th, 9th, 10th, 11th, 12th, 13th, 14th, 16th, 17th, 18th, 19th, 20th, 21st, 22nd, 23rd, 25th, 26th, 27th, 28th, and 29th of 2024.
11: p.m. to 7:00 a.m. shift -Treatment not completed on February 9th, 10th, 12th, 18th, 24th, 25th, and 27th of 2024.
Review of Resident #9's TAR for March 2024 revealed the following:
7:00 a.m. to 3:00 p.m. shift - Treatment was not completed on March 2nd of 2024.
3:00 p.m. to 11:00 p.m. shift - Treatment was not completed on March 1st, 2nd, 3rd, 4th, and 5th of 2024.
11:00 p.m. to 7:00 a.m. shift - Treatment was not completed on March 1st, 2nd, 3rd, and 4th of 2024.
During an interview on 03/06/2024 at 10:35 a.m., S2 DON (Director of Nursing) reviewed Resident #9's TAR for February and March of 2024. S2 DON verified treatments were not completed as ordered and should have been completed for the following shifts and dates:
7:00 a.m. to 3:00 p.m. shift - Treatment not completed on February 22nd, 24th, and 28th of 2024.
3:00 p.m. to 11:00 p.m. shift - Treatment was not completed on February 7th, 8th, 9th, 10th, 11th, 12th, 13th, 14th, 16th, 17th, 18th, 19th, 20th, 21st, 22nd, 23rd, 25th, 26th, 27th, 28th, and 29th of 2024.
11: p.m. to 7:00 a.m. shift -Treatment not completed on February 9th, 10th, 12th, 18th, 24th, 25th, and 27th of 2024.
7:00 a.m. to 3:00 p.m. shift - Treatment was not completed on March 2nd of 2024.
3:00 p.m. to 11:00 p.m. shift - Treatment was not completed on March 1st, 2nd, 3rd, 4th, and 5th of 2024.
11:00 p.m. to 7:00 a.m. shift - Treatment was not completed on March 1st, 2nd, 3rd, and 4th of 2024.
Dec 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
Pressure Ulcer Prevention
(Tag F0686)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews and interviews, the facility failed to ensure resident received care and necessary treatment and service...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews and interviews, the facility failed to ensure resident received care and necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing for 1 (#1) out of 4 (#1, #2, #3, #4) sampled residents. The facility failed to follow up on Resident #1 identified skin issue and complete weekly skin checks for Resident #1.
Findings:
Review of MDS (Minimum Data Sets) revealed Resident #1 was admitted to facility on 10/13/2023 from a short-term general health hospital.
Review of Resident #1's Medical Diagnoses on admit 10/13/2023 revealed a diagnoses but not limited to hemiplegia and hemiparesis following non-traumatic intracerebral hemorrhage affecting right dominant side, and aphasia following non-traumatic intracerebral hemorrhage.
Review of S4 LPN's (Licensed Practical Nurse): Skin Evaluation dated 10/13/2023 at 7:57 p.m. revealed a skin issue: small open area to coccyx-purulent exudate, dressing saturated 26-75%, no wound odor, tunneling, or undermining
Further review of Skin Evaluation revealed Resident #1 was admitted with a small open wound to coccyx area. No other open areas.
Further review of Resident #1's Electronic record failed to reveal follow up to skin evaluation until 10/25/2023.
Review of Initial and weekly pressure ulcer healing record dated 10/25/2023 by S3 LPN (Licensed Practical Nurse) Treatment Nurse revealed a pressure ulcer to sacrum with measurements of length 10.5, width 8.5, unable to determine depth with a scant amount of serous exudate date of onset: 10/13/2023
Writer called to room by CNA (Certified Nurse Assistant) x 2 to assess area. Writer cleaned area. 10% granulation/ 10% slough/ 80% eschar noted to wound bed. Writer informed S5 NP (Nurse Practitioner) of pressure injury to sacrum (including both buttocks). Order received for treatment. S5 NP will assess in the morning and stage.
Review of Resident #1's NP Progress Notes from 10/13/2023 through 10/25/2023 failed to identify Resident #1 had any skin issues.
Review of Resident #1's NP Progress Notes dated 10/26/2023 revealed Chief complaint: reports of a new pressure ulcer sacrum, appears more like a Kennedy ulcer with evaluation. HPI: I received a call yesterday afternoon from the nurse who reported that resident was found to have an extremely large pressure ulcer to the sacrum . Physical Exam: Wound: sacrum .Date identified: 10/25/2023. Type of wound: pressure. Measurement/size: 10.5 x 8.54 x 0.1cm Drainage/exudate: moderate. Odor: No Plan: unstageable pressure ulcer of sacral region - this wound appears more like a Kennedy ulcer, start Santyl to the wound bed with calcium alginate and cover daily until evaluated and seen by S7 Wound Care Specialist who will be managing wounds.
During an interview on 12/28/2023 at 12:00 p.m. S3 LPN Treatment Nurse reported she just became the treatment nurse around the end of November (around Thanksgiving). S3 LPN Treatment Nurse reported she was working as a floor nurse on the hall as Resident #1 resided on admit. S3 LPN Treatment Nurse reviewed Resident #1's electronic record and reported there was an area identified to Resident #1's backside on admit and there was not a follow up done until 10/25/2023.
During an interview on 12/28/2023 at 12:30 p.m. S1 Administrator reported previous treatment nurse (S6 Treatment Nurse) last date of employment was 10/5/2023. S1 Administrator reported during the time from 10/5/2023 through the end of November 2023 the facility had PRN (as needed), RN (Registered Nurses) and the floor nurses were responsible for performing wound care.
During an interview on 12/28/2023 at 3:40 p.m. S4 LPN reported on Resident #1 admit, a skin evaluation was done and Resident #1 had a very small area to the coccyx. S4 LPN reported the facility procedure is to complete a skin evaluation and the nurse practitioner and treatment nurse round the following day and assess the skin ans at that time the practitioner will write treatment orders.
During an interview on 12/28/2023 at 4:25 p.m. S1 Administrator reviewed Resident #4 electronic record and reported there was not a follow up until 10/25/2023 after Resident #1 had a skin issue identified on admission [DATE].
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
Comprehensive Care Plan
(Tag F0656)
Could have caused harm · This affected multiple residents
Based on record reviews and interview, the facility failed to develop a comprehensive care plan for 2 (#1, #2) out of 4 (#1, #2, #3, #4) sampled residents reviewed.
Findings:
Review of Resident #1's ...
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Based on record reviews and interview, the facility failed to develop a comprehensive care plan for 2 (#1, #2) out of 4 (#1, #2, #3, #4) sampled residents reviewed.
Findings:
Review of Resident #1's Medical Records revealed an admit date of 10/13/2023 from with the following diagnoses, in part: hemiplegia and hemiparesis following non-traumatic intracerebral hemorrhage affecting right dominant side, dysphagia following non-traumatic intracerebral hemorrhage, aphasia following non-traumatic intracerebral hemorrhage, acute and chronic respiratory failure with hypoxia, acute and chronic respiratory failure with hypercapnia, encounter for attention to tracheostomy, encounter for attention to gastrostomy, essential hypertension, abnormalities of breathing, and acute upper respiratory infection
Review of Resident #1's Physician Orders revealed:
10/13/2023:
Trach: trach care every shift and as needed, suction every shift and as needed
NPO (Nothing by mouth) diet
Tube: peg tube .RN (Registered Nurse) to replace as needed for occlusion and dislodgement, check placement tube by aspiration of gastric contents, check residuals. If more than 60 ml (milliliters), discard and hold feeding. Notify MD (Medical Doctor) of gastric emptying, elevate head of bed 30 to 45 degrees at all times during feeding and one hour after feeding is stopped, flush with 30 ml water before and after each medication, replace syringe every 24 hours on 11-7 shift, If tube becomes dislodged, LPN (Licensed Practical Nurse) is to insert Foley of equivalent size, Tube: Flush with 200 ml water every (4) hours
10/14/2023:
Lovenox Injection solution prefilled syringe 40 mg (milligram) /0.4 ml (milliliter) in the morning for DVT (Deep Vein Thrombosis)
Keppra oral tablet 750 mg (2 two times a day for seizures)
10/16/2023: Trach: humidified oxygen (4 liters) at 28% to trach to trach collar continuously
10/18/2023: Enteral feed: Osmolite 1.5 at 60 ml/hour per peg pump continuously
10/26/2023: Clean pressure injury to sacrum (including buttocks) with wound cleanser. Apply Santyl to wound bed and cover with dry dressing every day and PRN (as needed)
10/30/2023:
Multivitamin (Give 1 tablet via Peg-tube at bedtime for wound)
Zinc oral tablet 50 mg (Give 1 tablet via Peg-tube at bedtime for wound)
Vitamin C 500 mg (1 tablet via Peg-tube at bedtime for wound- D/C when wound heals)
Review of Medical Record failed to reveal Resident #1 had a person centered comprehensive care plan with appropriate goals and intervention.
During an interview on 12/28/2023 at 12:30 p.m. S2 Care Plan Nurse reported Resident #1 did not have a comprehensive care plan completed and should.
Resident #2
Review of Resident #2's Medical Records revealed an admit date of 10/09/2023 with the following diagnoses, in part: type 2 diabetes mellitus with other specified complication, morbid (severe) obesity due to excess calories, hemiplegia and hemiparesis following unspecified cerebrovascular disease affecting left non-dominant side, acquired absence of right leg below knee, acquired absence of left leg below knee, chronic obstructive pulmonary disease(COPD)/unspecified, low back pain/unspecified, essential hypertension, depression/unspecified and major depressive disorder/recurrent/moderate.
Review of Resident #2's Physician's Orders revealed:
12/07/2023 - Melatonin oral tablet 3mg (milligram) give 3 tablet by mouth at bedtime for insomnia
11/23/2023 - Synthroid oral tablet 175mcg (microgram). Give 1 tablet by mouth in the morning
11/15/2023 - Cymbalta oral capsule delayed release particles 20mg give 1 capsule by mouth one time a day r/t (related to) depression . Give with 60mg to equal 80mg total and give 1 capsule by mouth one time a day Give with 20mg to equal 80mg total
10/09/2023 - Plavix oral tablet 75mg. Give 1 tablet by mouth one time a day for CVA (cerebrovascular accident)
10/10/2023 - Nifedical XL (extralong) oral tablet extended release 24 hour 60mg. Give 1 tablet by mouth one time a day for hypertension (HTN) and Breo Ellipta inhalation aerosol powder breath activated 100-25 mcg/act (actuation) 1 inhalation. Inhale orally one time a day for COPD
Review of Medical Record failed to reveal Resident #2 had a person centered comprehensive care plan with appropriate goals and intervention.
During an interview on 12/28/2023 at 10:55 a.m. S2 Care Plan Nurse acknowledged Resident #2 does not have a comprehensive care plan completed and should.
Jun 2023
11 deficiencies
2 IJ
CRITICAL
(J)
Immediate Jeopardy (IJ) - the most serious Medicare violation
Accident Prevention
(Tag F0689)
Someone could have died · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews and interviews, the provider failed to ensure residents received adequate supervision and to prevent elo...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews and interviews, the provider failed to ensure residents received adequate supervision and to prevent elopement for 1 (#140) out of 1 (#140) residents reviewed for wandering.
This failed practice led to an immediate jeopardy situation for Resident #140, which began on 05/06/2023 at 3:25 p.m. when he exited the facility, attempted to walk home and received a ride from a person unknown to him. S20 Agency LPN (licensed practical nurse) failed to notify the appropriate staff after he had not observed Resident #140 after administering four o'clock medications on the evening shift of 05/06/2023. S21 LPN failed to notify the appropriate staff when S20 Agency LPN reported Resident #140 had not been seen after four o'clock. S21 LPN failed to notify appropriate staff during the night shift on 05/06/2023 when Resident #140 was not observed. On 05/07/2023, Resident #140 was located at 9:02 a.m. at his home, which is located 6.1 miles from the facility, and had been missing from the facility for 18 hours. Resident #140 returned to the facility on [DATE] at 10:25 a.m.
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:
Provider's Elopement Policy dated 09/21/2017 revealed in part:
Policy interpretation and implementation:
It is the standard of this health care center that appropriate procedures exist in the case of a missing resident. A missing resident is defined as a resident who has left the facility grounds without being signed out on pass.
Standard of Practice:
Step 1.
Should an employee discover that a resident is missing from the facility, he/she should notify the charge nurse. The charge nurses will: b) make a thorough search of the building (s) and premises. If not located within 15 minutes; c) notify the administrator and the director of nursing services; d) notify the resident's representative; notify the attending physician; notify the law enforcement officials; i) make an extensive search of the surrounding area.
Step 2.
At any time in which a resident is determined missing, the items below should be strictly followed: A. alert - the supervisor/charge nurse will alert all other personnel by paging Dr. Wander and location (including unit, floor, and room number). B. Search - a search of the immediate area (buildings) will be initiated under the director of the nursing shift supervisor/charge nurse. All rooms will be searched (including locked rooms) The nursing shift supervisor/charge nurse will designate staff to search the area surrounding the building, as appropriate (patio, parking areas, etc.)
Review of Resident #140's Medical Records revealed an admit date [DATE] with the following diagnoses, in part: hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, traumatic subdural hemorrhage with loss of consciousness of unspecified duration/subsequent encounter, history of falling, chronic obstructive pulmonary disease, paroxysmal atrial fibrillation, hypertension heart failure, and anemia.
Review of Resident #140's MDS (Minimum Data Set) Assessment's dated 05/03/2023 and 05/09/2023 revealed BIMS (Brief Interview for Mental Status) of 09 (moderately impaired cognition).
Review of Resident #140's Care Plan revealed the following problems, in part: At risk for falls related to gait/balance problems, right hemiplegia, and history of falls.
Review of Resident #140's Nurses' Notes revealed the following entries:
05/07/2023 18:14 - Incident Note - Writer noted last charted documentation was at approx. 2200 and that meds were given at approx. 2000. Writer noted that administrative staff and resident's sister arrived to this facility and after further search, that resident had gone home to his house all per administrative staff report. Administrative staff also informed writer that resident will be returning back to this facility via facility transport and to get a wander guard placed on resident as soon as possible and to do a thorough assessment.
Review of Resident #140's Progress Noted dated 05/07/2023 12:06 - Skilled Evaluation - Late entry: Safety concerns - note resident did elope on 5/06 - 5/07 was found at his house by police.
Review of SIMS (Statewide Incident Management System) report dated 05/12/2023 revealed the resident was seen on video surveillance going out the door at 3:25 p.m. on 05/06/2023. At 9:02 a.m., sister received call from her husband that resident was located at his home sitting on the porch Transportation arrived at the facility at 10:25 a.m. with resident.
Review of Resident #140's Physical Therapy (PT) Evaluation & Plan of Treatment dated 05/03/2023 revealed:
Reason for referral - Patient is a [AGE] year old with recent hospitalization status following acute CVA (cerebral vascular accident) with hemorrhage. Patient exhibits new onset of decrease in strength, decrease in functional mobility, reduced ability to safely ambulate and reduced balance indicating the need for physical therapy to improve dynamic balance, increase functional activity tolerance, increase lower extremity range of motion and strength, facilitate with all functional mobility, increase independence with gait and promote safety awareness
Additional abilities/Underlying impairments - Cardiopulmonary: standing duration = 1-3 minutes/standing supported; Coordination: gross motor coordination impaired; Cognition safety awareness impaired.
Functional Assessment - Gait: distance level surfaces 200 feet; assistive device rolling walker; Gait analysis: patient exhibits knee wobble and occasional inadequate toe clearance which are associated with the underlying cause of muscle paralysis/weakness and lack of/impaired coordination.
Impressions: Clinical impressions - Patient presents to physical therapy with deficits in bilateral lower extremity strength, gross motor coordination, balance deficit, safety awareness, trunk stability, postural awareness, and reduced functional activity tolerance limiting patient's safety and functional mobility .
Evaluation Summary - clinical decision making - moderate complexity.
Review of Resident #140's Elopement Evaluations revealed on admit of 05/02/23 - score of 0 (score > 1 = at risk for elopement).
Review of S21 LPN's personnel file revealed she received elopement training during orientation on 04/05/2023.
Review of Facility's In-Service Records revealed an in-service on elopement was conducted on 04/02/2023.
Review of Resident #140's May and June 2023 Medication Administration Record's revealed wander guard was checked every shift.
During an interview on 06/06/2023 at 4:20 p.m. S7 CNA (certified nurse assistant) reported she was working the 3-11 shift when Resident #140 eloped. S7 CNA further reported she was on the hall and noticed him walking with his cane going towards the front of the facility. S7 CNA confirmed she did not observe Resident #140 again but later noticed he was not in his room. S7 CNA further acknowledged she notified S20 Agency LPN that she had not seen Resident #140 in a while, he was not in his room and he did not eat his dinner because his tray was untouched. S7 CNA reported she did not know if the nurse looked for him or not but assumed he would do something about it.
During a telephone interview on 06/07/2023 at 8:00 a.m. Resident #140's sister reported he was there for rehab following a stroke and was not able to walk well. She further reported Resident #140 told her he fell after he left the facility.
During an interview on 06/07/2023 at 8:05 a.m. S8 PT confirmed Resident #140's could only walk 200 feet and required stand-by assistance. S8 PT further reported Resident #140 had safety awareness needs and needed supervision. S8 PT confirmed at the time of the elopement Resident #140 was using a single point cane he had brought from home and was not safe enough to walk by himself.
During an interview on 06/07/2023 at 8:10 a.m. S4 Social Services reported Resident #140 walks really slow and purposefully. S4 Social Services further reported he requested a wheelchair to take home because he said he would feel safer having it.
During an interview on 06/07/2023 at 8:15 a.m. S9 CNA reported Resident #140 used both a wheelchair and a cane depending on how he was feeling. S9 CNA acknowledged when he did use his cane he was a little unsteady.
During an interview on 06/07/2023 at 8:16 a.m. S10 CNA reported Resident #140 used cane and that he was unsteady when walking.
During an interview on 06/07/3023 at 8:17 a.m. S11 CNA reported Resident #140 was a little wobbly when walking.
During an interview on 06/07/2023 at 8:20 a.m. S6 LPN reported Resident #140 was slightly unsteady and sometimes would use his wheelchair to get around. S6 LPN indicated she was unsure Resident #140 would be capable of walking a long distance outside the facility.
During an interview on 06/07/2023 at 8:25 a.m. Resident #140 reported the day he left the facility he walked outside and went to the stop sign. Resident #140 confirmed he then walked somewhere near the food stamp office and someone gave him a ride home. Resident #140 indicated he was very tired after walking that far.
During an interview on 06/07/2023 at 8:35 a.m. S1 Administrator reported she was notified on 05/07/2023 Resident #140 was missing when the day shift nurse discovered he had not been observed during the night shift. S1 Administrator reported Resident #140 told her he left because he was worried about his house and wanted to check on it. She further reported he told her it was daylight when he left, he walked to the bus stop but there was no bus, and ended up somewhere near the food stamp office. She reported he told her he got a ride with someone he did not know and that person took him straight to his house and he paid him. S1 Administrator reported she asked Resident #140 if he fell and he told her no but they observed small areas on the base of his palms. S1 Administrator verified video surveillance showed Resident #140 left the facility at 3:25 p.m. unsupervised and returned on the morning of 05/06/23 to the facility. S1 Administrator acknowledged both S20 Agency LPN and S21 LPN did not report Resident #140 was not observed during their shifts on 05/06/2023 and did not follow the elopement policy. She further reported and produced documentation S20 Agency Nurse, S21 LPN and S32 Receptionist received elopement training prior to the incident on 5/06/2023. S1 Administrator further acknowledged the receptionist on duty 05/06/2023 was not looking at the front door when Resident #140 left the facility and should have been. S1 Administrator provided documentation Resident #140's wander guard is checked every shift.
Review of Resident #140's Progress Notes revealed Nurse's Note dated 05/07/2023 19:13 - at approximately 10:34 a.m .Writer proceeded to thoroughly assess resident at bedside and placed on his wander guard to left ankle .neurochecks WNL (within normal limits) .skin intact with scant-small red bruising to bilateral palms of hand .Writer has educated resident to please notify staff for any needs and assistance getting up and use of call light and he voiced understanding .
On 05/07/2023 the facility implemented the following actions to correct the deficient practice with completion on 05/26/2023.
Immediate Actions:
1. Resident assessed by staff upon return, interviewed.
2. Entry door was switched from a from a 12 hour night locking mode to a 24 hours a day
locking mode schedule
3. Receptionist was counseled and re-educated
4. S20 Agency Nurse - notified agency of incident and placed nurse on do not return list.
Reported nurse to LPN (licensed practical nurse) board.
5. S21 LPN night shift nurse - suspended pending investigation. After investigation, was
terminated and reported to board.
6. Ad Hoc meeting with Medical Director, Director of Nursing and [NAME] President Clinical.
Reviewed investigation and actions.
7. A complete root cause analysis and investigation.
8. Trauma Assessment completed on resident with no adverse actions noted. Re-educated
resident and sister (Responsible Person) on leave of absence procedure.
Systemic Actions:
1. Staff re-education on elopement of resident policy and code alert - Dr. Wander (staff on leave
of absence will not return to duty until in-serviced on elopement of resident policy). Education
is on-going.
2. Agency staff received education on elopement of resident policy and code alert - Dr. Wander.
Agency staff were educated prior to working.
3. Resident meeting to review and re-educate leave of absence procedure. Re-education and
missing resident drills ongoing. Two table top elopement scenarios were conducted.
Monitoring:
1. Initiated audit of assessments to ensure residents are safe and correct placement.
2. Administrator makes random rounds throughout the facility quizzing staff on the process when
a resident elopes.
CRITICAL
(J)
Immediate Jeopardy (IJ) - the most serious Medicare violation
Administration
(Tag F0835)
Someone could have died · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews and interviews the facility failed to be administered to in a manner that used its resources efficiently...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews and interviews the facility failed to be administered to in a manner that used its resources efficiently to ensure staff supervised residents to prevent elopement for 1 (#140) of 1 (#140) residents reviewed for wandering.
This failed practice led to an immediate jeopardy situation for Resident #140, which began on 05/06/2023 at 3:25 p.m. when he exited the facility, attempted to walk home and received a ride from a person unknown to him. S20 Agency LPN (licensed practical nurse) failed to notify the appropriate staff after he had not observed Resident #140 after administering four o'clock medications on the evening shift of 05/06/2023. S21 LPN failed to notify the appropriate staff when S20 Agency LPN reported Resident #140 had not been seen after four o'clock. S21 LPN failed to notify appropriate staff during the night shift on 05/06/2023 when Resident #140 was not observed. On 05/07/2023, Resident #140 was located at 9:02 a.m. at his home, which is located 6.1 miles from the facility, and had been missing from the facility for 18 hours. Resident #140 returned to the facility on [DATE] at 10:25 a.m.
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:
Cross refer to 689.
Provider's Elopement Policy dated 09/21/2017 revealed in part:
Policy interpretation and implementation:
It is the standard of this health care center that appropriate procedures exist in the case of a missing resident. A missing resident is defined as a resident who has left the facility grounds without being signed out on pass.
Standard of Practice:
Step 1.
Should an employee discover that a resident is missing from the facility, he/she should notify the charge nurse. The charge nurses will: b) make a thorough search of the building (s) and premises. If not located within 15 minutes; c) notify the administrator and the director of nursing services; d) notify the resident's representative; notify the attending physician; notify the law enforcement officials; i) make an extensive search of the surrounding area.
Step 2.
At any time in which a resident is determined missing, the items below should be strictly followed: A. alert - the supervisor/charge nurse will alert all other personnel by paging Dr. Wander and location (including unit, floor, and room number). B. Search - a search of the immediate area (buildings) will be initiated under the director of the nursing shift supervisor/charge nurse> All rooms will be searched (including locked rooms) The nursing shift supervisor/charge nurse will designate staff to search the area surrounding the building, as appropriate (patio, parking areas, etc.)
Review of Resident #140's Elopement Evaluations revealed on admit of 05/02/23 - score of 0 (score > 1 = at risk for elopement).
Review of S21 LPN's personnel file revealed she received elopement training during orientation on 04/05/2023.
Review of Facility's In-Service Records revealed an in-service on elopement was conducted on 4/02/2023.
Review of Resident #140's May and June 2023 Medication Administration Record's revealed wander guard was checked every shift.
During an interview on 06/07/2023 at 8:35 a.m. S1 Administrator reported she was notified on 05/07/2023 Resident #140 was missing when the day shift nurse discovered he had not been observed during the night shift. S1 Administrator reported Resident #140 told her he left because he was worried about his house and wanted to check on it. She further reported he told her it was daylight when he left, he walked to the bus stop but there was no bus, and ended up somewhere near the food stamp office. She reported he told her he got a ride with someone he did not know and that person took him straight to his house and he paid him. S1 Administrator reported she asked Resident #140 if he fell and he told her no but they observed small areas on the base of his palms. S1 Administrator verified video surveillance showed Resident #140 left the facility at 3:25 p.m. unsupervised and returned on the morning of 05/06/23 to the facility. S1 Administrator acknowledged both S20 Agency LPN and S21 LPN did not report Resident #140 was not observed during their shifts on 05/06/2023 and did not follow the elopement policy. She further reported and produced documentation S20 Agency Nurse, S21 LPN and S32 Receptionist received elopement training prior to the incident on 5/06/2023. S1 Administrator further acknowledged the receptionist on duty 05/06/2023 was not looking at the front door when Resident #140 left the facility and should have been. S1 Administrator provided documentation Resident #140's wander guard is checked every shift.
On 05/07/2023 the facility implemented the following actions to correct the deficient practice with completion on 05/26/2023.
Immediate Actions:
1. Resident assessed by staff upon return, interviewed.
2. Entry door was switched from a from a 12 hour night locking mode to a 24 hours a day
locking mode schedule
3. Receptionist was counseled and re-educated
4. S20 Agency Nurse - notified agency of incident and placed nurse on do not return list.
Reported nurse to LPN (licensed practical nurse) board.
5. S21 LPN night shift nurse - suspended pending investigation. After investigation, was
terminated and reported to board.
6. Ad Hoc meeting with Medical Director, Director of Nursing and [NAME] President Clinical.
Reviewed investigation and actions.
7. A complete root cause analysis and investigation.
8. Trauma Assessment completed on resident with no adverse actions noted. Re-educated
resident and sister (Responsible Person) on leave of absence procedure.
Systemic Actions:
1. Staff re-education on elopement of resident policy and code alert - Dr. Wander (staff on leave
of absence will not return to duty until in-serviced on elopement of resident policy). Education
is on-going.
2. Agency staff received education on elopement of resident policy and code alert - Dr. Wander.
Agency staff were educated prior to working.
3. Resident meeting to review and re-educate leave of absence procedure. Re-education and
missing resident drills ongoing. Two table top elopement scenarios were conducted.
Monitoring:
1. Initiated audit of assessments to ensure residents are safe and correct placement.
2. Administrator makes random rounds throughout the facility quizzing staff on the process when
a resident elopes.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
MDS Data Transmission
(Tag F0640)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure resident assessments were transmitted within the required ti...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure resident assessments were transmitted within the required timeframe for 1 (#127) of 1 (#127) residents reviewed for assessments.
Findings:
Review of Resident #127's medical record revealed in part, Resident was admitted to facility on 01/06/2023 and left the facility AMA (Against Medical Advice) on 01/23/2023.
Review of Resident #127's MDS (Minimum Data Set) assessments revealed the last transmitted MDS was an admission assessment dated [DATE]. Further review of Resident #127's MDS assessments failed to reveal a discharge MDS had been transmitted.
During an interview on 06/06/2023 at 2:10 p.m. S12 MDS Nurse and S26 MDS Nurse reported a discharge MDS had not been transmitted for Resident #127 and should have been.
CONCERN
(D)
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 review and interviews, the facility failed to ensure MDS (Minimum Data Set) assessments were accurate for 1 (#14...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to ensure MDS (Minimum Data Set) assessments were accurate for 1 (#141) out of 2 (#131, #141) residents reviewed for hospitalization. The facility failed to enter an accurate discharge status for Resident #141.
Findings:
Review of resident #141's electronic medical record revealed an admission date of 3/9/2023 and a discharge date of 4/1/2023.
Review of resident #141's MDS dated [DATE] revealed a (planned) discharge with a return not anticipated to an acute hospital.
Review of resident #141's progress note dated 3/31/2023 at 12:11 p.m. revealed resident is being discharged on 4/1/2023 home with wife.
Review of resident #141's Discharge Summary by S28 Nurse Practitioner dated 3/31/2023 revealed chief complaint: discharge to home on 4/1/2023.
During an interview on 6/7/2023 at 9:25 a.m. S29 MDS nurse confirmed Resident #141 was discharged home on 4/1/2023. S29 MDS confirmed Resident #141's MDS was coded inaccurately.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Incontinence Care
(Tag F0690)
Could have caused harm · This affected 1 resident
Based on record review, observation and interview the facility failed to ensure a resident who was incontinent of the bladder received appropriate treatment to prevent urinary tract infections for 1 (...
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Based on record review, observation and interview the facility failed to ensure a resident who was incontinent of the bladder received appropriate treatment to prevent urinary tract infections for 1 (#7) of 1 (#7) residents reviewed. The facility failed to position resident #7's catheter bag above the floor.
Findings:
Review of the facility's Urinary Catheter Care, Anchoring and Changing Policy revealed the following:
Standard of Practice #16: Secure Foley catheter drainage bag below level of bladder and above the floor.
Review of the facility's Catheter Insertion Policy revealed the following:
Standard of Practice #23: .Keep drainage system off the floor.
Review of resident #7's electronic medical record revealed an admit date of 12/10/2019 with diagnoses of but not limited to toxic encephalopathy, history of sepsis and urinary tract infection, type 2 diabetes, quadriplegia, essential hypertension and convulsions.
Observation on 06/07/2023 at 8:30 a.m. with S13 LPN (licensed practical nurse) revealed resident #7's catheter bag lying on the floor with cloudy yellow urine noted inside.
Review resident #7's lab results dated 06/05/2023 revealed resident #7's urine culture was positive for Escherichia Coli and Pseudomonas Aeruginosa.
During an interview on 06/07/2023 at 8:30 a.m. S13 LPN confirmed resident #7's urine culture was positive for Escherichia Coli and Pseudomonas Aeruginosa indicating resident #7 had a current urinary tract infection. S13 LPN also confirmed resident #7's catheter bag should not have been lying on the floor.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0729
(Tag F0729)
Could have caused harm · This affected 1 resident
Based on record reviews and interview the facility failed to ensure the state Adverse Action Website checks were completed at time of hire and then monthly for 5 [S15 CNA (Certified Nursing Assistant)...
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Based on record reviews and interview the facility failed to ensure the state Adverse Action Website checks were completed at time of hire and then monthly for 5 [S15 CNA (Certified Nursing Assistant), S16 CNA, S17 CNA, S18 CNA, S19 CNA] of 5 employees whose personnel files were reviewed.
Findings:
Review of S15 Contract CNA's personnel file revealed the first day of work in the facility was 05/27/2023. Further review of S15 Contract CNA's personnel file failed to reveal the State Adverse Action website check performed prior to first day worked in the facility.
Review of S16 CNA's personnel file revealed a hire date of 02/23/2022. Further review of S16 CNA's personnel file revealed no State Adverse Actions checks were completed.
Review of S17 CNA's personnel file revealed a hire date of 06/21/2022. Further review of S17 CNA's personnel file revealed no State Adverse Actions checks were completed.
Review of S18 CNA's personnel file revealed a hire date of 04/15/2020. Further review of S18 CNA's personnel file revealed no Stage Adverse Actions checks were completed.
Review of S19 CNA's personnel file revealed a hire date of 06/27/2013. Further review of S19 CNA's personnel file revealed no State Adverse Actions checks were completed.
During an interview on 06/07/2023 at 1:30 p.m. S14 Human Resources acknowledged State Adverse Action checks had not been completed.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0947
(Tag F0947)
Could have caused harm · This affected 1 resident
Based on record reviews and interview the facility failed to ensure nurse aides received required in-service training for 1 [S15 CNA (Certified Nursing Assistant)] of 5 employees whose personnel files...
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Based on record reviews and interview the facility failed to ensure nurse aides received required in-service training for 1 [S15 CNA (Certified Nursing Assistant)] of 5 employees whose personnel files were reviewed.
Findings:
Review of S15 Contract CNA's personnel file revealed the first day of work in the facility was 05/27/2023. Further review of S15 Contract CNA's personnel file failed to reveal S15 had received required dementia training.
During an interview on 06/07/2023 at 3:15 p.m. S2 DON confirmed S15 Contract CNA had not completed the required dementia training.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Comprehensive Care Plan
(Tag F0656)
Could have caused harm · This affected multiple residents
Based on observations, interviews and record review the facility failed to ensure the plan of care was developed and/or implemented for 6 (#32, #40, #73, #109, #125 and #130) of 6 residents reviewed.
...
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Based on observations, interviews and record review the facility failed to ensure the plan of care was developed and/or implemented for 6 (#32, #40, #73, #109, #125 and #130) of 6 residents reviewed.
1. The facility failed to ensure labs were obtained for resident #32 as ordered by the physician
2. The facility failed to ensure splint devices were used according to resident's plan of care for residents #40, #73, #109, #125 and #130.
Findings:
Resident #32
Review of the facility's Laboratory, Radiology and other Diagnostic Services Policy (reviewed in 11/2022) revealed in part: The facility will provide laboratory and diagnostic services to meet the needs of the residents in a timely manner.
If facility does not provide laboratory services on-site; it shall have an agreement to obtain these services from a laboratory or radiology provider or supplier that is approved to provide these services under Medicare.
It is the practice of this facility to provide laboratory or diagnostic services upon an order from a physician, physician assistant, nurse practitioner or clinical nurse specialist in accordance with state law, including scope of practice laws.
Review of resident #32's electronic medical record revealed a diagnosis of but not limited to: unspecified atrial fibrillation, type 2 diabetes mellitus without complications, hemiplegia and hemiparesis following unspecified cerebrovascular disease affecting right dominant side and cerebrovascular disease.
Review of resident #32's June 2023 Physician Orders revealed an order for annual lab in May, CBC (Complete Blood Count), CMP (Comprehensive Metabolic Panel), TSH (Thyroid Stimulating Hormone), Vitamin B12, FLP (Fasting lipid profile), and HBGA1C (hemoglobin A1C) .
Review of resident #32's electronic medical record failed to reveal annual lab (CBC, CMP, TSH, Vitamin B12, FLP, and HbA1c) was done.
During an interview on 06/8/2023 at 11:00 a.m. S24 LPN (licensed practical nurse) confirmed resident #32's annual lab was not obtained in May 2023 as ordered.
During an interview on 06/8/2023 at 11:05 a.m. S25 RN (registered nurse) Supervisor reported resident #32's annual lab was not obtained as ordered.
Resident #40
Review of resident #40's electronic medical record revealed an admit date of 12/2/2013 and re-admit date of 09/27/2021 with diagnosis of but not limited to hemiplegia and hemiparesis following non-traumatic intra cranial hemorrhage affecting right dominant side, aphasia, essential hypertension, major depressive disorder, convulsions, contracture of left and right ankle, type 2 diabetes, convulsions, and contracture to right hand.
Observation on 06/05/2023 at 1:56 p.m. revealed resident #40 lying in bed with bilateral hand contractures without hand rolls or a splint devices in place.
Observations on 06/7/2023 at 9:00 a.m. revealed resident #40 lying in bed with lying in bed with bilateral hand contractures without hand rolls or a splint devices in place.
Review of resident #40's June 2023 Physicians Orders revealed an order for abdominal pads rolled up and placed in palms of contracted hands to prevent/heal.
Review of resident #40's Comprehensive Plan of Care revealed a problem and approaches of:
Restorative- Resident receiving restorative program for contractures. Staff to apply splint and monitor for altered skin.
Review of resident #40's progress noted dated 02/3/2023 revealed the following: Writer was notified by therapy that resident #40 had darkening underneath her middle and pointer fingernails on right hand. Soft roll splint to be placed to palm to wrap fingers around.
Review of resident #40's Occupational Therapy Restorative Referral Plan revealed the following:
Continue range of motion exercises and apply splinting device per instructions from occupational therapy, palm guards to bilateral hands daily. Splint to be placed to bilateral hands for up to 4 hours.
During an interview on 06/7/2023 at 10:30 a.m. S3 Restorative LPN reported, residents are recommended for restorative care. S3 Restorative LPN stated, I think resident #40 had hand splints.
Resident #73
Review of resident #73's electronic medical record revealed an admit date of 11/28/2017 and a diagnosis of but not limited to essential hypertension, dysphagia, unspecified hemiplegia and hemiparesis with cerebrovascular disease.
Observation on 06/06/2023 11:26 a.m. revealed resident #73 had a contracture to right upper extremity without a splint device in place.
Review of resident #73's June 2023 physician's orders revealed an order for resident #73 to attend restorative nursing program for splinting to right upper extremity 6 times a week for up to hours per day.
Review of resident #73's Occupational Therapy discharge summary revealed the resident #73 was to safely wear a resting hand splint.
Review of resident #73's Comprehensive Plan of Care revealed a Restorative Plan of splinting to right upper extremity. staff to apply splint and monitor altered skin.
Review of client #73 progress notes revealed the following entries:
06/6/2023- Due to restorative working from the front desk all day Tuesday, resident did not wear splint.
06/4/2023-Due to restorative aid being pulled to transportation resident wasn't able to wear hand splint.
During interview on 06/7/2023 at 10:23 a.m. S3 Restorative LPN (Licensed Practical Nurse) confirmed resident #73 should have had a resting hand splint in place on his right upper extremity and did not have one in place.
Resident #109
Review of resident #109's electronic medical record revealed resident #109 had an admit date of 05/20/2022 and a diagnosis of but not limited to hemiplegia and hemiparesis following cardiovascular accident, essential hypertension, stiffness to right hand, stiffness to right elbow, and contracture to right knee.
Observation on 06/5/2023 at 10:00 a.m. revealed resident #109 had right arm contracture with no splint device in place to upper or lower extremity.
Observation on 06/06/2023 at 4:10 p.m. revealed resident #109 lying in bed positioned on back and slightly to his left side with wedge. Further observation failed to reveal a splint in place to upper or lower extremity.
Review of resident #109's June 2023 Physician's orders revealed an order for
Resident to attend Restorative for splinting to right knee 6 times a week for a minimum of 15 minutes per session and splinting to upper right extremity 6 times a week for 6 to 8 hours a day.
Review of resident #109's Comprehensive Plan of Care revealed resident #109
was receiving restorative program for contractures, limited range of motion. Approaches included range of motion on right lower extremities for at least 15 minutes a week and splinting to right upper extremity for 6-8 hours up to 6 days a week.
During an interview on 06/7/2023at 8:45 a.m. S13 LPN (licensed practical nurse) reported she was not aware of resident #109's recent use of splints and stated, The restorative aid used to put them on.
During an interview on 06/7/2023 at 10:45 a.m. S3 Restorative LPN confirmed resident #109 should have had a splint in place on the right upper extremity, and a splint to right knee.
Resident #125
Review of Resident #125's electronic medical record revealed an admit date of 01/05/2023 with a diagnosis of but not limited to non-traumatic intracerebral hemorrhage/intraventricular, arteriovenous malformation/site unspecified, Moyamoya disease, encounter for attention to tracheostomy, encounter for attention to gastrostomy, metabolic encephalopathy, and other seizures.
Review of Resident #125's Physician's Orders revealed the following orders:
03/28/2023 resident to attend restorative nursing program for splinting of multi podus boots and left orthosis knee splint 6 times a week for 4-6 hours per day
03/25/2023 - resident to attend restorative nursing program for passive range of motion 6 times a week for a minimum of 15 minutes per session. Right hand and left upper and lower extremities 3 sets x 5.
Observation on 06/05/2023 at 8:00 a.m. revealed resident #125 lying in bed with no splint devices on resident's feet or left knee. Upon further observation, resident #125's knee splint and multi podus boots were noted in the closet.
Observation on 06/05/2023 at 2:30 p.m. revealed resident #125 lying in bed with no splint devices on resident's feet or left knee. Upon further observation, resident #125's knee splint and multi podus boots were noted in the closet.
Observation on 06/06/23 at 1:30pm revealed Resident #125 lying on left side. No splint devices or boots observed on resident. Further observation revealed resident # 125 splint and boots were noted in the closet.
During an interview on 06/07/2023 at 1:00 p.m. S3 Restorative LPN confirmed resident #125 had an order to receive restorative care with use of a right knee splint and multi podus boots to both feet.
During an interview on 06/08/2023 at 8:45 a.m. S12 Care Plan Nurse confirmed Resident #125 was not care planned for restorative care and this should have been added by S3 Restorative LPN.
During an interview on 06/08/2023 at 9:10 a.m. S3 Restorative LPN reported some days the Restorative Nurse Aide is unable to complete restorative therapy because they are pulled to do other things like work the front desk or transport residents.
During an interview on 06/08/2023 at 9:15 a.m. S5 Restorative Nurse Aide reported sometimes she doesn't have time to put the splints/boots on because she gets pulled to work the front desk. S5 Restorative Nurse Aide reported she didn't get to complete restorative duties Monday because she had to do transporting and now today she's working the front desk.
Resident #130
Review of resident #130's electronic medical record revealed an admit date of 02/03/2023 with a diagnosis of but not limited to encounter for attention to tracheostomy, traumatic subarachnoid hemorrhage with loss of consciousness of 30 minutes or less/subsequent encounter, encounter for attention to gastrostomy, other muscle spasm, cerebral infarction due to embolism of bilateral middle cerebral arteries, and other injury of other muscle (s) and tendon (s) at lower leg level, right leg, subsequent encounter.
Observation on 06/05/2023 at 8:10 a.m. revealed resident #130 lying in bed with no splints to hands and no multi podus boots on feet.
Observation on 06/06/2023 8:30 a.m. revealed resident #130 lying in bed with no splints to hands and no multi podus boots on feet.
Observation on 06/07/2023 at 12:40 p.m. revealed resident #130 lying in bed with no splints on hands and no multi podus boots on feet. Further observation revealed resident #130's feet both in an extended toe pointing position.
Review of resident #130's Physician's Orders revealed:
03/07/2023 - resident to attend restorative nursing program for foot splint to right foot 6 times a week for 4-6 hours per day
02/10/2023 - resident to attend restorative nursing program for passive range of motion RLE (right lower extremity) & LLE (left lower extremity) up to set up 3 x 10
Review of email correspondence sent by S8 PT (physical therapist) on 04/14/2023 to include S3 Restorative Nurse with subject line: PT quarterly screens revealed: PT quarterly screens complete today. Please see below for recommendations .for bilateral LE (lower extremity) ROM (range of motion) Resident #130 (continue with BLE (bilateral Lower extremity) PROM (passive range of motion) and application of multi-podus boots .
During an interview on 06/07/2023 at 12:40 p.m. resident #130's aunt was present and reported she has never seen splints on her feet and was hoping the staff would put them on her.
During an interview on 06/07/2023 at 1:00 p.m. S3 Restorative LPN confirmed resident #130 had an order to receive restorative for mutil podus boots and a splint to her right hand with passive range of motion. S3 LPN further confirmed resident #130 should have splints in place.
During an interview on 06/08/23 at 8:33 a.m. S8 PT (physical therapist) reported they made recommendations to the restorative nurse for multi-podus boots for her feet. S8 PT (physical therapist) further indicated resident #130 had a splint for her right hand.
During an interview on 06/08/2023 at 8:45 a.m. S12 Care Plan Nurse confirmed resident #130 was not care planned for restorative care and this should have been added by S3 Restorative LPN.
CONCERN
(E)
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 record reviews, observations and interviews the facility failed to ensure residents who were unable to complete their (...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews, observations and interviews the facility failed to ensure residents who were unable to complete their (ADLs) activities of daily living received the necessary services to maintain proper hygiene and grooming for 4 (#91, #5, #43, #79) of 7 (#32, #67, #5, #43, #91, #79, #111) residents reviewed for ADL. The facility failed to ensure Resident
#91 received nails care and weekly skin assessments
#5, #43, #79 received nail care
#79 face was shaved
Findings:
Resident #91
Review of facility policy for Activity of Daily Living with a date of November 2022 revealed:
Policy statement in part revealed
Each resident shall receive, and this facility will provide necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, consistent with the resident comprehensive assessment and care plan.
Scope:
Residents will be given the appropriate treatment and services to maintain or improve their ability to carry out the activities of daily living, including hygiene bathing, grooming, and oral care, mobility, transfer, ambulation, elimination, toileting, dining, eating, and communication functions.
Review of Facility's clinical documentation guidelines presented by S1 Administrator revealed in part weekly skin assessments should be done by license staff.
Review of Resident #91's face sheet revealed admit date of 11/10/2022 with the following diagnoses including but not limited to unspecified osteoarthritis, muscle weakness, lack of coordination, right and left upper arm muscle wasting and atrophy
Review of Admit MDS (minimum data sets) dated 11/17/2022 revealed Resident #91 required total dependence with one person physical assist with personal hygiene
Review of Care Plan revealed Resident #91 had an ADL self-care performance deficit with interventions skin inspection: the resident requires skin inspection per facility policy. Observe for redness, open areas, scratches, cuts, bruises, and report changes to the nurse.
Review of Resident #91's skin evaluation revealed the following:
04/16/2023 at 8:29 p.m. revealed resident did not have any current skin issues.
06/6/2023 at 11:00 a.m. revealed an unstageable pressure ulcer to right inner heel; treatment already in progress.
Further review of skin evaluation on 06/6/2023 failed to identify skin issue to right hand.
Observation on 06/05/23 at 9:30 a.m. revealed Resident #91 had a contracture to right hand and finger nails had grown past the nail bed. Further observation revealed when Resident #91 extended her right hand Resident #91 fingernails had made a red indention in palm of right hand.
Observation on 06/7/2023 at 10:00 a.m. with S27 LPN (Licensed Practical Nurse) assisted Resident #91 with opening right contracted hand to reveal Resident #91's finger nails had made a red indention in the palm of Resident #91's hands.
During an interview on 06/7/2023 at 10:00 a.m. S27 LPN reported Resident #91 kept her hand clinched tight and finger nails have caused an indention in Resident #91's palm.
During an interview on 06/08/2023 at 9:25 a.m. S2 DON (Director of Nursing) reported the charge nurse on each floor is responsible for performing weekly skin assessments on all residents. S2DON confirmed weekly skin assessments had not been performed on Resident #91 and should have been.
During an interview on 06/08/2023 at 11:20 a.m. S25 Registered Nurse Supervisor reported skin assessments should be done weekly on every resident.
Resident # 5
Review of Facility's Nail Care (Finger and Toe) policy with a date of October 20, 2022 revealed the following in part:
Policy statement: The purpose is to clean the nail bed, prevent infection and comfort the resident.
Key Points:
1. Nails can be partially cleaned during bathing
2. nursing assistants do not trim the nails of diabetic residents
3. nail care includes daily cleaning and regular trimming
4. stop and report any evidence of ingrown toe nails, infection, pain, or if nails are too hard or thick to cut with ease.
Review of Resident #5's diagnoses revealed the following but not limited to hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, left non-dominant side
Review of Care Plan revealed Resident #5 had an ADL self-care performance deficit related to stroke with interventions to check nail length and clean on bath day and as necessary. Report any changes or necessity for trimming to the nurse
Observation on 06/06/23 at 10:11 a.m. revealed Resident #5's bilateral hands contracted, nails were grown over the nail bed.
During an interview on 06/06/23 at 10:11 a.m. S32 LPN confirmed Resident #5's nails needed to be trimmed.
During an interview on 06/7/2023 at 10:05 a.m. S25 Registered Nurse Supervisor reported CNA (certified nursing assistant) should trim resident's nails when daily care is performed.
Resident #43
Review of resident #43's record revealed in part an admit date of 04/17/2014 with diagnoses that including but not limited to hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, Parkinson's disease, convulsions, muscle spasms, essential tremor, and anoxic brain damage.
Review of Resident #43's comprehensive care plan revealed in part Resident #43 has an ADL (activities of daily living) self-care performance deficit due to (d/t) his tremors causing a decrease in dexterity. Resident #43 requires fluctuating assistance with ADL's from extensive to total assist due to right hemiplegia and requires 1-2 staff participation with bathing and requires 1 staff participation with personal hygiene.
Resident #43's MDS dated [DATE] revealed in part, a BIMS (Brief Interview for Mental Status) score of 9 indicating moderate cognitive impairment.
Observation on 06/05/2023 at 9:00 a.m. revealed fingernails very long.
Observation on 06/06/2023 at 8:00 a.m. revealed fingernails very long.
Observation on 06/06/2023 at 4:30 p.m. revealed fingernails very long.
Observation on 06/07/2023 at 8:40 a.m. revealed resident lying in bed, feeding self breakfast with moderate difficulty due to tremors. Alert and responsive but difficulty with speech, able to understand and make self understood. Fingernails on both hands very long (approximately 1 inch +). When asked if resident liked his nails to be long, resident shook his head no. When asked about having his nails trimmed, resident responded yes and gestured to have nails cut shorter but not too short.
During an interview and observation on 06/07/2023 at 08:55 a.m. S30 CNA observed resident #43's fingernails and acknowledged the nails were very long and needed to be trimmed.
During an interview on 06/07/2023 at 9:00 a.m. S31 LPN (Licensed Practical Nurse) acknowledged resident #43's nails were long and needed to be trimmed.
Resident #79
Review of resident #79's medical record revealed an admit date of 01/03/2019 with diagnoses that include in part type 2 diabetes, muscle weakness, lack of coordination, muscle wasting and atrophy right and left upper arm, dementia without behavioral disturbance, and Parkinson's disease.
Review of quarterly MDS dated [DATE] revealed resident #79 had moderate cognitive impairment.
Review of resident #79's comprehensive care plan revealed resident has an ADL (activities of daily living) self-care performance deficit related to disease process and Parkinson's. Resident #43 requires 1-2 staff participation with bathing and requires 1 staff participation for personal hygiene.
Observation on 06/05/2023 at 8:00 a.m. revealed resident #79 with unkempt beard and facial hair down his neck. Resident #79 reported he wanted to be shaved and nails cleaned. Resident #79's fingernails long past fingertips with black substance underneath.
Observation on 06/05/2023 at 12:05 p.m. revealed resident #79 with dried black and brown substance around nail beds and underneath nails on left hand, facial hair remains long and scruffy on face and neck. Resident #79 reported he wanted a shave.
Observation on 06/05/2023 at 4:10 p.m. revealed resident #79 with dried black and brown substance around nail beds and underneath nails on left hand and facial hair remains long and scruffy on face and neck.
Observation on 06/06/2023 at 8:05 a.m. revealed resident #79 with dried black and brown substance around nail beds and underneath nails on left hand. Resident reported no-one had washed his hands.
Observation on 06/06/2023 at 4:40 p.m. revealed resident #79 with dried black and brown substance around nail beds and underneath nails on left hand and facial hair remains long and scruffy on face and neck.
Observation on 06/07/2023 at 8:40 a.m. resident #79 lying in bed, feeding self breakfast with dried black and brown substance around nail beds and underneath nails on left hand and facial hair remains long and scruffy on face and neck. Resident #79 reported he does not like the beard and neck hair and wants a shave.
During an interview and observation on 06/07/2023 at 8:50 a.m. S30 CNA observed resident #79's fingernails, facial and neck hair. S30 CNA acknowledged resident #79's fingernails were dirty with brown and black substance around nail beds and underneath nails and should have been cleaned. S30 CNA reported it doesn't matter if they go to the shower or get a bed bath, we should do hair and nails and wash their hands during the day. S30 CNA reported resident #79's nails are dirty and he needs a shave.
During an interview on 06/07/2023 at 9:00 a.m. S31 LPN acknowledged resident #79's nails were dirty and should not have been and resident #79 needed a shave.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Tube Feeding
(Tag F0693)
Could have caused harm · This affected multiple residents
Based on record reviews, interviews and observations, the facility failed to provide appropriate treatment and services to prevent complications of enteral feeding for 4 (Residents #31, #22, #66, #132...
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Based on record reviews, interviews and observations, the facility failed to provide appropriate treatment and services to prevent complications of enteral feeding for 4 (Residents #31, #22, #66, #132) of 4 sampled residents (Residents #31, #43, #79, #142) who received nutrition via a PEG (percutaneous endoscopic gastrostomy) tube. There were 25 residents in the facility with orders for feeding via gastrostomy tube.
The facility failed to:
1. Assure tolerance to feedings with gastric residual checks prior to restarting resident's daily feedings for residents #22, #66, and #132.
2. Ensure the water flush and feeding bags were labeled properly for residents #22, #66, and #132.
3. Ensure the tubing was covered to prevent contamination for resident #31.
Findings:
Review of facility's policy Gastrostomy, checking placement of Gastrostomy feeding tube policy dated 12/07/2017 revealed in part:
To prevent aspiration and assure tolerance of feedings.
-3. Place stethoscope over abdomen. Inject 30ml (milliliters) of air into the stomach; listen for a swish of air.
-4. Slowly aspirate stomach contents. If you get less than 60 ml. continue with the feeding. If you get over 60 ml. stop feeding for one (1) hour. Repeat procedure in one (1) hour. If over 60 ml. call physician for further orders. If less than 60 ml. resume feeding at prescribed rate.
Review of facility policy Gastrostomy Tube feeding and monitoring policy dated 12/07/2017 revealed in part:
To prevent adequate nourishment and hydration to the residents unable to consume food normally, and to observe for and prevent complications.
--1. Check physician's orders for nutritional formula, rate of flow, flush amount, medication administration, checking for tube placement, and checking for gastric residual.
--8. Check for gastric residual, if ordered. Gently aspirate stomach contents into a 60 ml syringe. Follow physician orders regarding amount obtained and actions to follow.
--11. Ensure resident's name, date, rate and time hung is on the feeding solution container.
Review of Resident #22's medical record revealed an admit date of 09/09/2011 with diagnoses that include in part anoxic brain damage, tracheostomy, and gastrostomy.
Resident #31
Review of Resident #31's Medical Records revealed an admit date of 10/11/2016 with the following diagnoses, in part: non-traumatic intracerebral hemorrhage/intraventricular, aphasia following non-traumatic intracerebral hemorrhage, dysphasia following non-traumatic intracerebral hemorrhage, encounter for oropharyngeal phase, unspecified severe protein-calorie malnutrition, encounter for attention to gastrostomy, type 2 diabetes mellitus/without complications, gastro-esophageal reflux disease without esophagitis, and anemia/unspecified.
Review of Resident #31's Physician's Orders revealed an order dated 03/01/23 - Enteral feed - Osmolite 1.5 at 65cc (cubic centimeters)/hour per peg per pump times 20 hours.
Observation on 06/05/23 at 7:58 a.m. revealed Resident #31 Osmolite 1.5 tube feeding bag dated 06/05/2023 with no time noted on label or water flush bag. Further observation revealed tube feedings were not infusing or connected to Resident #31's peg and tubing was hanging on pole and end of tubing unprotected.
Observation on 06/07/2023 at 12:30 p.m. revealed Resident #31's Osmolite 1.5 tube feeding bag dated 06/07/2023 failed to reveal a time noted on the label or water flush bag. Further observation revealed tube feeding was not infusing or connected to Resident #31's peg and tubing was hanging on pole and end of tubing unprotected. S6 LPN was observed grabbing the tubing with the end noted to touch the privacy curtains.
During an interview on 06/07/2023 at 12:30 p.m. S6 LPN (licensed practical nurse) confirmed tube feeding tip should be protected while the feedings are turned off.
Resident #22
Review of Resident #22's physician orders revealed in part the following orders:
-02/23/2023 Enteral feed order every shift Pulmocare 1.5 at 55 ml (milliliter) per hour per PEG pump for 20 hours per day. Off at 10 a.m., on at 2:00 p.m. (1900 calories per 20 hours)
-03/31/2022 Turn PEG tube pump off one time a day
-03/31/2022 turn PEG tube pump on one time a day
-07/08/2020 Tube: Flush PEG tube via pump with 200 cc water every 4 hours
-10/24/2014 Tube: check tube placement by aspiration of gastric contents/auscultation with stethoscope and injection of approximately 30 ml of air. Listening for a swish sound. Perform before initiation of feeding/flushing and prior to medication administration or at least every shift.
-09/09/2011 Tube: check gastric residuals. If greater than 150 ml, discard and hold feeding. Notify MD (medical doctor) of gastric emptying as needed.
Observation on 06/05/2023 at 12:30 p.m. revealed a spiked bag of Pulmocare 1.5 tube feeding and water flush bag hanging on resident #22's infusion pole. Water Flush bag was labeled 06/03/2023 at 0600 with no initials and no label was on the formula bag.
Review of resident #22's May 2023 MAR (Medication Administration Record) documentation revealed in part medication administration per orders, Peg tube feedings off at 10:00 a.m. and on at 2:00 p.m., and water flushes. Further review failed to reveal gastric residual checks were documented as completed per physician's order.
During an interview on 06/08/2023 at 10:00 a.m. S3 ADON (Assistant Director of Nursing) ireviewed resident #22's medical record and confirmed there was no documentation for gastric residual checks and should have been.
Resident #66
Review of resident #66's medical record revealed an admit date of 02/03/2021 with diagnoses that include in part non-traumatic intracerebral hemorrhage, dysphagia oropharyngeal phase, Gastrostomy, and tracheostomy.
Review of Physician orders revealed in part the following orders:
-03/21/2023 enteral feed order-every shift related to dysphagia following non-traumatic intracerebral hemorrhage. Pulmocare at 55 cc per hour per PEG tube via pump continuously for 20 hours from 1400-1000 (1950 calories per 24 hours): May substitute Nutren Pulmonary.
-01/27/2023 Tube: Flush PEG tube via pump with 200 cc water every 4 hours.
-04/29/2022 Turn tube feeding off one time a day
-04/28/2022 Turn tube feeding on one time a day
-11/20/2020 Tube: check gastric residuals. If greater than 60 ml, discard and hold feeding. Notify MD of gastric emptying as needed.
-11/20/2020 Tube: check tube placement by aspiration of gastric contents/auscultation with stethoscope and injection of approximately 30 ml of air. Listening for a swish sound. Perform before initiation of feeding/flushing and prior to medication administration or at least every shift.
-11/20/2020 Tube: Flush with 30 cc water before and after medication administration every shift.
Resident #132
Review of record revealed an admit date of 02/14/2023 with diagnoses that include in part diffuse traumatic brain injury with loss of consciousness, tracheostomy, and dysphagia oropharyngeal phase.
Review of physician orders revealed in part the following orders:
-05/10/2023 Enteral feed order at bedtime Jevity 1.5 at 60/hour per PEG per pump turn on at 8:00 p.m.
-05/09/2023 Enteral feed order in the morning Jevity 1.5 @ 60 cc to be turned off at 6:00 a.m.
-05/10/2023 Enteral feed order three times a day Tube: Jevity 1.5 bolus one can per PEG tube. IF less than 50 % of meal consumed. Document meal intake %.
-03/14/2023 Tube: Flush with 30 cc water before and after medication administration every shift.
-02/14/2023 Tube: check gastric residuals. If greater than 60 ml, discard and hold feeding. Notify MD of gastric emptying as needed.
-02/14/2023 Tube: check tube placement by aspiration of gastric contents/auscultation with stethoscope and injection of approximately 30 ml of air. Listening for a swish sound. Perform before initiation of feeding/flushing and prior to medication administration or at least every shift.
-02/14/2023 Tube: check gastric residuals. If greater than 60 ml, discard and hold feeding. Notify MD of gastric emptying as needed.
Review of resident #132's May 2023 MAR documentation failed to reveal gastric residual checks as per physician's order.
Observation on 06/05/2023 at 8:00 a.m. revealed Jevity tube feeding hanging on pump pole, no label on Jevity tube feeding.
During an interview on 06/05/2023 at 12:40 p.m. S3 ADON confirmed resident #132's Jevity tube feeding bag was not labeled and should have been.
During an interview on 6/8/2023 at 10:00 a.m. S3 ADON reviewed resident #132's medical record and confirmed there was no documentation for gastric residual checks and should have been.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0698
(Tag F0698)
Could have caused harm · This affected multiple residents
Based on record review and interview, the facility failed to ensure that a resident who required dialysis received services consistent with professional standards of practice for 1 (#46) of 1 (#46) re...
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Based on record review and interview, the facility failed to ensure that a resident who required dialysis received services consistent with professional standards of practice for 1 (#46) of 1 (#46) resident reviewed for dialysis by failing to communicate and collaborate with the dialysis facility as evidenced by completing dialysis pre/post evaluation form.
Findings:
Review of Electronic Scanning of Medical Records Policy (reviewed 03/04/2020) revealed:
Policy statement revealed in part .Medical records will be maintained to reflect documentation of care and services for each resident. All documents must be uploaded into PCC (point click care) within 24 hours. Although the majority of the scanning is done by the Medical Records department, other departments listed below are responsible for scanning these documents into PCC.
Nursing: dialysis return documentation
Review of Resident #46's Medical Diagnoses revealed the following, but not limited to end stage renal disease and dependence on renal dialysis.
Review of Resident #46's June 2023 Physician Orders revealed the following orders related to dialysis:
12/30/2022: Return documentation received from dialysis unit upon each visit- Monday, Wednesday, and Friday
12/28/2022: Dialysis at 10:15 a.m. on Monday, Wednesday, and Friday
05/13/2022: Notify dialysis unit if documentation is not returned to facility. Document in E-MAR (Electronic Medication Administration Record) supplemental note
Review of Resident #46's Progress Notes revealed Resident #46 attended scheduled dialysis appointments in May 2023.
Review of Resident #46's electronic health record failed to reveal Dialysis Pre/Post Evaluation forms were completed on the following dates in May 2023 : 5/1, 5/3, 5/5, 5/8, 5/10, 5/22, 5/26, 5/29 & 5/31/2023.
During an interview on 06/07/2023 at 1:30 p.m. S23 LPN (Licensed Practical Nurse) reported dialysis sheets should be returned with the resident and placed in the medical records box to be scanned in.
During an interview on 06/07/2023 at 2:20 p.m. S23 LPN reported all dialysis communication forms have been scanned into the electronic health record.
During an interview on 06/07/2023 at 2:40 p.m. S22 Medical Records reported all dialysis communication forms have been uploaded in the system.
During an interview on 06/07/2023 at 2:45 p.m. S2 DON (Director of Nursing) reported sometimes it is a challenge for dialysis communication forms to be returned from dialysis. If form is not returned from dialysis the nurse should call the dialysis clinic to have forms faxed over. S2 DON confirmed dialysis communication forms have not been scanned into Resident #465's electronic health record.
Feb 2023
4 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
Based on record reviews and interview the facility failed to report an injury of unknown origin that resulted in serious bodily injury immediately, but not later than 2 hours to the State Survey Agenc...
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Based on record reviews and interview the facility failed to report an injury of unknown origin that resulted in serious bodily injury immediately, but not later than 2 hours to the State Survey Agency and Certification Agency as required for 1(#2) of 5 (#1, #2, #3, #4 and #5) sample residents reviewed for accidents.
Findings:
Review of the facility's Abuse Prevention Policy revealed in part # 6. Report and Investigate: e) Ensure that all alleged violations involving abuse, neglect, exploitation or property, or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported 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, 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 of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long term care facilities in accordance with State law).
Review of resident #2's clinical records revealed an admit date of 5/19/2021 with the following diagnoses, but not limited to age related osteoporosis, cerebral Infraction, other specified arthritis multiple sites, repeated falls, muscle weakness, dementia, Alzheimer's disease, unsteadiness on feet and cognitive communication deficit.
Review of resident #2's Quarterly MDS (Minimum Data Sets) dated 11/17/2022 revealed a BIMS (Brief Interview of Mental Status) summary score 6 out of 15 indicating severe cognitive impairment.
Review of Resident #2's Functional Status revealed Resident #2 required one person physical assistance for bed mobility, walk in room, walk in corridor, locomotion on and off unit and two person physical assist with transfers and toilet use.
Review of Progress notes dated 02/03/2023 at 10:35 p.m. S4 LPN (Licensed Practical Nurse) documented she was called to resident #2's room at 10:00 p.m. by S5 CNA (Certified Nurse Assistant) during perineal care, resident #2's hip bone looked mal placed.
Review of Resident #2's ED (emergency department) notes dated 02/04/2023 at 12:09 a.m. on arrival to hospital revealed chief complaint, hip pain. Obvious deformity of right hip. Pain with palpation, range of motion < dorsalis pedis 2+.
Review of resident #2's Hospital Emergency Department dated 02/04/2023 revealed physician records x-ray imaging of right hip and pelvis revealed significantly displaced and angulated right proximal shaft fracture of the femur. Acute, closed right hip and femoral fracture.
Review of resident #2's Orthopedics Consult notes dated 02/04/2023 revealed the surgeon discussed injury and treatment options with the responsible party. Further review of the surgeon notes revealed resident #2 NPO (nothing by mouth) consented and to OR (operating room) 02/04/2023 for a right femur TFN (Titanium Trochanteric Fixation Nail)
Review of the facility's SIMS report (Statewide Incident Management System) for resident #2 revealed the injury was discovered 02/03/2023 at 10:00 p.m. Further review revealed SIMS report was entered into the system 02/04/2023 at 8:27 a.m., not within the required time.
During an interview on 02/15/2023 at 10:30 a.m. S1 Administrator reported Resident #2 was not identified on facility incident reports.
During an interview on 2/15/2023 at 3:30 p.m. S5 CNA reported between 4:30 p.m. and 5:30 p.m. after the dinner she took resident #2 to the shower and gave her a complete shower. S5 CNA reported during the shower that's when she noticed resident #2's hip. She reported it was very obvious something was wrong with that hip. She report she hurried and place resident #2 in the bed between 6:00 p.m. and 7:00 p.m. and asked S4 LPN to go and check her hip. She reported she did notice a small bruise under chin where you may have been shaved.
During an interview on 2/16/2023 at 11:00 a.m. S4 LPN was asked did she assess or administer resident #2 for pain. S4 LPN reported when she assessed resident #2 right hip, the right hip appeared dislocated. She reported she then notified the nurse practitioner. When asked what medication she administered, she refused to answer and asked if she could talk with S1 Administrator and call me back. S4 LPN did not answer any further questions.
During an interview on 02/16/2023 at 1:00 p.m. S2 DON (Director of Nursing) reported after she spoke with S4 LPN about resident #2's incident, S4 LPN had not done any assessment after the incident and no documentation. S2 DON reported S4 LPN should have assessed the resident and documented the incident in the medical records.
During an interview on 02/16/2023 at 3:30 p.m. S1 Administrator reported she was not aware the SIMS report had to be entered in the system within 2 hours of the injury being discovered. S1 Administrator confirmed the SIMS report was not entered within the required time frame.
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 F0637
(Tag F0637)
Could have caused harm · This affected multiple residents
Based on record reviews and interviews the facility failed to conduct a significant change MDS (Minimum Data Set) for 1 (#1) of 5 (#1, #2, #3, #4 and #5) sample residents after changes were noted that...
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Based on record reviews and interviews the facility failed to conduct a significant change MDS (Minimum Data Set) for 1 (#1) of 5 (#1, #2, #3, #4 and #5) sample residents after changes were noted that had an impact on the resident's health status and required interdisciplinary review and revision of the care plan.
Findings:
Review of resident #1's clinical records revealed diagnoses that include, but not limited to Alzheimer's disease, hemiplegia and hemiparesis following unspecified Cerebrovascular Disease, muscle weakness (generalized), muscle wasting and atrophy right and left upper arms.
Review of resident #1's Comprehensive Plan of Care revealed a problem with potential for injury from falls related to history of falls. Actual falls: 01/23/2022, 01/31/2022,0 5/17/2022, (Discoloration to left forehead from fall reported by resident), 09/16/2022 fall sitting on side of bed, 09/12/2022 in room, 09/23/2022, 09/25/2022 fall with injury, 10/02/2022 fell out of wheelchair with no injury, 11/30/2022, 12/16/2022, 01/20/2023. Date Plan of Care was initiated 10/07/2015. Date Plan of Care created, potential for injury 10/07/2015. Date Revision of Care was documented as 01/31/2023. No revisions were actual made to the plan of care.
Review of the NP (Nurse Practitioner) notes dated 01/23/2023 revealed documentation of resident #1 with Severe Alzheimer's dementia: Patient has had a progressive decline over the last couple of months. Her dementia has continued to worsen. Recurrent falls and severely debilitated. Patient has had a progressive decline over the last 6 months requires interdisciplinary review or revision of the care plan, or both.
During an interview on 02/15/2023 at 3:00 p.m. S3 CCC (Clinical Care Coordinator) report the Comprehensive Plan of Care is updated with different interventions when the resident's nurse gives them one. S3 CCC reported IDT (interdisciplinary team) consist of the DON, ADON, Floor Nurse and the CCCs meet each morning and discuss the resident's condition, at that time the interventions may be changed. S3 CCC reported when Revision is written on the Comprehensive Plan of Care there should be updated/revised interventions documented on the plan of care. S3 CCC reported a significant change MDS should be completed when a resident has 1 or 2 activities of daily living changes or any other significant changes. S3 CCC agreed a Significant Change MDS should have been completed within 14 days of identifying theses' changes. S3 CCC the Comprehensive Plan of Care should also have been updated or revised.
During an interview on 02/16/2023 at 1:00 p.m. S2 DON reported resident #1 had really declined over the last few months. S2 DON reported and agreed she had noticed the Comprehensive Plan of Care for residents had not been revised or updated like they should. S2 DON reported that's why they have the IDT meetings, they have these discussions about different interventions and they never put them on the plan of care after the decision to revise them.
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
Quality of Care
(Tag F0684)
Could have caused harm · This affected multiple residents
Based on record reviews and interviews the facility failed to ensure 1 (#2) of 5(#1, #2, #3, #4 and #5) sample clients received treatment and care in accordance with professional standards of practice...
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Based on record reviews and interviews the facility failed to ensure 1 (#2) of 5(#1, #2, #3, #4 and #5) sample clients received treatment and care in accordance with professional standards of practice by failing to perform a thorough physical assessment including pain assessment for resident (#2) after an injury of unknown origin.
Findings:
Review of the facility's Incident Report - Documentation, Investigating, and Reporting policy revealed in part the following: Procedures: Practice Guidelines
Step 2: The Charge Nurse at the time of the incident is responsible for documenting the incident in the resident's medical record. The nurse's note should contain the following documentation. (b) A thorough assessment of the resident's condition at the time of the accident/incident. This assessment should include a description of the resident, vital signs, and any other physical characteristics apparent as a result of the accident/incident.
Review of the facility's Nurse's Progress notes failed to reveal documentation S4 LPN (Licensed Practical Nurse) performed a thorough assessment of resident #2's condition at the time the injury was found.
During an interview on 02/15/2023 at 3:30 p.m. S5 CNA (Certified Nursing Assistant) reported when she first started her shift she made rounds at around 3:00 p.m. S5 CNA reported she let S4 LPN know that resident #2 was complaining about her leg hurting. S5 CNA reported later when she took resident #2 to the shower between 6:00 p.m. and 7:00 p.m. she noticed there was something obviously wrong with resident #2's right hip. S5 CNA report she hurried and place resident #2 in the bed and reported her findings to S4 LPN.
During an interview on 02/16/2023 at 11:00 a.m. S4 LPN denied performing a thorough assessment including a pain assessment of resident #2 when she was made aware of the condition of her right hip.
Review of the ED (emergency department) notes dated 02/4/2023 at 12:09 a.m. on arrival to hospital revealed history of present illness, extremity problem. Chief complaint, hip pain. Obvious deformity of right hip. Pain with palpation, range of motion < dorsalis pedis 2+.
Review of resident #2's Hospital Emergency Department physician records revealed x-ray imaging of right hip and pelvis - Significantly displaced and angulated right proximal shaft fracture of the femur. Acute, closed right hip and femoral fracture.
During an interview on 02/16/2023 at 1:00 p.m. S2 DON (Director of Nursing) reported after she spoke with S4 LPN after resident #2's incident she agreed she did not do a thorough assessment. S2 DON reported S4 LPN should have assessed the resident and documented the incident in the medical records. S2 DON reported this is something she had noticed the new nurses are not doing.
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
Accident Prevention
(Tag F0689)
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 risk for falls had been assessed for 1 (#5) out of 5 (#1, #...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews and interviews the facility failed to ensure risk for falls had been assessed for 1 (#5) out of 5 (#1, #2, #3, #4, #5) sampled residents. Facility failed to ensure a Fall Risk Assessment had been conducted after falls for Resident #5.
Findings:
Review of Facility's Fall Prevention Protocol Policy revealed in part
CMS (Centers for Medicare & Medicaid Services) definition of a fall:
Fall refers to unintentionally coming to a rest on the ground, floor, or other lower level, but not as a result of an overwhelming external force
An episode where a resident lost his/her balance and would have fallen, if not for staff intervention, is considered a fall
A fall without injury is still a fall. Unless there is an evidence suggesting otherwise, when resident is found on floor, a fall is considered to have occurred.
Action:
1.
All residents are screened for fall risk on admission, significant change of condition, quarterly and annually.
4.
After an incident of a fall:
a.
Complete a post fall risk assessment
Review of Resident #5 Medical Diagnoses revealed the following, but not limited to Cerebral infarction (6/24/2022), cerebral atherosclerosis (6/24/2022), COPD (Chronic Obstructive Pulmonary disease) (7/6/2022), chronic respiratory failure with hypoxia (12/30/2022), idiopathic peripheral autonomic neuropathy (12/29/2022), calcaneal spur, right foot (12/29/2022), pain in right ankle and joints of right foot (11/7/2022), cough, unspecified (6/24/2022), unspecified convulsions (6/24/2022), unspecified dementia (6/24/2022), post COVID (12/19/2022), muscle weakness (11/7/2022), cognitive communication deficit (10/4/2022)
Review of Admission/ 5 day MDS (Minimum Data Set) dated 7/1/2022 revealed BIMS (Brief Interview of Mental Status): 3 out of 15 indicating severe impairment. Review of Resident #5 MDS functional status revealed Resident #5 required extensive assistance with two person physical assistance for bed mobility, transfer and toilet use. Further review of Resident #5 Functional Status revealed Resident #5 was not steady, only able to stabilize with staff assistance during balance during transitions and walking.
Review of Quarterly MDS dated [DATE] revealed BIMS: 6 out of 15 indicating severe impairment. Review of Resident #5 functional status revealed Resident #5 required supervision with one person physical assistance for bed mobility, limited assistance with one person physical assist with transfers, walk in room, locomotion on unit/ off unit, dressing and toilet use. Further review of Resident #5 Functional Status revealed Resident #5 was not steady, only able to stabilize with staff assistance during balance during transitions and walking.
Review of Resident #5 care plan revealed Resident #5 was at risk for falls r/t confusion with interventions in place including follow facility fall protocol.
Review of Resident #5 Incident Reports revealed Resident #5 had falls on the following dates 7/6/2022, 9/2/2022, 9/8/2022, and 1/30/2023.
Review of Fall Assessments failed to reveal a fall assessment was completed after Resident #5 had falls on 7/6/2022, 9/2/2022, 9/8/2022, and 1/30/2023.
During an interview on 2/15/2023 at 3:00 PM S3 MDS nurse reported fall screen/ assessments should be completed by the floor nurse after a resident have a fall.
During an interview on 2/16/2023 at 9:20 AM S2 DON (Director of Nursing) reported fall assessments should be done upon admit, significant change, quarterly and after a resident have a fall. S2 DON reviewed Resident #5 fall assessments and reported fall assessments were not done after Resident #5 had falls on 7/6/2022, 9/2/20222, 9/8/2022, and 1/30/2023.
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?"
- "What safeguards are in place to prevent abuse and neglect?"
- "Can I speak with families of current residents?"
- "What's your RN coverage like on weekends and overnight?"
Our Honest Assessment
Strengths
- • 32% turnover. Below Louisiana's 48% average. Good staff retention means consistent care.
Concerns
- • Multiple safety concerns identified: Federal abuse finding, 4 life-threatening violation(s), 1 harm violation(s), $373,587 in fines. Review inspection reports carefully.
- • 74 deficiencies on record, including 4 critical (life-threatening) violations. These warrant careful review before choosing this facility.
- • $373,587 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 a substantiated abuse finding. Extreme caution advised. Explore alternatives.
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About This Facility
What is Highland Place Rehab And Nursing Center's CMS Rating?
CMS assigns HIGHLAND PLACE REHAB AND NURSING CENTER 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 Highland Place Rehab And Nursing Center Staffed?
CMS rates HIGHLAND PLACE REHAB AND NURSING CENTER's staffing level at 1 out of 5 stars, which is much below average compared to other nursing homes. Staff turnover is 32%, compared to the Louisiana average of 46%. This relatively stable workforce can support continuity of care. RN turnover specifically is 64%, which is notably high. RNs provide skilled clinical oversight, so turnover in this role can affect medical care quality.
What Have Inspectors Found at Highland Place Rehab And Nursing Center?
State health inspectors documented 74 deficiencies at HIGHLAND PLACE REHAB AND NURSING CENTER during 2023 to 2025. These included: 4 Immediate Jeopardy (the most serious level, indicating potential for serious harm or death), 1 that caused actual resident harm, and 69 with potential for harm. Immediate Jeopardy findings are rare and represent the most serious regulatory concerns. They require immediate corrective action.
Who Owns and Operates Highland Place Rehab And Nursing Center?
HIGHLAND PLACE REHAB AND NURSING CENTER is owned by a for-profit company. For-profit facilities operate as businesses with obligations to shareholders or private owners. The facility is operated by WELLINGTON HEALTH CARE SERVICES, a chain that manages multiple nursing homes. With 227 certified beds and approximately 168 residents (about 74% occupancy), it is a large facility located in SHREVEPORT, Louisiana.
How Does Highland Place Rehab And Nursing Center Compare to Other Louisiana Nursing Homes?
Compared to the 100 nursing homes in Louisiana, HIGHLAND PLACE REHAB AND NURSING CENTER's overall rating (1 stars) is below the state average of 2.4, staff turnover (32%) is significantly lower than the state average of 46%, and health inspection rating (1 stars) is much below the national benchmark.
What Should Families Ask When Visiting Highland Place Rehab And Nursing Center?
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?" "What safeguards and monitoring systems are in place to protect residents from abuse or neglect?" "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 substantiated abuse finding on record, and the below-average staffing rating.
Is Highland Place Rehab And Nursing Center Safe?
Based on CMS inspection data, HIGHLAND PLACE REHAB AND NURSING CENTER has documented safety concerns. The facility has 1 substantiated abuse finding (meaning confirmed case of resident harm by staff or other residents). Inspectors have issued 4 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 Highland Place Rehab And Nursing Center Stick Around?
HIGHLAND PLACE REHAB AND NURSING CENTER has a staff turnover rate of 32%, which is about average for Louisiana nursing homes (state average: 46%). Moderate turnover is common in nursing homes, but families should still ask about staff tenure and how the facility maintains care continuity when employees leave.
Was Highland Place Rehab And Nursing Center Ever Fined?
HIGHLAND PLACE REHAB AND NURSING CENTER has been fined $373,587 across 2 penalty actions. This is 10.1x the Louisiana average of $36,815. 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 Highland Place Rehab And Nursing Center on Any Federal Watch List?
HIGHLAND PLACE REHAB AND NURSING CENTER is not on any federal watch list. The most significant is the Special Focus Facility (SFF) program, which identifies the bottom 1% of nursing homes nationally based on persistent, serious quality problems. Not being on this list means the facility has avoided the pattern of deficiencies that triggers enhanced federal oversight. This is a positive indicator, though families should still review the facility's inspection history directly.