GRACE NURSING HOME
For profit - Corporation
128 Beds
Independent
Data: November 2025
1 Immediate Jeopardy citation
Trust Grade
8/100
#127 of 264 in LA
Last Inspection: October 2024
Within standard 12-15 month inspection cycle. Federal law requires annual inspections.
Overview
Grace Nursing Home in Slaughter, Louisiana has received a Trust Grade of F, indicating significant concerns about the quality of care provided. Ranking #127 out of 264 facilities in Louisiana places it in the top half, but this is misleading given the overall poor performance. The facility is currently improving, with issues decreasing from 13 in 2024 to 4 in 2025, but it still has a long way to go. Staffing is a mixed bag; while turnover is at 44%-slightly below the state average-there is less RN coverage than 92% of facilities in Louisiana, which raises concerns about the level of medical attention residents receive. Notably, there have been serious incidents, such as a resident being left outside overnight without care and another suffering a fracture due to improper transfer methods, alongside multiple issues related to food safety and hygiene. Families should weigh these strengths and weaknesses carefully while considering this facility for their loved ones.
- Trust Score
- F
- In Louisiana
- #127/264
- Safety Record
- High Risk
- Inspections
- Getting Better
- Staff Stability ○ Average
- 44% turnover. Near Louisiana's 48% average. Typical for the industry.
- Penalties ✓ Good
- $53,262 in fines. Lower than most Louisiana facilities. Relatively clean record.
- Skilled Nurses ⚠ Watch
- Each resident gets only 6 minutes of Registered Nurse (RN) attention daily — below average for Louisiana. Fewer RN minutes means fewer trained eyes watching for problems.
- Violations ⚠ Watch
- 42 deficiencies on record. Higher than average. Multiple issues found across inspections.
8/100
Top 48%
Review needed
13 → 4 violations
★★☆☆☆
2.0
Overall Rating
★★☆☆☆
2.0
Staff Levels
★★☆☆☆
2.0
Care Quality
★★☆☆☆
2.0
Inspection Score
↔
Stable
2024: 13 issues
2025: 4 issues
The Good
-
Full Sprinkler Coverage · Fire safety systems throughout facility
-
No fines on record
-
Staff turnover below average (44%)
4 points below Louisiana average of 48%
Facility shows strength in fire safety.
The Bad
2-Star Overall Rating
Near Louisiana average (2.4)
Below average - review inspection findings carefully
Staff Turnover: 44%
Near Louisiana avg (46%)
Typical for the industry
Federal Fines: $53,262
Above median ($33,413)
Moderate penalties - review what triggered them
The Ugly 42 deficiencies on record
1 life-threatening 1 actual harm
Jun 2025
3 deficiencies
1 Harm
SERIOUS
(G)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Actual Harm - a resident was hurt due to facility failures
Free from Abuse/Neglect
(Tag F0600)
A resident was harmed · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews and record reviews, the facility failed to ensure each resident had the right to be free from n...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews and record reviews, the facility failed to ensure each resident had the right to be free from neglect for 1 (#1) of 3 (#1, #2 and #3) sampled residents reviewed for neglect. S3CNA and S4CNA neglected Resident #1 when they failed to verify Resident #1's transfer status prior to transferring Resident #1, who required mechanical lift for transfer.
This deficient practice resulted in actual physical harm on 05/13/2025 at approximately 12:30 p.m., when S3CNA and S4CNA transferred Resident #1, who required a mechanical lift, by using a draw sheet without verifying what type of transfer assistance Resident #1 required. Following the transfer, Resident #1 yelled out in pain and an x-ray of the left shoulder was ordered. Resident #1 was diagnosed with a Closed Displaced Fracture of Proximal End of Left Humerus and was sent to the local emergency room for evaluation and treatment. After returning to the facility, Resident #1 continued to have pain and required her left arm to remain in a sling.
Findings:
Review of the facility's policy titled Identifying Neglect with a revision date of 09/2022, revealed the following in part:
Policy Interpretation and Implementation:
4. Neglect occurs when the facility is aware of, or should have been aware of, goods or services that a resident requires but the facility fails to provide them and this has resulted in (or may result in) physical harm, mental anguish or emotional distress.
7. Neglect of goods or services may occur when staff are aware, or should be aware, of residents' care needs, based on assessment and care planning, but are unable to meet the identified needs due to other circumstances, such as:
d. staff lack of knowledge of the needs of the resident.
9. Examples of failures to provide care and services to the resident that result in neglect include:
f. Failure of staff to implement resident interventions, even when residents are assessed and interventions are identified in the care plan.
Review of Resident #1's Clinical Record revealed she was admitted to the facility on [DATE], with diagnoses which included but were not limited to Parkinson's Disease, Unspecified Osteoarthritis, History of Falling, Presence of Left Artificial Knee Joint and Acquired Absence of Right Leg Below the Knee.
Review of Resident #1's Quarterly MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 05/16/2025, revealed a BIMS (Brief Interview for Mental Status) of 3, which indicated the resident was severely cognitively impaired and her cognitive skills for daily decision making were severely impaired. Further review revealed in Section GG that the resident was dependent on staff for chair/bed transfers.
Review of Resident #1's current care plan revealed a focus problem of self-care deficit related to needs assistance with ADLs, decreased mobility, diagnosis of Parkinsons, and right BKA (below knee amputation). Interventions included the following in part, requires Hoyer lift with 2 staff assistance for transfers.
Review of the nurse's notes dated 05/13/2025 revealed the following in part:
05/13/2025 at 1:46 p.m.: Resident #1 screaming in pain regarding left shoulder. Resident unable to move shoulder without significant pain. Notified Nurse Practitioner, x-ray ordered. Tylenol given. Resident states nothing happened to shoulder, that it just hurts. Resident did get up into chair today and sat up for a few hours. No falls noted. Signed by S5LPN.
05/13/2025 at 4:51 p.m.: See x-ray results. Nurse practitioner notified. Ordered to be sent to emergency room for evaluation and pain management. Signed by S5LPN.
Review of the facility's investigation report revealed in part the following:
05/13/2025
Resident #1 was brought to her room by S3CNA and S4CNA around 12:30 p.m. At this time, she was being transferred to the bed by S3CNA and S4CNA. She began to yell after the transfer. The CNAs reported to nurse the resident was yelling after she was put in bed. The nurse then assessed her and gave her some Tylenol. She notified the Nurse Practitioner who ordered an x-ray. X-ray showed fracture to left humerus. She was sent out acute to emergency room and later returned that night.
05/14/2025
DON and Administrator interviewed S3CNA and S4CNA. It was determined by administration after interviewing both CNAs the fracture happened after lunch when being put to bed. After interviewing both employees, it was determined that they did not transfer her using the Hoyer lift.
Review of the hospital after visit summary dated 05/13/2025, revealed the resident was seen in the emergency department for left arm pain where she was diagnosed with a closed displaced fracture of proximal end of left humerus. Further review revealed she received the following treatment x-ray left Humerus and x-ray of left shoulder. Prescribed Hydrocodone-acetaminophen for pain. She was seen by orthopedic surgery who recommended a sling and follow-up outpatient. Resident is to wear sling until able to follow-up with orthopedic surgery.
On 06/11/2025 at 1:00 p.m., a telephone interview was conducted with S5LPN. She stated she was the nurse assigned to Resident #1 on 05/13/2025 and confirmed Resident #1 had obtained a fracture to her left arm that day after being transferred. She stated she had taken care of the resident since then and Resident #1 complained of pain to her arm periodically. S5LPN said when the resident complained of pain, she administered PRN pain medication as ordered.
On 06/11/2025 at 3:10 p.m., an observation and interview was conducted with Resident #1. The resident was observed lying in bed with a sling to her left arm. Resident #1 stated she hurt her arm but, did not know how. The resident said her arm hurt sometimes, but not right now. When asked if she received any pain medication when her arm hurt she answered yes. Resident #1 was unable to provide any more information due to being cognitively impaired.
On 06/11/2025 at 2:00 p.m., a telephone interview was conducted with S4CNA. She confirmed she assisted S3CNA with transferring Resident #1 on 05/13/2025. She stated that morning she and S3CNA went into Resident #1's room and transferred her from her bed to her wheelchair using a draw sheet. She stated she did not often work with Resident #1 and was not familiar with the type of assistance she required for transfers. She stated normally, when she was unsure of what type of assistance a resident required with transferring, she would ask the nurse, another CNA, or look it up on the kiosk on the wall under tasks or Kardex. She stated after lunch she and S3CNA bought Resident #1 back into her room and used the same draw sheet to transfer her back to the bed. She stated when they moved her back into bed, the resident yelled out in pain. She stated at that time the nurse practitioner was walking down the hall, heard the resident yell, went in the room to assess the resident, and came out saying that the resident complained of left arm pain. S4CNA stated she told Resident #1's nurse about the resident complaining her arm was in pain. She confirmed she had not looked in the system to verify the level of assistance Resident #1 required for transfer prior to transferring her from the bed to her wheelchair and from her wheelchair back to bed with the draw sheet, and should have.
On 06/12/2025 at 9:15 a.m., an interview was conducted with S3CNA. She stated on 05/13/2025 she was pulled to work on Resident #1's hall due to a call in. She stated she had not cared for Resident #1 often and had never gotten her up prior to that day. She stated she and S4CNA transferred Resident #1 using the bed draw sheet from the bed to her wheelchair and she remained in her wheelchair until after lunch. She stated after lunch she and S4CNA brought Resident #1 back to her room and transferred her back into bed from her wheelchair using the draw sheet. She stated when they transferred Resident #1 back to bed, she yelled out in pain. S3CNA stated she reported it to the nurse practitioner, who was in the hallway, and S5LPN. She stated the resident had not complained of pain prior to being transferred back to bed after lunch. She stated if she needed to determine the type of level of assistance a resident required for transfer she would look in the kiosk to verify. She confirmed she did not look at the kiosk to verify Resident #1's transfer status prior to transferring her with the draw sheet and should have. She stated she was not aware Resident #1 required a Hoyer lift for transfer prior to transferring her that day.
On 06/11/2025 at 3:33 p.m., an interview was conducted with S6LPN. She stated she was responsible for completing resident care plans. She reviewed Resident #1's care plan and confirmed the resident required a hoyer lift with 2 staff assistance for transfers. She stated if a resident was care planned for Hoyer lift transfers then she expected staff to transfer the resident using a Hoyer lift with 2 staff assistance.
On 06/12/2025 at 10:48 a.m., an interview was conducted with S2DON. He stated on 05/13/2025 S3CNA and S4CNA told him they had transferred Resident #1 from her wheelchair back into her bed and when they did, she yelled out and stated she was in pain. He stated once the results of the x-ray showed Resident #1's left arm was fractured he began to further investigate the situation. He stated after speaking with both S3CNA and S4CNA, it was determined Resident #1's fracture occurred after lunch when S3CNA and S4CNA transferred Resident #1 from her wheelchair back to bed using a draw sheet. He confirmed Resident #1 required Hoyer lift with 2 staff assist for transfers and staff had not transferred her according to her plan of care and should have. He stated if a resident was care planned for Hoyer lift transfers then he expected staff to transfer the resident using a Hoyer lift with 2 staff assist. He stated if staff did not know what type of assistance a resident required he expected staff to look in the kiosk and verify what type of assistance is required and provide care according to the resident's plan of care. He stated he had not considered what occurred with Resident #1 to be neglect. He stated only S3CNA and S4CNA received in-service training on the proper way to use a hoyer lift and ensuring to look in the kiosk to verify transfer assistance required for residents prior to transfer. He confirmed no monitoring of staff was done after the in-service training was completed.
On 06/12/2025 at 1:50 p.m., an interview was conducted with S1ADM. He stated he did not consider staff failing to transfer Resident #1 according to her care plan and sustaining an injury during improper transfer as neglect. He stated he considered it to be a mistake and stated S3CNA and S4CNA were in-serviced afterwards. He confirmed no monitoring of staff was done after in-service training was completed.
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 review and interviews, the facility failed to ensure an allegation involving neglect was reported to the State S...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to ensure an allegation involving neglect was reported to the State Survey Agency in the required timeframe for 1 (#1) of 3 (#1, #2 and #3) sampled residents reviewed for neglect.
Findings:
Review of the facility's policy titled Abuse Investigation and Reporting with a revision date of 06/2022, revealed the following in part:
Reporting:
1. All alleged violations involving neglect will be reported by the facility Administrator, or his/her designee, to the following persons or agencies:
a. The State licensing/certification agency responsible for surveying/licensing the facility;
2. An alleged violation of neglect will be reported immediately, but not later than:
a. Two (2) hours if the alleged violation involves abuse OR has resulted in serious bodily injury; or
b. Twenty-four (24) hours if the alleged violation does not involve abuse AND has not resulted in serious bodily injury.
Review of the facility's policy titled Identifying Neglect with a revision date of 09/2022, revealed the following in part:
Policy Interpretation and Implementation:
4. Neglect occurs when the facility is aware of, or should have been aware of, goods or services that a resident requires but the facility fails to provide them and this has resulted in (or may result in) physical harm, mental anguish or emotional distress.
7. Neglect of goods or services may occur when staff are aware, or should be aware, of residents' care needs, based on assessment and care planning, but are unable to meet the identified needs due to other circumstances, such as:
d. staff lack of knowledge of the needs of the resident.
9. Examples of failures to provide care and services to the resident that result in neglect include:
f. Failure of staff to implement resident interventions, even when residents are assessed and interventions are identified in the care plan.
Review of Resident #1's Clinical Record revealed she was admitted to the facility on [DATE], with diagnoses which included but were not limited to Parkinson's Disease, Unspecified Osteoarthritis, History of Falling, Presence of Left Artificial Knee Joint and Acquired Absence of Right Leg Below the Knee.
Review of Resident #1's Quarterly MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 05/16/2025, revealed a BIMS (Brief Interview for Mental Status) of 3, which indicated the resident was severely cognitively impaired. Further review revealed in Section GG that the resident was dependent on staff for chair/bed transfers.
Review of the facility's investigation report revealed in part the following:
05/13/2025
Resident #1 was brought to her room by S3CNA and S4CNA around 12:30 p.m. At this time, she was being transferred to the bed by S3CNA and S4CNA. She began to yell after the transfer. The CNAs reported to nurse the resident was yelling after she was put in bed. The nurse then assessed her and gave her some Tylenol. She notified the Nurse Practitioner who ordered an x-ray. X-ray showed fracture to left humerus. She was sent out acute to emergency room and later returned that night.
05/14/2025
DON and Administrator interviewed S3CNA and S4CNA. It was determined by administration after interviewing both CNAs the fracture happened after lunch when being put to bed. After interviewing both employees, it was determined that they did not transfer her using the Hoyer lift.
Review of the facility's self-reported incidents to the state agency revealed no entries related to Resident #1's incident on 05/13/2025.
Review of the hospital after visit summary dated 05/13/2025, revealed the resident was seen in the emergency department for left arm pain where she was diagnosed with a closed displaced fracture of proximal end of left humerus.
On 06/11/2025 at 2:00 p.m., a telephone interview was conducted with S4CNA. She confirmed she assisted S3CNA with transferring Resident #1 on 05/13/2025. She stated she did not often work with Resident #1 and was not familiar with the type of assistance she required for ADLs or transfers. She stated normally, when she was unsure of what type of assistance a resident required with transferring, she would ask the nurse, another CNA or look it up on the kiosk on the wall under tasks or Kardex. She stated after lunch she and S3CNA brought Resident #1 back into her room and used a draw sheet to transfer her back to the bed. She stated when they moved her back into bed, she yelled out in pain. She confirmed she had not looked in the system to verify the level of assistance Resident #1 required for transfer prior to transferring her and should have.
On 06/12/2025 at 9:15 a.m., an interview was conducted with S3CNA. She stated on 05/13/2025 she was pulled to work on Resident #1's hall due to a call in. She stated she had not cared for Resident #1 often and had never gotten her up prior to that day. She stated she and S4CNA transferred Resident #1 using the bed draw sheet after lunch. She stated when they transferred Resident #1 back to bed, she yelled out in pain. She stated if she needed to determine the type of level of assistance a resident required for transfer she would look in the kiosk to verify. She confirmed she did not look at the kiosk to verify Resident #1's transfer status prior to transferring her with the draw sheet and should have. She stated she was not aware Resident #1 required a Hoyer lift for transfer prior to transferring her that day. She confirmed failing to look up the correct way to transfer the Resident and the resident sustaining an injury at transfer was considered neglect.
On 06/12/2025 at 10:48 a.m., an interview was conducted with S2DON. He stated on 05/13/2025 S3CNA and S4CNA told him they had transferred Resident #1 from her wheelchair back into her bed and when they did, she yelled out and stated she was in pain. He stated once the results of the x-ray showed Resident #1's left arm was fractured he began to further investigate the situation and had notified S1ADM. He stated after speaking with both S3CNA and S4CNA, it was determined Resident #1's fracture occurred after lunch when S3CNA and S4CNA transferred Resident #1 from her wheelchair back to bed using a draw sheet. He confirmed Resident #1 required Hoyer lift with 2 staff assist for transfers and staff had not transferred her according to her plan of care and should have. He stated he had not considered what occurred with Resident #1 to be neglect. He stated the Administrator was responsible for reporting incidents of alleged neglect to the state survey agency.
On 06/12/2025 at 1:50 p.m., an interview was conducted with S1ADM. He stated he was responsible for reporting any allegations of neglect, to the State Survey Agency within 2 hours. He stated S2DON had notified him of the incident that occurred on 05/13/2025 the day it occurred. He stated he did not consider staff failing to transfer Resident #1 properly according to her care plan and sustaining an injury during improper transfer as neglect. He stated he considered it to be a mistake. He confirmed he had not reported the incident that occurred with Resident #1 to the State Survey Agency.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Comprehensive Care Plan
(Tag F0656)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to implement a comprehensive person-centered care plan for 1 (#1) of ...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to implement a comprehensive person-centered care plan for 1 (#1) of 3 (#1, #2 and #3) residents reviewed in the sample. The facility failed to ensure Resident #1 was transferred properly using the mechanical lift with two person assistance.
Findings:
Review of Resident #1's Clinical Record revealed she was admitted to the facility on [DATE], with diagnoses which included but were not limited to Parkinson's Disease, Unspecified Osteoarthritis, History of Falling, Presence of Left Artificial Knee Joint and Acquired Absence of Right Leg Below the Knee.
Review of Resident #1's Quarterly MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 05/16/2025, revealed a BIMS (Brief Interview for Mental Status) of 3, which indicated the resident was severely cognitively impaired and her cognitive skills for daily decision making were severely impaired. Further review revealed in Section GG that the resident was dependent in chair/bed transfers.
Review of Resident #1's current care plan revealed a focus problem of self-care deficit related to needs assistance with ADLs, decreased mobility, diagnosis of Parkinsons, and right BKA (below knee amputation). Interventions included the following in part, requires Hoyer lift with 2 staff assistance for transfers.
On 06/11/2025 at 2:00 p.m., a telephone interview was conducted with S4CNA. She confirmed she assisted S3CNA with transferring Resident #1 on 05/13/2025. She stated that morning she and S3CNA went into Resident #1's room and transferred her from her bed to her wheelchair using a draw sheet. She stated she did not often work with Resident #1 and was not familiar with the type of assistance she required for ADLs or transfers. She stated normally, when she was unsure of what type of assistance a resident require with transferring, she would ask the nurse, another CNA or she would look it up on the kiosk on the wall under tasks or Kardex. She stated after lunch she and S3CNA bought Resident #1 back into her room and used the same draw sheet to transfer her back to the bed. She confirmed she had not looked in the system to verify the level of assistance Resident #1 required for transfer prior to transferring her from the bed to her wheelchair and from her wheelchair back to bed with the draw sheet, and should have.
On 06/12/2025 at 9:15 a.m., an interview was conducted with S3CNA. She stated on 05/13/2025 she was pulled to work on Resident #1's hall due to a call in. She stated she had not cared for Resident #1 often and had never gotten her up prior to that day. She stated she and S4CNA transferred Resident #1 using the bed draw sheet from the bed to her wheelchair and she remained in her wheelchair until after lunch. She stated after lunch she and S4CNA brought Resident #1 back to her room and transferred her back into bed from her wheelchair using the draw sheet. She stated if she needed to determine the type of level of assistance a resident required for transfer she would look in the kiosk to verify. She confirmed she did not look at the kiosk to verify Resident #1's transfer status prior to transferring her with the draw sheet and should have. She stated she was not aware Resident #1 required a Hoyer lift for transfer prior to transferring her that day.
On 06/12/2025 at 10:48 a.m., an interview was conducted with S2DON. He stated on 05/13/2025 S3CNA and S4CNA told him they had transferred Resident #1 from her wheelchair back into her bed using a draw sheet. He confirmed Resident #1 required Hoyer lift with 2 staff assist for transfers and staff had not transferred her according to her plan of care and should have. He stated if a resident was care planned for Hoyer lift transfers then he expected staff to transfer the resident using a Hoyer lift with 2 staff assist. He stated if staff did not know what type of assistance a resident required he expected staff to look in the kiosk and verify what type of assistance is required and provide care according to the resident's plan of care.
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
Comprehensive Care Plan
(Tag F0656)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to develop a Comprehensive Person-Centered Care Plan for 1 (#2) of 3 ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to develop a Comprehensive Person-Centered Care Plan for 1 (#2) of 3 (#1, #2, #3) sampled residents reviewed. This was evidenced by the facility failing to ensure Resident #2's Comprehensive Person-Centered Care Plan was accurately updated to reflect his current Physician's Orders.
Findings:
Review of Resident #2's Clinical Record revealed he was admitted on [DATE] with diagnoses including, in part, the following: Dysphagia following Cerebral Infarction and Gastrostomy.
Review of Resident #2's Quarterly Minimum Data Set (MDS) with Assessment Reference Date (ARD) of 02/04/2025 revealed the provider assessed the resident as having a Brief Interview for Mental Status (BIMS) of 2, which indicated the resident had severe cognitive impairment.
Review of Resident #2's current active Physician's Orders revealed the following, in part:
Enteral feeds - every shift related to Hyperglycemia, Glucerna 1.5 @ 60 cc/hr continuous per Percutaneous Endoscopic Gastrostomy (PEG) with 40ml/hr flush (Start date 12/29/2024)
NPO Diet, NPO texture (Start date 04/20/2024)
Review of Resident #2's current Care Plan revealed the following, in part:
Focus: Potential for alteration in nutrition related to PEG tube - at risk for aspiration: NPO: Formula changed to Glucerna 1.5 @ 60 ml/hr with 60 m/hr water flush.
Intervention: Administer medications as ordered
Focus: Preference for customary routines
Interventions: Allow resident to have snacks between meals.
On 04/01/2025 at 12:56 p.m., an interview was conducted with S2LPN. She stated she and one other nurse were responsible for resident care plans. She reviewed Resident #2's Physician's Orders and current Care Plan and confirmed the order for 60 ml/hr water flush did not reflect the current care plans 40ml/hr water flush and Resident #2's Care Plan Intervention of allowing snacks between meals did not reflect his current NPO Physician's Order. She confirmed Resident #2's care plan should accurately reflect his Physician's Orders and did not.
On 04/01/2025 at 2:06 p.m., an interview was conducted with S1DON. He reviewed Resident #2's current Physician's Orders and current Care Plan. S1DON confirmed the Care Plan did not accurately reflect the Physician's Orders and should have.
Oct 2024
9 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Resident Rights
(Tag F0550)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews, the facility failed to ensure each resident was treated with respect and ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews, the facility failed to ensure each resident was treated with respect and dignity in a manner and in an environment that promoted maintenance or enhancement of his or her quality of life for 1(#50) of 24 residents reviewed in the final sample. The facility failed to ensure Resident #50's urinal was emptied in a timely manner prior to meals being served in the resident's room.
Findings:
Review of Resident #50's Clinical Record revealed he was admitted to the facility on [DATE] with diagnoses which included, Acquired Absence of Right and Left Leg Above the Knee, Anxiety, and Post Traumatic Stress Disorder.
Review of Resident #50's most recent MDS (Minimum Data Set), with an ARD of 09/24/2024, revealed a BIMS (Brief interview for Mental Status) of 15, indicating Resident #50 was cognitively intact.
Review of Resident #50's Progress Notes revealed, in part:
Nutritional Note dated 09/24/24 at 3:00 p.m. - Resident eats all of his meals in his room.
On 10/15/2024 at 9:00 a.m., an observation and interview was made of Resident #50. His urinal was present at his bedside and contained 400 cc of urine. Resident #50 stated the urinal had been there since 6:00 a.m., and staff have not routinely emptied it when they entered his room. He confirmed he had breakfast in his room this morning, with the urinal containing urine present during his meal.
On 10/15/2024 at 11: 15 a.m., an observation was made of Resident #50. His urinal remained at his bedside with 400 cc of urine noted. Resident #50 confirmed it has not been emptied or used since 9:00 a.m. Resident #50 stated he asked for the urinal to be emptied. Resident #50 stated he feels leaving urine during meals is not respectful of his feelings.
On 10/15/2024 at 12:30 p.m., an observation was made of Resident #50 as he was served his lunch tray in his room. His urinal remained at the bedside, in plain sight from the door and to the resident in his bed, with 400 cc of urine noted.
On 10/15/2024 at 12:35 p.m., an interview was conducted with S17CNA. She confirmed she was caring for Resident #50. She stated his urinal with 400 cc of urine had not been emptied on her shift, and should have been. She further confirmed she had served Resident #50 his breakfast and lunch in his room, with the urinal containing urine present at bedside.
On 10/15/2024 at 12:38 p.m., an observation and interview was conducted with S2DON. S2DON confirmed the Resident #50's urinal was hanging on the garbage can at bedside, with 400 cc of urine noted. He further confirmed staff had not emptied the urinal during their shift and should have. S2DON confirmed serving meals to residents with a urinal at the bedside was disrespectful.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Free from Abuse/Neglect
(Tag F0600)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews and interviews, the facility failed to ensure each resident had the right to be free from physical abuse...
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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 each resident had the right to be free from physical abuse by another resident for 1(#28) of 1 sampled resident reviewed for abuse. The facility failed to ensure Resident #28 was free from physical abuse by Resident #100.
Findings:
The undated facility policy, reviewed on 10/16/2024, titled Abuse Prevention Program revealed,
Policy Statement:
Our residents have the right to be free from abuse. This includes freedom from Resident to Resident Abuse.
Policy Interpretation:
As part of the resident abuse prevention, the administration will:
1. Protect residents from abuse by anyone including other residents.
Resident #28
Review of the Clinical Record revealed Resident #28 was admitted to the facility on [DATE].
Review of the Current MDS (Minimum Data Set) revealed Resident #28 had a BIMS (Brief Interview of Mental Status) score of 15, which indicated he was cognitively intact.
On 10/16/2024 at 3:10 p.m., an interview was conducted with Resident #28. He stated on 09/01/2024, his roommate, Resident #100 was sitting by his bed punching and elbowing him. He stated he felt aggravated and scared the incident would happen again. He said he reported this to S3LPN.
Review of S3LPN's Nurses Progress Note for Resident #28 revealed on 09/01/2024 at 10:47 a.m., Resident #28 informed S3LPN that he was awakened during the night to Resident #100 sitting next to his bed punching and elbowing him. Writer spoke to Resident #100 who stated yes I punched him.
Resident #100
Review of the Clinical Record revealed Resident #100 was admitted to the facility on [DATE] with diagnoses, which included Dementia.
Review of the Current MDS revealed Resident #100 had a BIMS of 8, which indicated he was cognitively intact.
Review of the Health Status Note completed by facility staff for Resident #100 dated 09/01/2024 revealed the resident was transferred to the emergency room for evaluation due to aggressive behaviors at 11:00 a.m., and returned to the facility at 1:13 p.m. He was still confused. Resident #100 was educated on physical abuse and staying in his room.
On 10/15/2024 at 1:45 p.m., an interview was conducted with S4LPN. She stated Resident #100 had a history of issues including aggressive behaviors, delusional behaviors, and hallucinations.
On 10/16/2024 at 4:20 p.m., an observation and interview was conducted with Resident #100. He was unable to be interviewed, due to refusal to talk to me.
On 10/16/2024 at 2:40 p.m., an interview was conducted S3LPN. S3LPN stated she was informed on 09/01/2024 by Resident #28 of an incident during the night. S3LPN stated Resident#28 said he woke up to find Resident #100 sitting at his bedside punching and elbowing him. She stated Resident #28 said he was afraid. She stated she spoke to Resident #100 who confirmed the incident. S3LPN stated the incident was reported to S1ADM. She stated Resident #28 was moved to another room. She confirmed there was no additional staff training or other interventions implemented after the incident.
On 10/16/2024 at 3:15 p.m., an interview was conducted with S2DON. S2DON stated on 09/01/2024 Resident #28 and Resident #100 were involved in an altercation. He stated Resident #100 was at the bedside of Resident #28 punching and elbowing him. S2DON confirmed no staff in-service was provided related to this incident. S2DON stated Resident #100 was sent to the hospital for evaluation and Resident #28 was moved to another room. S2DON confirmed Resident#100 punching and elbowing Resident #28 was abuse. S2DON did not report any further interventions.
On 10/16/2024 at 3:30 p.m., an interview was conducted with S1ADM. S1ADM confirmed that he was made aware Resident # 28 was hit by Resident #100 while asleep in his bed. S1ADM stated Resident #28 was moved to another room, and Resident #100 was sent to the emergency room for evaluation. S1ADM did not report any further interventions. He further confirmed that the incident was Resident/Resident abuse.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
PASARR Coordination
(Tag F0644)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to ensure a resident with an identified mental health diagnosis was r...
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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 resident with an identified mental health diagnosis was referred for a Preadmission Screening and Resident Review (PASRR) Level II evaluation as required for 1 (#11) of 3 (#6, #11, and #92) residents reviewed for PASRR.
Findings:
A review of Resident #11's Clinical Record revealed she was admitted to the facility on [DATE] with diagnoses which included Depression. Further review revealed additional medical diagnoses of Brief Psychotic Disorder (onset date of 09/28/2023).
A review of Resident #11's Level 1 PASSR dated 10/24/2022, revealed Resident #11's diagnosis of Brief Psychotic Disorder was not included.
Further review revealed no documented evidence a review had been resubmitted for a Level II evaluation and determination after Resident #11 received a diagnosis of Brief Psychotic Disorder on 09/28/2023.
On 10/15/2024 at 10:45 a.m., an interview was conducted with S16SW. He stated he was responsible for submitting PASRR's for residents in the facility. He stated when a resident acquired a new mental health diagnosis he submits a request to the state agency for a PASRR Level II referral. He reviewed the Level I PASRR on file for Resident #11 dated 10/24/2022. He confirmed Resident #11 had acquired a diagnosis of Brief Psychotic Disorder since the last Resident Review submission. He confirmed a Resident Review form should have been resubmitted for evaluation and determination for Level II services for Resident #11, after the diagnosis of Brief Psychotic Disorder on 09/28/2023 and was not.
On 10/15/2024 at 4:17 p.m., an interview was conducted with S2DON. He was notified of the above findings. He stated he did not know if Resident #11 required a Resident Review form resubmitted for a PASRR Level II referral, following the diagnosis of Brief Psychotic Disorder on 09/28/2023.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0658
(Tag F0658)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, and record review, the facility failed to ensure services provided by the facility met profess...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, and record review, the facility failed to ensure services provided by the facility met professional standards of quality by failing to ensure nursing staff did not leave medications at bedside for 1 (#82) of 24 residents reviewed in final sample.
Findings:
Review of Resident #82's Clinical Record revealed she was admitted to the facility on [DATE]. Further review of Resident #82's quarterly MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 09/13/2024 revealed she had a BIMS (Brief Interview of Mental Status) of 13, indicating she was cognitively intact.
On 10/14/2024 at 8:55 a.m., an observation and interview was conducted with Resident #82 in her room. She had seven pills in a medication cup on her bedside table as well as a 4 ounce cup of liquid supplement. She stated S5LPN gave her medications at the bedside and left her room.
On 10/14/2024 at 9:07 a.m., an interview was conducted with S5LPN in Resident #82's room. She confirmed there were 7 pills in the medication cup and 4 ounces of liquid supplement at resident's bedside. She confirmed she gave Resident #82 her morning medications, but did not observe Resident #82 swallow the medications prior to leaving the room. She further confirmed Resident #82 did not have Physician Orders to self-administer medications, and medications should not have been left at the bedside.
On 10/16/2024 at 3:09 p.m., an interview was conducted with S2DON. He confirmed S5LPN should not have left mediations at the resident's bedside. He further confirmed no medications should be left at the bedside of a resident who is unable to self-administer medications.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Respiratory Care
(Tag F0695)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to provide necessary care and services for the provisi...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to provide necessary care and services for the provision of respiratory care in accordance with professional standards. The facility failed to ensure oxygen tubing and humidifier bottle were labeled for 1 (#2) of 2 (#2 and #75) residents reviewed for oxygen therapy.
Findings:
Review of the facility's policy titled Departmental (Respiratory Therapy), with a revision date of 11/2011, revealed in part:
Purpose:
The purpose of this procedure is to guide prevention of infection associated with respiratory therapy tasks, and equipment among residents and staff.
General Guidelines:
1. Pre-filled water reservoir packs used in respiratory therapy must be dated when opened and discarded every (7) days, or when the water level becomes low.
Steps in the Procedure: Infection Control Considerations Related to Oxygen Administration:
2. [NAME] bottle with date upon opening.
Review of Resident #2's Clinical Record revealed she was admitted to the facility on [DATE] with diagnoses, which included Chronic Respiratory Failure with Hypoxia, Chronic Obstructive Pulmonary Disease, and Obstructive Sleep Apnea.
Review of Resident #2's Physician's Orders revealed the following, in part:
Start date: 01/03/2024: Oxygen at 4 liters per minute via nasal cannula continuously.
On 10/14/2024 at 10:30 a.m., an observation what made of Resident #2 lying in bed wearing her oxygen via nasal cannula. The oxygen tubing nor the humidifier bottle were labeled with date last changed.
On 10/14/2024 at 10:36 a.m., an observation and interview was conducted with S14LPN. She stated resident oxygen tubing and humidification was changed every Sunday. She stated all oxygen tubing and humidifier bottles should be labeled with the date it was changed. S14LPN confirmed Resident #2's oxygen tubing and humidifier bottle was not dated and should have been.
On 10/15/2024 at 4:15 p.m., an interview was conducted with S2DON. He was notified of the observation of Resident #2's oxygen tubing and humidifier bottle not being labeled with a date. He stated the facility's policy was to change all oxygen tubing and humidifier bottles every 7 days on Sunday. He stated oxygen tubing and humidifier bottles should be labeled with the date it was changed. S2DON confirmed Resident #2's oxygen tubing and humidifier bottle should have been labeled with the date it was changed.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Food Safety
(Tag F0812)
Could have caused harm · This affected 1 resident
Based on observation, interviews, and record review, the facility failed to store and prepare food under sanitary conditions. This deficient practice had the potential to affect 121 residents who were...
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Based on observation, interviews, and record review, the facility failed to store and prepare food under sanitary conditions. This deficient practice had the potential to affect 121 residents who were served meals from the facility's kitchen.
Findings:
Review of the facility's policy titled Food Receiving and Storage dated November 2022, revealed in part, the following:
1.
All foods stored in the refrigerator or freezer are covered, labeled and dated.
7. Refrigerated foods are labeled and dated so they are used prior to expiration, frozen, or discarded.
During the initial tour of the facility's kitchen with S11DM on 10/14/2024 at 9:00 a.m., the following observation was made:
Walk-In Cooler:
1 package of block cheese, wrapped in plastic wrap, opened, dated 08/24/2024.
An interview was conducted on 10/14/2024 at 9:30 a.m. with S11DM. She verified the above observation and confirmed the facility failed to store foods under sanitary conditions. She confirmed opened food products should be labeled with date it was opened and an expiration/discard date. She further stated she was responsible for ensuring staff complied with policy.
An interview was conducted on 10/15/2024 at 11:57 a.m. with S12CD. She confirmed opened cheese should have a discard date. She stated the cheese should have had a use-by date of 7 days from opening and it did not.
An interview was conducted on 10/14/2024 at 9:40 a.m. with S1ADM. He confirmed all food storage items should be labeled and dated.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0761
(Tag F0761)
Could have caused harm · This affected multiple residents
Based on observation, record review, and interviews, the facility failed to ensure drugs and biologicals used in the facility were stored in accordance with currently accepted professional principles....
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Based on observation, record review, and interviews, the facility failed to ensure drugs and biologicals used in the facility were stored in accordance with currently accepted professional principles. The facility failed to ensure expired medications were not available for administration to residents on 1 (Med Cart 1) of 4 (Med Cart 1, 2, 3, and 4) medication carts observed.
Findings:
Review of the facility's policy titled Medication Labeling and Storage dated 02/2023 revealed the following:
Medication Storage:
2. Nursing staff was responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner.
An observation was made on 10/14/2024 at 2:37 p.m. with S4LPN of Cart 1. The following was observed:
1 bottle of lubricant eye drops dated 08/21/2024, no expiration date;
1 bottle of eye drops dated 08/10/2024, no expiration date;
1 nasal inhaler with an expiration date of 08/17/2024.
An interview was conducted with S4LPN on 10/14/2024 at 2:40 p.m. She reviewed the aforementioned two bottles of eye drops and stated eye drop medications were only used for 30 days. S4LPN confirmed expired nasal inhaler should have been removed from Med Cart 1 and was not. She confirmed medications were in use.
An interview was conducted with S2DON on 10/14/2024 at 3:00 p.m. He stated staff nurses were responsible for checking medication carts for expired medications. He further stated nurses who administered medications were responsible for checking expiration dates before administering medications. S2DON confirmed the aforementioned two bottles of eye drops were beyond the 30 day use and nasal inhaler was expired, should have been discarded, and had not been.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews, the facility failed to maintain an infection prevention and control progr...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary environment to help prevent the development and transmission of infection for 3 (#35, #107, and #271) of 3 (#35, #107, and #271) residents reviewed for infection control. The facility failed to ensure:
1. Staff implemented appropriate EBP (Enhanced Barrier Precautions) for Resident #107 and #271); and
2. Staff used proper hand hygiene during wound care for Resident #107,
3. Staff used proper infection control technique when providing catheter care for Resident #35.
Findings:
Review of the facility's policy titled Enhanced Barrier Precautions, dated August 2022, revealed the following, in part:
Policy Interpretation and Implementation:
1. EBPs are used as an infection prevention and control intervention to reduce the spread of multi-drug resistant organisms MDRO (Multi-Drug Resistant Organism) to residents.
3. Examples of high- contact resident care activities requiring the use of gown and gloves for EBPs include: c.) transferring.
5. EBPs are indicated (when contact precautions do not otherwise apply) for residents with wounds and/or indwelling medical devices regardless of MDRO colonization.
6. Effective implementation of EBR requires the availability of PPE supplies at the point of care.
1.
Resident #107
Review of Resident #107's Clinical Record revealed he was admitted to the facility on [DATE] with diagnoses which included Pressure Ulcer to Left Heel, Pressure Ulcer to Right Heel Unstageable, Osteomyelitis, and Need for Assistance With Personal Care.
On 10/15/2024 at 12:35 p.m., an observation was conducted of S7CNA's transfer of Resident #107 from a stretcher back into his bed. Resident #107 had an EBP sign and PPE in a caddy on his door. S7CNA failed to don gloves or gown prior to transferring Resident #107.
On 10/15/2024 at 12:40 p.m., an interview was conducted with S7CNA. She confirmed Resident #107 was under Enhanced Barrier Precautions for having wounds, and she transferred Resident #107 without donning gloves or a gown, but should have.
On 10/16/2024 at 3:06 p.m., an interview was conducted with S2DON. S2DON confirmed transferring a resident who was on EBP was considered high-contact patient care and staff should have worn gown and gloves when transferring a resident on Enhanced Barrier Precautions.
Resident #271
Review of Resident #271's Clinical Record revealed he was admitted to the facility on [DATE] with diagnosis of Stable Burst Fracture and Urinary Retention.
On 10/14/2024 at 2:00 p.m., an observation was made of Resident #271 with an indwelling urinary catheter. Resident #271's door had no sign notifying staff or visitors EBP were in place and no PPE supplies were at his door.
On 10/14/2024 at 2:10 p.m., an interview was conducted with S4LPN. S4LPN confirmed there was no EBP Precaution Sign or PPE supplies present for Resident #271, and should have been.
On 10/14/2024 at 2:40 p.m., an interview was conducted with S2DON. S2DON stated residents with urinary catheters should have EBP measures implemented. S2DON further confirmed nursing staff should have implemented EBP on admission, and did not.
2.
Review of facilities policy titled Handwashing/Hand Hygiene, dated August 2019, revealed, in part:
Policy Statement: This facility considers hand hygiene the primary means to prevent the spread of infections.
6. Use of Alcohol-based hand rub containing at least 62% alcohol, or alternatively soap and water for the following situations:
g. before handling clean dressings, gauze pads etc.
k. after handling used dressings
m. after removing gloves
Resident#107
On 10/15/2024 at 3:10 p.m., an observation was conducted of S6LPN performing wound care for Resident #107. S6LPN applied clean gloves removed soiled dressings to bilateral lower extremities. S6LPN removed soiled gloves and applied clean gloves without performing proper hand hygiene. She then cleansed the right heel with wound cleanser, removed soiled gloves and applied clean gloves without performing proper hand hygiene. S6LPN dressed the right heel with a clean dressing, removed soiled gloves and applied clean gloves without performing hand hygiene. S6LPN cleansed left heel with wound cleanser, removed soiled gloves and applied clean gloves without performing proper hand hygiene. S6LPN dressed left heel with a clean dressing, removed soiled gloves and gown, washed hands with soap and water, and left Resident #107's room.
On 10/15/2024 at 3:35 p.m., an interview was conducted with S6LPN. S6LPN confirmed she did not have hand sanitizer in resident's room and did not perform appropriate hand hygiene in between glove changes during Resident #107's wound care. S6LPN confirmed she should have used hand sanitizer or washed her hands with soap and water between glove changes.
On 10/16/2024 at 3:06 p.m., an interview was conducted with S2DON. S2DON confirmed proper hand hygiene was using hand sanitizer or washing hands with soap and water. S2DON confirmed all staff should be performing proper hand hygiene between glove changes.
3.
Review of the facility's policy titled Perineal Care, with a revision date of 02/2018, revealed the following, in part:
Steps in the Procedure
For a male resident:
c. If the resident has an indwelling catheter, gently wash the juncture of the tubing from the urethra down the catheter about 3 inches.
Resident #35
Review of Resident #35's Clinical Record revealed he was admitted to the facility on [DATE] with diagnoses which included, Urinary Tract Infections, Chronic Kidney Disease Stage 3, Acute Cystitis with Hematuria, and Neuromuscular Dysfunction of Bladder.
Review of Resident #35's Physician's Orders revealed the following in part:
Clean indwelling catheter with soap and water daily and as needed.
On 10/16/2024 at 10:32 a.m., an observation was made of S15CNA performing catheter care on Resident #35. [NAME] residue was observed on Resident #35's catheter tubing where the catheter tubing connects to the catheter bag near the resident's knees. S15CNA cleaned Resident #35's catheter tubing, starting at the brown residue near the resident's knees and wiped up the tubing going toward his urethra.
On 10/16/2024 at 10:39 a.m., immediately following the above observation, an interview was conducted with S15CNA. She confirmed she performed Resident #35's catheter care incorrectly using improper technique, and stated she should have cleaned the catheter tubing starting at the catheter insertion site then away from the resident.
On 10/16/2024 at 3:55 p.m., an interview was conducted with S2DON. He stated when performing catheter care on a resident, staff should clean catheter tubing starting at the insertion site then away from the resident, and it is not appropriate to clean the tubing going towards the insertion site.
MINOR
(C)
Minor Issue - procedural, no safety impact
Deficiency F0577
(Tag F0577)
Minor procedural issue · This affected most or all residents
Based on observation, record review, and interview, the facility failed to ensure all surveys during the 3 preceding years, including complaint surveys since the last annual survey, were accessible fo...
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Based on observation, record review, and interview, the facility failed to ensure all surveys during the 3 preceding years, including complaint surveys since the last annual survey, were accessible for residents, family members, legal representatives, and the public's review.
Findings:
An observation was made on 10/14/2024 at 8:35 a.m. of the facility's entrance. There was no facility binder available with Survey results located near the entrance of the facility.
An observation was made on 10/14/2024 at 12:55 p.m. of dining area information display section. There were no previous surveys posted within the facility for residents, family members, legal representatives, or the public to review.
An interview was conducted on 10/14/2024 at 1:15 p.m. with S1ADM. S1ADM verified the facility's survey results binder was not present for public view, and stated it was in his office. He reviewed the facility's Survey results binder and confirmed survey results from preceding annual recertification surveys dated 10/2023, 10/2022, 10/2021 should have been available for public review. S1ADM further confirmed the complaint surveys since the annual recertification survey, dated 08/27/2024 and 09/05/2024, should have been available for public review, and were not.
Sept 2024
3 deficiencies
1 IJ
CRITICAL
(J)
📢 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 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews, the facility failed to protect a resident's right to be free from neglect for 1 (#1) of ...
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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 a resident's right to be free from neglect for 1 (#1) of 4 (#1, #2, #3, and #4) residents reviewed for neglect. The facility failed to ensure an effective system was in place for staff to identify whether a resident was out of the facility on pass or missing, which resulted in Resident #1 being left outside overnight without required care.
This deficient practice resulted in an Immediate Jeopardy (IJ) situation on 08/26/2024 at 5:44 p.m., when Resident #1, a severely cognitively impaired resident who required extensive assistance, self-propelled outside the facility without staff knowledge. From 5:44 p.m. until the next morning at 8:15 a.m., staff assumed the resident was out of the facility on pass with family. When Resident #1 was found, she was lethargic, wet with urine, and her vital signs were pulse 119, blood pressure 155/54, and blood glucose of 287. Resident #1 was transferred to the hospital and admitted for Hypertensive Urgency, Hyponatremia, Dehydration and Mild AKI (Acute Kidney Injury).
S1ADM was notified of the Immediate Jeopardy situation on 08/30/2024 at 5:39 p.m.
The Immediate Jeopardy situation was removed on 08/30/2024 at 8:37 p.m., as confirmed by onsite verification through observations, interviews, and record reviews. The facility implemented an acceptable Plan of Removal (POR) prior to the survey exit.
The deficient practice continued at the potential for more than minimal harm for the remaining 123 residents residing in the facility.
Findings:
Review of the facility policy titled Identifying Neglect, with a revision date of 09/2022, revealed the following, in part:
5. Neglect is defined as the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical pain, mental anguish, or emotional distress. Neglect occurs when the facility is aware of or should have been aware of, goods or services that a resident requires but the facility fails to provide them and this has resulted in (or may result in) physical harm, pain, mental anguish, or emotional distress. Neglect includes cases where the facility's indifference to or disregard for resident care, comfort or safety results in (or could have resulted in) physical harm, pain, mental anguish, or emotional distress.
Review of Resident #1's Clinical Record revealed Resident #1 was admitted to the facility on [DATE] and had diagnoses which included Type 2 Diabetes Mellitus, Essential (Primary) Hypertension, Paroxysmal Atrial Fibrillation, Need For Assistance With Personal Care, and Acquired Absence of Left Leg Below Knee. Further review revealed Resident #1 was transferred to a local hospital on [DATE] and had not returned to the facility.
Review of Resident #1's MDS (Minimum Data Set), with an ARD (Assessment Reference Date) of 07/09/2024, revealed Resident #1 had a BIMS (Brief Interview for Mental Status) of 07, which indicated severe cognitive impairment. Further review revealed Resident #1 was always incontinent of bladder and bowel, and required extensive two person assistance with bed mobility, transfers, and toilet use.
Review of Resident #1's Care Plan revealed the following, in part:
Focus: Alteration in elimination related to incontinent of bowel and bladder
Interventions/Tasks: Assist with personal hygiene and perineal care as needed; Check every 2 hours for dryness.
Focus: Diagnoses Diabetes Mellitus: Potential for hypoglycemia/hyperglycemia
Interventions: Insulin as ordered; Medication as ordered.
Focus: Diagnoses Atrial Fibrillation: At risk for decreased cardiac output.
Interventions: Medications as ordered.
Focus: Diagnosis Hypertension: at risk for fluctuations in blood pressure.
Interventions: Medications as ordered.
Focus: Potential for skin breakdown related to decreased mobility, incontinence.
Interventions: Check for incontinent episode every 2 hours; Encourage frequent position changes.
Review of Resident #1's August 2024 Medication Administration record revealed Resident #1 was not administered Atorvastatin Calcium Oral 40 mg, Insulin Glargine 15 units, Apixaban Oral Tablet 2.5 mg, and
Metoprolol Tartrate Oral Tablet 50 mg as ordered on 08/26/2024 at 8:00 p.m. Further review revealed Resident #1 was not administered Diltiazem HCI ER Beads Capsule Extended Release 24 Hour 300 mg, Lisinopril Oral Tablet 5 mg, Synthroid Oral Tablet 25 mcg, Apixaban Oral Tablet 2.5 mg, and Metoprolol Tartrate Oral Tablet 50 mg as ordered on 08/27/2024 at 7:00 a.m.
Review of Resident #1's Incident Report dated 08/27/2024 at 9:00 a.m. revealed Resident #1 was found outside by staff around 8:30 a.m. and sent to the hospital to be evaluated. The incident investigation revealed the LPN and CNA thought Resident #1 was out of the facility on pass with family.
Review of Resident #1's Nursing Progress Notes revealed the following, in part:
08/27/2024 at 6:30 a.m., Upon S6LPN making rounds, she observed Resident #1's bed was empty and continued to make rounds.
08/27/2024 7:50 a.m., S6LPN attempted to locate Resident #1 for morning medications. CNAs nor other staff were aware of Resident #1's location. S6LPN along with other facility staff members began to look for Resident #1. Resident #1 was located outside sitting in the wheelchair along the enclosed fence line. S6LPN observed Resident #1 was easily aroused per staff. Staff members rolled the resident into the facility to her room. Resident #1's clothes were wet with urine. The treatment nurse stated her bottom is red, but I don't see anything else. S6LPN questioned how did she get outside? Along with how long had she been outside? The resident stated I don't know. Assessment performed per S6LPN vital signs as follows: B/P 155/54; P=119, R=22, Oral Temp =97.8, Blood Glucose=287. Fluids offered and encouraged, resident drinking without difficulty. Resident stated I am tired and sleepy.
Review of the facility's document titled Resident Sign-Out Roster revealed Resident #1 was not signed out of the facility by family on 08/26/2024.
On 08/30/2024 at 2:43 p.m., video footage of Resident #1's incident was reviewed and confirmed with S1ADM, which revealed following:
On 08/26/2024 at 5:44 p.m., another resident opened the door and Resident #1 self-wheeled herself out on the patio. At 6:24 p.m., Resident #1 was observed wheeling her chair down the sidewalk, turned right where the sidewalk intersected, and got her left wheelchair leg stuck in the grass between the fence and side walk. Resident #1 was observed attempting to get her wheelchair unstuck. At around 8:30 p.m., Resident #1 was no longer visible due to darkness. On 08/27/2024 at 6:12 a.m., Resident #1 was observed asleep in her wheelchair and slightly leaned forward. At 8:12 a.m., S9AA came into the footage and at 8:15 a.m., facility staff were attending to Resident #1.
Review of the Prehospital Care Record from a local ambulance company dated 08/27/2024 revealed the following, in part:
On Scene: 9:37 a.m.
Vitals: 9:47 a.m. Blood Pressure 157/46, Pulse: 49, Respirations 18, Blood Sugar 326.
HPI (History of Present Illness) Some time yesterday Resident #1 was left outside and not found until this morning between 8-9 a.m. Resident #1 is very lethargic but arouses easily.
Review of the local hospital records for Resident #1's dated 08/27/2024 revealed the following, in part:
Vitals:
08/27/2024 10:24 a.m., Blood Pressure: 176/74; Pulse: 59
Chief Complaint:
Hyponatremia, Acute Kidney Injury (AKI)
History of Present Illness:
Resident #1 is a [AGE] year old female with a past medical history of Hypertension, Hyperlipidemia, Dementia, BKA (Below Knee Amputation), Diabetes Mellitus, Atrial Fibrillation, and Rheumatoid Arthritis, who presents to this hospital from a local nursing home after being found outside sitting in her wheelchair unattended by a fence. Here in the Emergency Department, labs reveled patient has an AKI with Creatinine of 1.18, Hyponatremia with Sodium 131. She has an elevated blood glucose of 319. Blood pressure was 186/62. Hospital Medicine was called to admit for Hypertensive Urgency, Hyponatremia, Dehydration and Mild AKI.
On 08/30/2024 at 12:30 p.m., an interview was conducted with S12CNA. S12CNA confirmed she worked on 08/26/2024 from 6:00 a.m. to 6:00 p.m. S12CNA stated the last time she saw Resident #1 was around 6:00 p.m. when she was leaving the facility and Resident #1 was visiting with her family.
On 08/30/2024 at 12:06 p.m., an interview was conducted with S5CNA. S5CNA stated staff should check on the residents every 2 hours. S5CNA stated if a resident was not in their room, she would ask the previous shift where the resident was or ask their roommate. S5CNA confirmed she worked the night shift from 6:00 p.m. to 6:00 a.m. on 08/26/2024, and she did not see Resident #1 during her shift. S5CNA stated she started her rounds at 6:00 p.m. and rounded on Resident #1's room around 7:20 p.m. S5CNA stated at that time the resident was not in her room and she asked Resident #1's roommate where Resident #1 was. The roommate told her Resident #1 left the facility with her family. S5CNA stated she reported Resident #1 was with her family to S7LPN. S5CNA stated she thought Resident #1's family had taken her out of the facility for a day when Resident #1 was not in bed the next morning. S5CNA stated she did not know there was a binder for the residents to sign out on pass, and to check if the resident had been signed out. S5CNA confirmed Resident #1 required incontinence care, assistance with dressing, and bed transfers, and confirmed she had not provided care for Resident #1 at any time during her 08/26/2024 shift.
On 08/30/2024 at 11:45 a.m., an interview was conducted S4LPN. S4LPN confirmed she worked on 08/26/2024 from 6:00 a.m. to 10:00 p.m. S4LPN stated on 08/26/2024 she went to Resident #1's room to administer medications around 8:00 p.m. and Resident #1 was not in her room. S4LPN stated she asked S5CNA where Resident #1 was and S5CNA stated Resident #1 was out on pass with her daughter. S4LPN stated Resident #1's daughters were at the facility between lunch and dinner on 08/26/2024. S4LPN stated there was a log book for signing residents out, and she did not check the book to see if Resident #1 had been signed out. S4LPN stated she reviewed the notes in the computer from the previous shift and did not see where Resident #1 had been signed out. S4LPN stated most families will notify staff if the residents will be out all night. S4LPN stated she assumed Resident #1 would return.
On 08/30/2024 at 10:53 a.m., an interview was conducted with S6LPN. S6LPN stated Resident #1 used a wheelchair and could propel it with her arms and upper body. S6LPN stated Resident #1 was forgetful at times, but knew who she was and could tell time with a watch. She stated she worked the morning of 08/27/2024. S6LPN stated Resident #1 was not in her room at 7:00 a.m. and she thought the resident could be in the whirlpool or the dining room. S6LPN confirmed at 7:50 a.m., she realized Resident #1 was missing and staff found Resident #1 outside by the fence in her wheelchair. S6LPN stated Resident #1 she was lethargic, sleepy, and wet with urine. S6LPN stated she did not know how long Resident #1 was outside. S6LPN confirmed she did not administer Resident #1's morning medications on 08/27/2024 at 7:00 a.m. prior to the resident being transferred to the hospital.
On 08/30/2024 at 11:08 a.m., an interview was conducted S9AA. S9AA stated on 08/27/2024 she saw Resident #1 asleep, outside in her wheelchair by the fence. S9AA stated Resident #1's wheelchair wheel had dropped off the sidewalk into a rut between the sidewalk and the grass. S9AA stated Resident #1's pants were soaked with urine from her knees up.
On 08/30/2024 at 12:34 p.m., an interview was conducted with S13WC. S13WC confirmed she worked on 08/27/2024. S13WC stated after the resident was found outside, she and S6LPN brought Resident #1 to her room and conducted a body audit. S13WC stated Resident #1's amputation stump and right leg were swollen, she had redness to her sacrum, and her pants were wet with urine. S13WC stated Resident #1 stated she was tired and could not remember how she got outside or how long she had been out there.
On 08/30/2024 at 2:11 p.m., an interview was conducted with S2DON. S2DON stated on the night of 08/26/2024, S5CNA asked Resident #1's roommate where the resident was. The roommate said Resident #1 was out of the facility on pass with family. S2DON reported S5CNA then reported this to S4LPN. S2DON confirmed neither staff verified if the resident was actually out on pass by checking the sign out log or calling the family. S2DON said he was not sure how long Resident #1 was outside for before being found.
On 08/30/2024 at 2:11 p.m., an interview was conducted with S3ADON. S3ADON stated Resident #1's family had visited the resident on 08/26/2024. S3ADON explained the evening staff presumed the resident was out of the building with family on the evening of 08/26/2024. S3ADON stated staff should have investigated and verified if Resident #1 was actually out on pass. S3ADON stated the situation could have been avoided had staff verified the resident was out of the facility on pass. S3ADON stated the nurse should have checked the sign out log book and/or called the family to verify the resident's location when they could not find a resident. S3ADON stated he did not know how long Resident #1 was outside. S3ADON stated there was a system breakdown when the staff did not verify if Resident #1 was out of the facility which resulted in the resident not receiving the required ADL (Activities of Daily Living) care or medications.
On 08/30/2024 at 2:50 p.m., and interview was conducted with S1ADM. S1ADM stated he became aware Resident #1 had been outside all night around 8:30 a.m. on 08/27/2024. S1ADM stated the CNA reported information to the nurse which was relayed by Resident #1's roommate. He explained the roommate said Resident #1 was out of the facility on pass with family. S1ADM stated the nurse should have checked the sign out binder, called the family, looked for the resident, and notified S3ADON, S2DON and S1ADM. S1ADM confirmed Resident #1 did not receive medications or incontinence care while she was outside.
On 09/03/2024 at 3:15 p.m., an interview was conducted with S7LPN. S7LPN confirmed she came in to work at 10:00 p.m. on 08/26/2024. S7LPN stated when she arrived she was notified by S4LPN and S5CNA that Resident #1 was out of the facility on pass with her family. S7LPN confirmed she did not check the log book to see if Resident #1 was signed out on pass.
On 09/04/2024 at 9:59 a.m., an interview was conducted with S2DON. S2DON reviewed Resident #1's medication administration record and confirmed Resident #1 had not received her 8:00 p.m. medications on 08/26/2024 or her 7:00 a.m. medications on 08/27/2024. S2DON stated the hospital reported the resident to be dehydrated and hypertensive with a low sodium level upon admission.
On 09/03/2024 9:38 a.m., an interview was conducted with S1ADM. S1ADM confirmed Resident #1 was neglected by nursing staff for over 14 hours when the resident was outside.
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 F0575
(Tag F0575)
Could have caused harm · This affected 1 resident
Based on observations and interviews, the facility failed to post the names, addresses, and telephone numbers of all pertinent state agencies and advocacy groups, such as the State Survey Agency and a...
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Based on observations and interviews, the facility failed to post the names, addresses, and telephone numbers of all pertinent state agencies and advocacy groups, such as the State Survey Agency and a statement as to how a resident may file a complaint with the State Survey Agency concerning any suspected violation of state or federal nursing facility regulation. This deficient practice had the potential to affect any of the 123 residents residing in the facility.
Findings:
On 09/03/2024 at 2:00 p.m., a brief tour of the facility revealed no postings of the names, addresses and telephone numbers of all pertinent state agencies and advocacy groups, and/or no postings regarding the process as to how a resident may file a complaint with the State Survey Agency.
On 09/04/2024 at 11:36 a.m., a brief tour of the facility was conducted with S8SS. S8SS confirmed there were no postings of the names, addresses and telephone numbers of all pertinent state agencies and advocacy groups, and/or no postings regarding the process as to how a resident may file a complaint with the State Survey Agency.
On 09/04/2024 at 11:43 a.m., an interview was conducted with S1ADM. S1ADM confirmed there were no postings of the names, addresses and telephone numbers of all pertinent state agencies and advocacy groups, and/or no postings regarding the process as to how a resident may file a complaint with the State Survey Agency.
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 observation of video surveillance, interviews and record review, the facility failed to ensure alleged violations involving neglect were reported to the state survey agency within twenty four...
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Based on observation of video surveillance, interviews and record review, the facility failed to ensure alleged violations involving neglect were reported to the state survey agency within twenty four hours after the allegations were made for 1 (#1) of 4 (#1, #2, #3, and #4) residents reviewed for neglect.
Findings:
Review of the facility policy titled Identifying Neglect, with a revision date of 09/2022, revealed the following, in part:
5. Neglect is defined as the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical pain, mental anguish, or emotional distress. Neglect occurs when the facility is aware of or should have been aware of, goods or services that a resident requires but the facility fails to provide them and this has resulted in (or may result in) physical harm, pain, mental anguish, or emotional distress. Neglect includes cases where the facility's indifference to or disregard for resident care, comfort or safety results in (or could have resulted in) physical harm, pain, mental anguish, or emotional distress.
Review of the facility policy titled Abuse Investigation and Reporting with a revision date of 06/2022, revealed the following, in part:
All reports of resident neglect shall be promptly reported to local, state and federal agencies (as defined by current regulations) and thoroughly investigated by facility management.
Reporting
1. All alleged violations involving neglect will be reported by the facility Administrator, or his/her designee, to the following persons or agencies:
a. The State licensing/certification agency responsible for surveying/licensing the facility;
2. An alleged violation of neglect will be reported immediately, but no later than:
b. Twenty-four (24) hours if the alleged violation does not involve abuse and has not resulted in serious bodily injury.
Review of Resident #1's Incident Report dated 08/27/2024 at 9:00 a.m. revealed Resident #1 was found outside by staff around 8:30 a.m. and sent to the hospital to be evaluated. The incident investigation revealed the LPN and CNA thought Resident #1 was out of the facility on pass with family.
Review of Resident #1's Nursing Progress Notes revealed the following, in part:
08/27/2024 at 6:30 a.m., Upon S6LPN making rounds, she observed Resident #1's bed was empty and continued to make rounds.
08/27/2024 7:50 a.m., S6LPN attempted to locate Resident #1 for morning medications. CNAs nor other staff were aware of Resident #1's location. S6LPN along with other facility staff members began to look for Resident #1. Resident #1 was located outside sitting in the wheelchair along the enclosed fence line. S6LPN observed Resident #1 was easily aroused per staff. Staff members rolled the resident into the facility to her room. Resident #1's clothes were wet with urine. The treatment nurse stated her bottom is red, but I don't see anything else. S6LPN questioned how did she get outside? Along with how long had she been outside? The resident stated I don't know. Assessment performed per S6LPN vital signs as follows: B/P 155/54; P=119, R=22, Oral Temp =97.8, Blood Glucose=287. Fluids offered and encouraged, resident drinking without difficulty. Resident stated I am tired and sleepy.
On 08/30/2024 at 9:47 a.m., an interview was conducted with S1ADM. S1ADM stated there have been no incidents reported to the state agency since last year.
On 08/30/2024 at 2:43 p.m., video footage of Resident #1's incident was reviewed and confirmed with S1ADM, which revealed following:
On 08/26/2024 at 5:44 p.m., another resident opened the door and Resident #1 self-wheeled herself out on the patio. At 6:24 p.m., Resident #1 was observed wheeling her chair down the sidewalk, turned right where the sidewalk intersected, and got her left wheelchair leg stuck in the grass between the fence and side walk. Resident #1 was observed attempting to get her wheelchair unstuck. At around 8:30 p.m., Resident #1 was no longer visible due to darkness. On 08/27/2024 at 6:12 a.m., Resident #1 was observed asleep in her wheelchair and slightly leaned forward. At 8:12 a.m., S9AA came into the footage and at 8:15 a.m., facility staff were attending to Resident #1.
On 08/30/2024 at 2:50 p.m., and interview was conducted S1ADM. S1ADM stated he became aware of the situation with Resident #1 around 8:30 a.m. on 08/27/2024. S1ADM stated staff reported Resident #1 was found outside.
On 09/03/2024 9:38 a.m., an interview was conducted with S1ADM. S1ADM confirmed Resident #1 was neglected by nursing staff for over 14 hours when the resident was outside. S1ADM confirmed he did not report the incident to the state agency. S1ADM confirmed the incident with Resident #1 should have been reported to the state agency.
Jun 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
Deficiency F0700
(Tag F0700)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record review, the facility failed to ensure residents were assessed for risk of entrapmen...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record review, the facility failed to ensure residents were assessed for risk of entrapment from bed rails and obtain informed consent for bed rails for 1 (#1) of 6 (#1, #R4, #R5, #R6, #R7, and #R8) residents identified for having bed rails in use.
Findings:
Review of the facility's undated policy titled Bed Rails, revealed the following:
Policy Interpretation and Implementation
Use of Bed Rails
1. Bed rails are adjustable metal or rigid plastic bars that attach to the bed. They are available in a variety of types, shapes, and sizes.
3. The use of bed rails or side rails is prohibited unless the criteria for use of bed rails have been met, including attempts to use alternatives, interdisciplinary evaluation, resident assessment, and informed consent.
5. If attempted alternatives do not adequately meet the resident's needs the resident may be evaluated for the use of bed rails. This interdisciplinary evaluation includes:
a. an evaluation of the alternatives to bed rails that were attempted and how these alternatives failed to meet the resident's needs;
b. the resident's risk associated with the use of bed rails;
7. The resident assessment also determines potential risks to the resident associated with the use of bed rails, including the following:
(2) A resident or part of his/her body could be caught between rails, the openings of the rails, or between the bed rails and mattress.
8. Before using bed rails for any reason, the staff shall inform the resident or representative about the benefits and potential hazards associated with bed rails and obtain informed consent.
Review of Resident #1's clinical record revealed she was admitted to the facility on [DATE] with diagnoses which included Alzheimer's Disease, Dementia, and Generalized Muscle Weakness.
Review of Resident #1's Quarterly MDS with an ARD of 04/02/2024 revealed the resident had a BIMS of 3, which indicated severe cognitive impairment. Review of Section GG titled Functional Abilities and Goals revealed Resident #1 required partial/moderate staff assistance for bed mobility.
Review of Resident #1's Clinical Record revealed no documentation of an Entrapment Risk Assessment for bed rails. Further review revealed no documentation of a Consent for bed rails.
Review of Resident #1's Nursing Notes revealed the following:
05/12/2024 at 6:15 a.m.: LATE ENTRY for 05/11/2024 at 4:30 a.m. This nurse was on MCU when S6CNA informed this nurse that Resident #1 had a skin tear to her left elbow resulting from Resident #1 holding onto the bed rail while S6CNA was turning her onto her left side during a brief change. This nurse noted that her left mid forearm to fist knuckles on that hand appeared discolored. Signed by: S5LPN
Review of the facility's Incident Investigation Report dated 05/13/2024 at 10:00 a.m. revealed the following:
Statement from Staff Involved: Resident #1's left arm got caught under the bed rail on the bed during a turn. S6CNA did not realize it was there until she saw a skin tear. S6CNA reported the skin tear to S5LPN. S6CNA stated Resident #1 was in bed against the wall on her left side when she went to turn and clean the resident. S6CNA stated she turned her to the left side, she did not realize the left arm was under the hand grip. Signed by: S3ADON
Review of Resident #1's Skin and Wound Report dated 05/13/2024 revealed the following:
Wound #1
Type of Wound: Bruise
Location: Left outer forearm
Dimensions: 15.3 cm x 4.1 cm, Area is 18.5 cm2
Wound #2
Type of Wound: Skin tear
Location: Left outer forearm
Category: Category I: Linear - Linear type (full thickness): Epidermis and dermis are pulled in one layer from supporting structures. The wound is incision-like in appearance.
Dimensions: 9.8 cm x 3.4 cm, Area is 20.6 cm2
Wound Bed: Bleeding, pink or red
Periwound: Non-attached edges; surrounding tissue discoloration black/blue
On 06/04/2024 at 1:50 p.m., an interview was conducted with S8TN. She stated she assessed Resident #1 on 05/13/2024 after she was notified by S3ADON of a new skin tear to her left elbow and bruising to the left hand and arm. She confirmed Resident #1 did have a skin tear to the left elbow and bruising to the left hand and arm.
On 06/05/2024 at 8:32 a.m., an interview was conducted with S6CNA. She stated she went to Resident #1's room around 4:00 a.m. on 05/11/2024 to change Resident #1's brief. She stated Resident #1 had assist bars on her bed. She stated Resident #1's bed was pushed against the wall on the left side with the assist bar attached to the left side of the bed against the wall. She stated Resident #1 was lying on the left side of the bed near the wall and assist bar. She stated when she went to roll Resident #1 to the right side to complete the brief change, Resident #1's left arm was caught on the assist bar and she had a skin tear to her left elbow.
On 06/05/2024 at 9:13 a.m., an interview was conducted with S5LPN. She stated she was notified by S6CNA around 4:30 a.m. on 05/11/2024 that Resident #1 had sustained a skin tear to her left elbow during her brief change. She stated her left arm was caught and her hand was holding on to the assist bar during the turn. She stated she noticed some bruising to Resident #1's left arm. She stated the assist bars were always on Resident #1's bed.
On 06/05/2024 at 11:29 a.m., a telephone interview was conducted with S4RNS. She stated she called S6CNA on 05/11/2024 when it was reported to her Resident #1 had bruising to her left hand, arm and shoulder and a skin tear to the left elbow. S4RNS stated S6CNA was in the room changing Resident #1's brief on 05/11/2023 around 4:00 a.m. or 4:30 a.m. S4RNS stated S6CNA when she was turning her over to her right side, Resident #1's left arm had become tangled in the assist bar on the left side of the bed and caused a skin tear to Resident #1's left elbow.
On 06/05/2024 at 12:12 p.m., an interview was conducted with S3ADON. He stated the facility does not use bed rails, but did use hand grab assist bars for residents. He stated a bed rail was a railing affixed to the side of the bed that can be moved up and down and is half the length or full length of the bed. He stated there was no formal entrapment assessment, consent, or monitoring for residents who use the assist bars.
On 06/05/2024 at 11:10 a.m., an observation was made of an assist bar attached to a bed on the MCU. The assist bar measured 8 inches wide by 15 inches tall and had two metal rungs in the middle length wise which created three openings 6 inches wide by 4.5 inches tall between the metal rungs of the bar.
On 06/05/2024 at 11:05 a.m., an interview was conducted with S7MDS. She stated the facility did not use bed rails. She confirmed there was no consents or entrapment risk assessments performed prior to installation of the assist bars.
On 06/05/2024 at 12:49 p.m., an interview was conducted with S2DON. He stated the facility did used assist bars or hand grabs on resident beds if requested by family and/or staff, as was the case with Resident #1. He stated since the assist bars are put in place by family request, he was not sure if any other interventions had been put into place prior to installation of the assist bar for Resident #1. He stated there was no resident risk assessment completed prior to use of the assist bars. He stated there is no consent completed and signed prior to use of the assist bars. He stated the facility only used one type of assist bars on the resident beds. He confirmed the observed assist bar on a resident bed in the MCU was the assist bar used in the facility.
On 06/05/2024 at 1:05 p.m., an interview was conducted with S1ADM. He stated bed rails were a risk for entrapment. He stated the facility used assist bars.
Dec 2023
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 F0658
(Tag F0658)
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 services were provided to meet quality professional standar...
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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 services were provided to meet quality professional standards for 1 (#4) of 3 (#2, #3, and #4) residents reviewed for falls. The facility failed to ensure Resident #4 was assessed via neurological assessments following unwitnessed falls.
Findings:
Review of the facility's policy titled, Neurological Assessment revealed, in part, the following:
Purpose:
The purpose of this procedure is to provide guidelines for a neurological assessment:
2) when following an unwitnessed fall;
3) subsequent to a fall with a suspected head injury
General Guidelines:
1. Neurological assessments are indicated:
b. Following an unwitnessed fall;
c. Following a fall or other accident/injury involving head trauma
2. When assessing neurological status, always include frequent vital signs.
Review of the facility's policy titled, Assessing Falls and Their Causes revealed, in part, the following:
After a Fall:
6. Observe for delayed complications of a fall for approximately forty-eight (48) hours after an observed or suspected fall, and document findings in the medical record.
Review of Resident #4's Clinical Record revealed he was admitted to the facility on [DATE] with diagnoses which included Generalized Muscle Weakness, Difficulty in Walking, and Cognitive Communication Deficit.
Review of Resident #4's Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 10/24/2023 revealed he had a Brief Interview for Mental Status (BIMS) of 9, which indicated Resident #4 was moderately cognitively impaired.
Review of the facility's Incident Log dated October through December 2023 revealed Resident #4 had falls on 10/14/2023 at 1:40 a.m., 10/17/2023 at 9:00 p.m., 10/18/2023 at 9:26 p.m., 10/23/2023 at 3:59 p.m., 11/07/2023 at 9:00 p.m., and 12/09/2023 at 4:16 a.m.
Review of the facility's Incident Report for Resident #4 dated 10/14/2023 at 1:40 a.m. revealed, in part, the following:
Incident Location: Hallway
Person Preparing Report: S3LPN
Description: Resident found on floor of hall near wheelchair at around 1:40 a.m. by nurse. Resident was sitting on his right hip with his upper body off the floor with his right arm extended and supporting him .
Witnesses: No witnesses found.
Review of Resident #4's Clinical Record revealed no neurological assessments following his unwitnessed fall on 10/14/2023.
Review of the facility's Incident Report for Resident #4 dated 10/17/2023 at 9:00 p.m. revealed, in part, the following:
Incident Location: Dining Room
Person Preparing Report: S3LPN
Description: Alerted by CNA that resident was on floor. Resident was found in the dining room area on his hands and knees crawling out of door way .
Witnesses: No witnesses found.
Review of Resident #4's Clinical Record revealed no neurological assessments following his unwitnessed fall on 10/17/2023.
Review of the facility's Incident Report for Resident #4 dated 10/18/2023 at 9:26 p.m. revealed, in part, the following:
Incident Location: Resident's Room
Person Preparing Report: S4LPN
Description: Informed by another nurse resident has fallen out of w/c in his room. Upon arrival to resident's room resident was noted on the floor laying on his back by his dresser .
Witnesses: No witnesses found.
Review of Resident #4's Clinical Record revealed no neurological assessments following his unwitnessed fall on 10/18/2023.
Review of the facility's Incident Report for Resident #4 dated 10/23/2023 at 3:59 p.m. revealed, in part, the following:
Incident Location: Resident's Room
Person Preparing Report: S5LPN
Description: Nurse was called to residents' room by CNA and found resident lying on floor on his right side .
Witnesses: No witnesses found.
Review of Resident #4's Clinical Record revealed no neurological assessments following his unwitnessed fall on 10/23/2023.
Review of the facility's Incident Report for Resident #4 dated 11/07/2023 at 9:00 p.m. revealed, in part, the following:
Incident Location: Common Area
Person Preparing Report: S2LPN
Description: Resident ambulating without assistance and fell
Witnesses: No witnesses found.
Review of Resident #4's Clinical Record revealed no neurological assessments following his unwitnessed fall on 11/07/2023.
Review of the facility's Incident Report for Resident #4 dated 12/09/2023 at 4:16 a.m. revealed, in part, the following:
Incident Location: Hallway
Person Preparing Report: S6LPN
Description: This nurse was informed per nurse's aide that resident was out of his wheelchair and ambulating when he fell hitting his head on the medication cart.
Review of Resident #4's Clinical Record revealed no neurological assessments following his fall on 12/09/2023.
On 12/21/2023 at 2:15 p.m., an interview was conducted with S2LPN. She stated she was assigned to Resident #4 on 11/07/2023 when he fell. She verified Resident #4's fall was unwitnessed. She stated nurses were required to initiate and document neurological assessments with all unwitnessed falls. She reviewed Resident #4's medical record at that time and confirmed there were no completed neurological assessments for his fall on 11/07/2023 and there should have been.
On 12/21/2023 at 2:53 p.m., an interview was conducted with S5LPN. She stated she was assigned to Resident #4 on 10/23/2023 when he fell. She verified Resident #4's fall was unwitnessed. She stated she was unable to recall if she initiated neurological assessments after Resident #4's fall on 10/23/2023. She confirmed neurological assessments should have been initiated and documented in the electronic medical record. She confirmed if there were no neurological assessments documented then they were not completed.
On 12/21/2023 at 1:55 p.m., an interview was conducted with S1DON. He stated when a resident had a fall and hit their head or had an unwitnessed fall, the nurse should initiate neurological assessments. He confirmed Resident #4 had unwitnessed falls on 10/14/2023, 10/17/2023, 10/18/2023, 10/23/2023, and 11/07/2023, and had a fall and hit his head on 12/09/2023. He reviewed Resident #4's clinical record and confirmed there were no documented neurological assessments for Resident #4's falls on 10/14/2023, 10/17/2023, 10/18/2023, 10/23/2023, 11/07/2023, and 12/09/2023. He stated if neurological assessments were completed by the nurses for the incidents above, he would have been able access them. He confirmed neurological assessments should have been initiated by the nurses for each incident above and they were not.
Sept 2023
12 deficiencies
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0578
(Tag F0578)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews the facility failed to ensure the resident's right to request, refuse and/or discontinue ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews the facility failed to ensure the resident's right to request, refuse and/or discontinue treatment, and to formulate an advanced directive was properly reflected in the resident's record. The facility failed to ensure all records regarding code status consistently reflected the residents wishes for 1 (#7) of 41 residents investigated for code status in the initial pool process .
Findings:
Review of the facility's Advance Directive Policy revealed (in part) the following:
Policy Statement
The resident has the right to formulate an advanced directive, including the right to accept or refuse medical or surgical treatment. Advanced directives are honored in accordance with state law and facility policy.
A review of Resident #7's clinical record revealed she was an [AGE] year-old female admitted to the facility on [DATE] with diagnoses which included Dementia without behavioral disturbance, Generalized Osteoarthritis, Atrial Fibrillation, Type 2 Diabetes Mellitus.
A review of Resident #7's hard medical chart revealed, in part:
No DNR sticker was visible on the Advanced Directive Instructions page.
The Louisiana Physician Orders for Scope of Treatment (LaPost) document dated 08/24/2023 revealed Resident #7 had a Do Not Resuscitate order in place.
A review of Resident #7's Electronic Health Record on 09/05/2023 revealed the following:
Full Code Status 07/23/2023
A review of Resident #7's Significant Change Minimum Data Set with an Assessment Reference Date of 08/14/2023 revealed the following:
Resident #7 had a BIMS of 8, indicating she had moderate cognitive impairment.
There was no update on the Significant Change Minimum Data Set since change in Advanced Directive Status on 08/24/2023.
A review of Resident #7's Care Plan revealed the following:
Problem onset: 09/06/2023
Resident has an advanced directive: do not resuscitate
On 09/06/2023 at 1:40 p.m., an interview was conducted with Resident #7's Daughter and POA. She stated her mother's wishes were to be a DNR due to decline in health and she initiated a LaPost with those wishes on 08/24/2023.
On 09/06/2023 at 1:45 p.m., an interview was conducted with S9LPN. She stated she would refer to the EMR to confirm resident code status. She also stated she would look at the hard chart and the most current LaPost. She confirmed the current EMR order reflected Resident #7 was a Full Code.
On 09/07/2023 at 11: 45 a.m., an interview was conducted with S12Hospice. She stated Resident #7 was admitted to hospice service on 08/29/2023. She stated her initial email with admission documentation indicated Resident #7 had physician's orders for DNR.
On 09/07/2023 at 11: 50 a.m., an interview was conducted with S12DATA. She stated if she needed to check the code status for a resident she would look in the front of the hard chart on their advanced directive instruction sheet. She stated the ward clerk would enter the orders, label the chart, and file the order in the appropriate sleeve for LaPost.
09/07/2023 at 1:45 p.m., an interview was conducted with S16WC. She stated when she obtained a new order for a resident, including LaPost orders she entered them in to the computer, labeled the advanced directive indicator in the hard chart, and then placed the LaPost Order in the chart sleeve with the most current order on the top. She stated she did not recall seeing a new LaPost for Resident #7. She stated if it was in the new order box, she would have entered it into the system.
09/11/2023 at 8:30 a.m., an interview was conducted with S6SW. He stated he initiated the LaPost order on 08/24/2023 for Resident #7 at the request of family. He stated once the order is complete and signed by the physician, it is placed in the new order box on the unit and the ward clerk would enter the orders and file them in the chart. S6SW stated he placed Resident #7's signed LaPost in the new box order on the unit after it was signed by the physician.
On 09/07/2023 at 10:00 a.m., an interview was conducted with S4RN. She confirmed that the care plan related to Advanced Directives for Resident #7 was updated on 09/06/2023 to reflect DNR wishes. She confirmed prior to 09/06/2023, the care plan reflected wishes for full code status. She confirmed the order for DNR was written on 08/24/2023 and was not updated in the Electronic Medical Record and should have been.
On 09/07/2023 at 1:40 p.m., an interview was conducted with S2DON. He stated once a LaPost order is obtained by Admissions, Social Worker, or Nursing Staff, it is then placed in the new order box for the [NAME] Clerk. He confirmed the ward clerk was responsible for order entry in the EMR, labeling the chart, and filing the LAPOST in the hard chart. He further confirmed that the ward clerk did not enter the order in the Electronic Medical Record or file the LaPost in Resident #7's chart, and should have.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Comprehensive Care Plan
(Tag F0656)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to implement a comprehensive care plan for 1 (#52) of 4 (#11, #52, #9...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to implement a comprehensive care plan for 1 (#52) of 4 (#11, #52, #90, and #100) residents reviewed for falls. The facility failed to ensure staff monitored Resident #52 every 90 minutes after a fall.
Findings:
Review of Resident #52's clinical record revealed he was admitted to the facility on [DATE] with diagnoses which included Parkinson's disease, Alzheimer's disease, Vascular Dementia Unspecified Severity without Behavioral Disturbance, Unspecified Convulsions, Morbid Severe Obesity due to Excess Calories, Unspecified Anxiety Disorder, and Insomnia.
Review of Resident #52's MDS with an ARD of 07/02/2023 revealed Resident #52 had a BIMS of 8, which indicated he was moderately cognitively impaired.
Review of the facility's Incident Report for Resident #52 revealed the following, in part:
Incident Type- Fall
Date/Time - 08/19/2023 5:07 a.m.
Incident Description: Summoned to room by CNA. Resident found sitting on the floor at bedside. Resident attempting to transfer unassisted.
Notes: 08/21/2023 -Spoke with resident's wife in regards to events on 08/19/2023, per resident's wife He just thinks he can do things he can't. Staff is to monitor location every 90 minutes. S17LPN
Review of Resident #52's current care plan revealed the following, in part:
Focus: Potential for falls related to history of falls, decreased mobility, medication effects and confusion; Fall 08/19/2023.
Goal: Resident will have no injuries from falls this quarter; Staff will assist resident as needed to eliminate possible falls/injuries this quarter.
Interventions/Tasks: 08/21/2023- monitor resident every 90 minutes
Review of Resident #52's clinical record revealed no documentation of staff rounding on Resident #52 every 90 minutes since 08/21/2023.
On 09/07/2023 at 11:43 a.m., an interview was conducted with S20CNA. She stated she was assigned to Resident #52 and rounded on him every 2 hours. She stated she was not aware of Resident #52 having a fall on 08/19/2023 or the intervention for staff rounding every 90 minutes to prevent falls. She stated there was no task assigned to her in the facility's computer system for documenting rounding every 90 minutes on Resident #52. She confirmed she had not been rounding every 90 minutes on Resident #52.
On 09/07/2023 at 12:25 p.m., an interview was conducted with S8LPN. She stated she was assigned to Resident #52. She stated the staff rounded on Resident #52 every 2 hours. She stated Resident #52 had a history of self-transferring without calling staff for assistance. She stated Resident #52 had a fall on the night shift last month. She reviewed Resident #52's care plan and stated she was not made aware of Resident #52's intervention added on 08/21/2023 for staff rounding every 90 minutes to prevent falls. She stated there was no task assigned to her in the computer system for documenting rounding every 90 minutes on Resident #52. She confirmed she had not rounded every 90 minutes on Resident #52.
On 09/07/2023 at 2:10 p.m., an interview was conducted with S17LPN. She stated Resident #52 had a fall on 08/19/2023. She stated Resident #52 was confused at times and transferred himself without calling staff for assistance. She stated the intervention to increase staff rounding had been added to Resident #52's care plan on 08/21/2023 after his fall on 08/19/2023.
On 09/07/2023 at 2:18 p.m., an interview was conducted with S21RN. She reviewed Resident #52's clinical record and stated Resident #52 had a fall on 08/19/2023. She stated on 08/21/2023, she added staff monitoring every 90 minutes as a fall intervention to Resident #52's care plan. She stated the task to round on Resident #52 every 90 minutes had not been assigned to staff since the intervention was added on 08/21/2023. She confirmed there was no documentation of staff rounding every 90 minutes to prevent falls for Resident #52.
On 09/07/2023 at 2:40 p.m., an interview was conducted with S3ADON. He stated he worked at the facility for one month and the facility was transitioning to a new computer system. He reviewed Resident #52's clinical record and stated staff monitoring every 90 minutes was initiated on 08/21/2023 after the resident's fall on 08/19/2023. He confirmed the task for staff to monitor Resident #52 every 90 minutes had not been assigned, implemented, or documented on by staff.
On 09/07/2023 at 2:45 p.m., an interview was conducted with S5RN. She reviewed the clinical record for Resident #52 and stated no task was assigned for staff to monitor Resident #52 every 90 minutes to prevent falls. She confirmed there was no documentation to ensure 90 minute rounding was completed on Resident #52 since 08/21/2023 and there should have been.
On 09/11/2023 at 9:55 a.m., an interview was conducted with S2DON. He stated S21RN was responsible for updating Resident #52's care plan after a fall. He stated CNA tasks including rounding should be scheduled on their ADL tasks. He stated S3ADON and himself were responsible for reviewing the CNA's documentation. He confirmed there was no documentation of staff rounding every 90 minute on Resident #52 beginning 08/21/2023 and there should have been.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
ADL Care
(Tag F0677)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to ensure 1 (#90) of 3 (#13, #81, and #90) residents r...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to ensure 1 (#90) of 3 (#13, #81, and #90) residents reviewed for activities of daily living received the necessary services to maintain personal hygiene for nail care.
Findings:
Review of the facility's policy titled, Fingernails/ Toenails, Care of revealed the following, in part:
Purpose: The purpose of this procedure are to clean the nail bed, to keep nails trimmed, and to prevent infections.
Preparation
1. Review the resident's care plan to assess for any special needs of the resident.
General Guidelines
1. Nail care includes daily cleaning and regular trimming.
2. Proper nail care can aid in the prevention of skin problems around the nail bed.
4. Trimmed and smooth nails prevent the resident from accidentally scratching and injuring his or her skin.
5. Watch for and report any changes in the color of the skin around the nail bed, blueness of the nails, any signs of poor circulation, cracking of the skin between the toes, any swelling, bleeding, etc.
6. Stop and report to the nurse supervisor if there is evidence of ingrown nails, infections, pain, or if nails are too hard or too thick to cut with ease.
Review of Resident #90's clinical record revealed he was admitted to the facility on [DATE] with diagnoses which included Heart Failure Unspecified, Paroxysmal Atrial Fibrillation, Unspecified Protein-Calorie Malnutrition, Depression Unspecified, Generalized Anxiety Disorder, and Unspecified Pain in Leg.
Review of Resident #90's MDS with an ARD of 06/06/2023 revealed Resident #90 had a BIMS of 11, which indicated he was moderately cognitively impaired.
Review of Resident #90's current care plan revealed the resident had an ADL self-care deficit related to needs assistance with some ADLs. Resident #90's interventions included assisting the resident with ADLs as needed and nail care.
On 09/05/23 at 9:55 a.m., an interview was conducted with Resident #90. He stated his toenails had not been trimmed in months. Resident #90's toenails were observed long, jagged, and extended past the tip of the toes on both feet. A blackened area was noted on the middle of the right great toenail. The left second toenail was thick and curled over the end of the toe. He stated the last time his toenails were trimmed the black spot on his right great toenail was near his skin at the base of the toenail. He stated he needed help from staff to trim his toenails. He stated he did not refuse to have his toenails trimmed.
On 09/06/2023 at 7:45 a.m., an observation was made of Resident #90's toenails. Resident #90's toenails were observed long, jagged and extended past the tip of the toes on both feet. A blackened area was noted on the middle of the right great toenail. The left second toenail was thick and curled over the end of the toe. He stated S19CNA was the last person that trimmed his toenails.
On 09/06/2023 at 1:00 p.m., an interview was conducted with S19CNA. She stated Resident #90 was on hospice and a hospice CNA came to the facility three days a week and bathed him. She stated the facility CNA's were responsible for assessing and trimming the resident's nails about once a week. She stated Resident #90 did not refuse care. She stated it had been a while since she last assessed Resident #90's toenails.
On 09/06/2023 at 1:05 p.m., an observation of Resident #90's toenails was made with S19CNA. She confirmed all ten of Resident #90's toenails were long, jagged, extended pass the tip of his toes and needed to be trimmed. She stated Resident #90's toenails should have been trimmed.
On 09/06/2023 at 1:17 p.m., an interview was conducted with S8LPN. She stated she was assigned to Resident #90 and he was on hospice. She stated Resident #90 was not diabetic and did not refuse care. She stated Resident #90 required staff assistance with nail care that would include trimming, filing, and cleaning of his toenails. She stated the CNA or whoever showered Resident #90, including the hospice aide, should provide nail care. She stated Resident #90 had scheduled weekly body audits and nail care was assessed during the body audit. She reviewed Resident #90's electronic record and confirmed she completed Resident #90's body audit on 08/14/2023. She stated she did not recall if Resident #90's toenails needed to be trimmed. She stated she did not recall when she assessed his toenails after that.
On 09/06/2023 at 1:30 p.m., an observation of Resident #90's toenails was made with S8LPN. She confirmed Resident #90's toenails were jagged, uneven, and extended past the tips of his toes. Resident #90 grimaced and complained of soreness when S8LPN touched his toes during the observation. She stated Resident #90's left second toenail was hard and very thick with a black substance on the nail. She confirmed Resident #90's toenails should have been trimmed.
On 09/06/2023 at 3:00 p.m., a telephone interview was conducted with Resident #90's resident representative. She stated she visited Resident #90 on 09/01/2023 and his toenails were long. She stated Resident #90's toenails had only been trimmed once or twice since he was admitted to the facility.
On 09/06/2023 at 3:16 p.m., a telephone interview was conducted with S12Hospice. She stated she assessed Resident #90 weekly at the facility. She stated the hospice CNA did not provide nail care. She stated she provided nail care to her assigned hospice residents. She stated she assessed Resident #90's toenails last week and noted they were long. She stated some of Resident #90's toenails were thick and it was hard to do much with them. She stated the last time she trimmed Resident #90's toenails was sometime last month. She stated she had not requested a podiatry consult for Resident #90's toenails.
On 09/06/2023 at 1:37 p.m., an interview was conducted with S2DON. He stated the CNA or the nurse should provide nail care for residents. He stated a resident's nails should be assessed during their bath. He stated the facility staff or the hospice aide could provide a resident nail care. He stated the facility nurses should assess resident's nails weekly during body audits. He stated if a resident was not diabetic, the hall nurse or CNA should clean, trim and file the resident's nails.
On 09/06/2023 at 1:40 p.m., an observation of Resident #90's toenails was made with S2DON. He stated Resident #90's toenails were a little long, uneven, and extended past the tip of the toes. He stated some of Resident #90's toenails were too thick for staff to trim safely and would need a professional consult like podiatry. He stated he would have expected staff to address Resident #90's toenails and consult podiatry.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Grievances
(Tag F0585)
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 document and make prompt efforts to resolve grievances for 3 of 3...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews and interviews, the facility failed to document and make prompt efforts to resolve grievances for 3 of 3 (#85, #90, and #267) residents reviewed for grievances.
Findings:
Review of the facility's policy titled, Grievances/Complaints, Filing revealed the following, in part:
Policy: Residents and their representatives have the right to file grievances, either orally or in writing, to the facility staff or to the agency designated to hear grievances (e.g., the state Ombudsman).The Administrator and staff will make prompt efforts to resolve grievances to the satisfaction of the resident and/ or representative.
Policy Interpretation and Implementation:
1. Any resident; family member, or appointed resident representative may file a grievance or complaint concerning care, treatment, behavior of other residents, staff members, theft of property, or any other concerns regarding he or her stay at the facility. Grievances also may be voiced or filed regarding care that has not been furnished.
8. Upon receipt of a grievance and/or complaint, the designee will review and investigate the allegations and submit a written report of such findings to the Administrator within five (5) working days of receiving the grievance and/or complaint.
11. The Administrator will review the findings to determine what corrective actions, if any, need to be taken.
12. The resident, or person filing the grievance and/or complaint on behalf of the resident, will be informed of the findings of the investigation and the actions that will be taken to correct any identified problems.
a. The Administrator, or his or her designee, will make such reports within 5 working days of the filing of the grievance or complaint with the facility.
b. A written summary of the investigation will also be provided to the resident upon request. The summary will ensure that all written grievance decisions include the date the grievance was received, a summary statement of the residents/ residents representative grievances the steps taken to investigate the grievance, a summary of the pertinent findings or conclusions regarding the residents/ resident's representatives concern(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.
Resident #85
Review of Resident #85's clinical record revealed he was admitted to the facility on [DATE] with diagnoses which included Hemiplegia and Hemiparesis following Cerebral Infarction Affecting Right Dominant Side, Chronic Systolic Congestive Heart Failure, Absence Acquired of Left Leg Above the Knee, and Major Depressive Disorder.
Review of Resident #85's MDS with an ARD of 07/28/2023 revealed Resident #85 had a BIMS of 15, which indicated he was cognitively intact.
On 09/05/2023 at 9:20 a.m., an interview was conducted with Resident #85. He stated he had fifty seven dollars cash go missing from his room earlier this year during a hospitalization. He stated he was unsure of the exact month. He stated he notified his family of the missing money who then reported it to S2DON. He stated he had not been notified verbally or in writing of what actions were taken to resolve his concerns.
On 09/06/2023 at 11:22 a.m., a telephone interview was conducted with Resident #85's resident representative. She stated in April 2023, Resident #85 was transferred from the facility to the hospital. She stated she went to the facility to pick up some of his belongings and fifty seven dollars cash. She stated Resident #85 told her he left the cash in his dresser drawer. She stated she only found seventeen cents in Resident #85's dresser drawer. She stated she spoke with S1ADM about the missing money. She stated S1ADM stated he reviewed video footage and so many staff were in and out of his room it was hard to tell if any staff took the money.
Resident #90
Review of Resident #90's clinical record revealed he was admitted to the facility on [DATE] with diagnoses which included Heart Failure Unspecified, Paroxysmal Atrial Fibrillation, Depression Unspecified, and Generalized Anxiety Disorder.
Review of Resident #90's MDS with an ARD of 06/06/2023 revealed Resident #90 had a BIMS of 11, which indicated he was moderately cognitively impaired.
On 09/05/2023 at 10:00 a.m., an interview was conducted with Resident #90. He stated a month after he admitted to the facility his silver ring went missing. He stated he told his family and S18HK the silver ring was missing. He stated he had not been notified verbally or in writing of any actions taken to resolve his concerns.
On 09/06/2023 at 3:00 p.m., a telephone interview was conducted with Resident #90's resident representative. She stated not long after Resident #90 admitted to the facility he reported missing his silver ring. She stated Resident #90 also reported the missing silver ring to a staff member in housekeeping.
On 09/07/2023 at 1:33 p.m., an interview was conducted with S18HK. She stated a while back Resident #90 reported he was missing a silver ring. She stated she searched his room and did not find it. She stated she had notified the CNAs and laundry staff of Resident #90's missing silver ring.
On 09/06/2023 at 3:52 p.m., an interview was conducted with S1ADM. He stated there were no grievances on file for Resident #85 or Resident #90 since December 2022 in regards to missing personal property.
On 09/07/2023 at 3:00 p.m., an interview was conducted with S2DON. He confirmed Resident #85's resident representative reported the resident was missing money from his room. He stated a resident reporting missing personal property or money should be written up as a grievance. He confirmed he did not write up a grievance or conduct an investigation for Resident #85. He confirmed there was no documented grievance on file for Resident #85's report of missing money. S2DON was informed of Resident #90's report of a missing silver ring. He could not recall if Resident #90's silver ring had been reported as missing. He confirmed there was no grievance on file for Resident #90's report of missing a silver ring.
On 09/07/2023 at 3:10 p.m., an interview was conducted with S1ADM. He stated when a resident or resident's family had a complaint, a grievance should be filed, investigated, and a follow up done with the resident and resident's family. He stated he did not always document a grievance when a resident reported a concern or missing item. He stated in April 2023, Resident #85's resident representative reported the resident was missing money from his room. He confirmed he did not have documentation to verify Resident #85's grievance was addressed and resolved. He confirmed Resident #85's report of missing money should have been documented and investigated as a grievance. S1ADM was informed of Resident #90's report of a missing silver ring. He could not recall if Resident #90's silver ring had been reported as missing. He could not provide a grievance for the silver ring Resident #90 reported as missing. He confirmed he did not have documentation to verify Resident #90's grievance was addressed and resolved. He confirmed Resident #90's report of missing a silver ring should have been documented and investigated as a grievance.
Resident #267
Review of Resident #267's clinical record revealed he was admitted to the facility on [DATE] with diagnoses which included Parkinson's disease, Schizoaffective Disorder, Generalized Anxiety Disorder, Pain Unspecified, Generalized Muscle Weakness, Difficulty in Walking, and Need for Assistance with Personal Care.
Review of Resident #267's MDS with an ARD of 08/15/2023 revealed Resident #267 had a BIMS of 15, which indicated he was cognitively intact.
Review of the Grievance Log dated July 2023 to current revealed no recorded grievances for Resident #267.
On 09/06/2023 at 9:32 a.m., an interview was conducted with Resident #267. He stated on 08/31/2023 and 09/04/2023 he went to S1ADM and informed him of a few issues he was having. He stated he informed S1ADM he had not received ice on a regular basis, received night medications late, housekeeping was only partially cleaning his room, and night snacks were not being passed out by staff. He stated he had never received any type of report to inform him of what actions were taken to resolve his concerns.
On 09/07/2023 at 2:18 p.m., an interview was conducted with S1ADM. He stated Resident #267 presented to his office on 08/31/2023 and 09/04/2023 voicing concerns. He stated on both occurrences Resident #267 voiced concerns about medications being passed out late on the night shift, ice not being passed out, and not receiving night time snacks. He confirmed he did not record a grievance for Resident #267's concerns and should have.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0727
(Tag F0727)
Could have caused harm · This affected multiple residents
Based on record review and interviews, the facility failed to ensure the facility had eight consecutive hours per day of registered nurse coverage for 13 days (01/01/2023, 01/07/2023, 01/14/2023, 01/1...
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Based on record review and interviews, the facility failed to ensure the facility had eight consecutive hours per day of registered nurse coverage for 13 days (01/01/2023, 01/07/2023, 01/14/2023, 01/15/2023, 01/21/2023, 01/22/2023, 01/28/2023, 01/29/2023, 02/04/2023, 02/11/2023, 02/12/2023, 02/25/2023, 06/08/2023) of 181 days (01/01/2023 - 06/30/2023) reviewed for registered nurse hours. This deficient practice had the potential to affect any of the 112 residents residing in the facility.
Findings:
Review of the facility's most current Staffing Policy, revealed the following:
Policy Statement
The nursing services department shall be under the direct supervision of a registered or licensed practical/vocational nurse at all times.
Policy Interpretation and Implementation
2. A registered nurse provides services at least eight (8) consecutive hours every 24 hours, seven (7) days a week. RNs may be scheduled more than eight (8) hours depending on the acuity needs of the resident.
Review of the facility's PBJ Staffing Data Report dated 01/01/2023-03/31/2023 and the facility's RN Staffing Report dated 01/01/2023-03/31/2023 provided by S1ADM revealed the facility did not have a registered nurse providing care in the facility on the following dates: 01/01/2023, 01/07/2023, 01/14/2023, 01/15/2023, 01/21/2023, 01/22/2023, 01/28/2023, 01/29/2023, 02/04/2023, 02/11/2023, 02/12/2023, 02/25/2023, and 06/08/2023. S1ADM confirmed the information reported to the PBJ Staffing Data Report was correct.
On 09/07/23 at 12:11p.m., an interview was conducted with S1ADM, he confirmed there was not a Registered Nurse present in the building for eight consecutive hours during the twenty-four hour period on the following dates: 01/01/2023, 01/07/2023, 01/14/2023, 01/15/2023, 01/21/2023, 01/22/2023, 01/28/2023, 01/29/2023, 02/04/2023, 02/11/2023, 02/12/2023, 02/25/2023, and 06/08/2023, and there should have been.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Unnecessary Medications
(Tag F0759)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record reviews, the facility failed to ensure the medication error rate was less than 5% b...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record reviews, the facility failed to ensure the medication error rate was less than 5% by having a medication error rate of 6.9% during the medication administration observation. A total of 29 opportunities were observed, which included 2 medication errors for 2 (#46 and #67) of 6 (#10, #39, #46, #64, #67, and #267) resident's observed during medication pass. This failed practice had the potential to affect any of the 112 residents currently residing in the facility.
Findings:
Review of the facility's policy titled Administering Medications, revealed, in part, the following:
Policy Statement
Medications are administered in a safe and timely manner, and as prescribed.
Policy Interpretation and Implementation
4. Medications are administered in accordance with prescriber orders, including any required time frame.
7. Medications are administered within one (1) hour of their prescribed time, unless otherwise specified (for example, before and after meals orders).
Resident #46:
Review of the Clinical Record for Resident #46 revealed he was admitted to the facility on [DATE] with diagnoses which included Parkinson's Disease, Type 2 Diabetes Mellitus, and Chronic Kidney Disease.
Review of the [DATE] Active Physician's Order Summary for Resident #46 revealed the following:
Novolog 100 units per milliliter inject as per Sliding Scale: if 0-130= 0 units, 131-180= 3 units, 181-240= 6 units, 241-30 0= 8 units, 301-350= 10 units, 351-400= 12 units. 12 units and notify MD, subcutaneously before meals and at bedtime.
On [DATE] at 11:20 a.m., an observation was made of S8LPN administering medications to Resident #46. She did not giving Resident #46 his ordered dose 8 units of Novolog.
On [DATE] at 11:21 a.m., an interview was conducted with S8LPN during morning medication pass. She said Resident #46 did not have Novolog available because it was expired.
Resident #67
Review of the Clinical Record for Resident #67 revealed she was admitted to the facility on [DATE] with diagnoses which included Type 2 Diabetes Mellitus, Peripheral Vascular Disease, and Hyperlipidemia.
Review of the [DATE] Active Physician's Order Summary for Resident #67 revealed the following:
Humalog 100 units per milliliter inject as per Sliding Scale: if 0-70= 0 units, Hypoglycemia protocol: 70-140= 0 units, 150-199=1 units, 200-249= 2 units, 250-299= 3 units, 300-349= 4 units, 350-999 = 5 units notify MD, subcutaneously before meals and at bedtime.
On [DATE] at 11:51 a.m., an observation was made of S8LPN administering medications to Resident #67. She did not give Resident #67 his ordered dose 2 units of Humalog.
On [DATE] at 11:52 a.m., an interview was conducted with S8LPN during morning medication pass. She stated Resident #67 did not have Humalog available because it was expired.
On [DATE] at 4:12 p.m., an interview was conducted with S2DON. He confirmed if a medication is not readily available to administer the nurse should call pharmacy immediately.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0760
(Tag F0760)
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 it was free of significant medication errors for 3 (#51, #...
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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 it was free of significant medication errors for 3 (#51, #89, and #267) of 8 (#10, #39, #46, #51, #64, #67, #89, and #267) residents reviewed for medications.
Findings:
Review of the facility's policy titled Administering Medications revealed the following, in part:
4.) Medications are administered in accordance with prescriber orders, including any required time frame.
7.) Medications are administered within one hour so their prescribed time, unless otherwise specified (for example, before and after meal orders.)
21.) If a drug is withheld, refused, or given at a time other than the scheduled time, the individual administering the medication shall initial and circle the MAR space provided for that drug and dose.
Resident #89
Review of Resident #89's clinical records revealed Resident #89 was admitted on [DATE] with diagnoses which included Hypothyroidism.
Review of Resident #89's annual MDS with an ARD of 07/10/2023 revealed a BIMS of 7 which indicated the resident had severe cognitive impairment.
Review of Resident #89's Physician's Orders for August 2023 revealed the following:
Levothyroxine 125mcg one tablet by mouth daily related to Hypothyroidism, with a start date of 07/16/2023 and a discontinue date of 08/16/2023.
Review of Resident 89's MAR dated August 2023 revealed an active order for Levothyroxine 150mcg one tablet by mouth daily related to Hypothyroidism with a start date of 08/18/2023. The August 2023 MAR further revealed the following:
Levothyroxine 125 mcg one tablet by mouth daily:
08/02/2023 5:00 p.m. - Not Administered
08/05/2023 5:00 p.m. - Not Administered
08/06/2023 5:00 p.m. - Not Administered
08/07/2023 5:00 p.m. - Not Administered
08/08/2023 5:00 p.m. - Not Administered
08/09/2023 5:00 p.m. - Not Administered
08/10/2023 5:00 p.m. - Not Administered
08/11/2023 5:00 p.m. - Not Administered
08/12/2023 5:00 p.m. - Not Administered
08/13/2023 5:00 p.m. - Not Administered
08/14/2023 5:00 p.m. - Not Administered
Review of Resident #89's lab value results revealed the following:
07/05/2023 TSH level- 0.216 µU/ml (low).
08/16/2023 TSH level- 6.557 µU/ml (high).
On 09/11/2023 at 9:29 a.m., an interview was conducted with S7LPN. She reviewed Resident #89's MAR. She confirmed if there were no remarks on the MAR and it was not charted as given, then the medication was not given. She confirmed if Resident #89 did not receive her Levothyroxine, her TSH level would be elevated.
On 09/11/2023 at 11:31 a.m., an interview was conducted with S13NP. She confirmed if Resident #89 did not receive her Levothyroxine this would cause her TSH level to be elevated.
On 09/11/2023 at 1:33 p.m., an interview was conducted with S2DON. He reviewed Resident #89's MAR and confirmed the Levothyroxine was not documented as administered on the aforementioned dates. He stated the medication should have been documented on the MAR if it was administered. He confirmed if the Levothyroxine was not administered this could have contributed to Resident #89's elevated TSH level.
Resident #51
Review of Resident #51's clinical record revealed she was admitted on [DATE] with diagnoses which included Bipolar disorder, Major Depressive Disorder, Anxiety Disorder, and Insomnia.
Review of Resident # 51's MDS with an ARD of 05/17/2023 revealed the resident had a BIMS of 15 which indicated intact cognition.
Review of Resident 51's current Physician's Orders revealed the following:
Start Date: 07/14/2023- Amitriptyline 25mg one tablet by mouth at bedtime
Start Date: 07/14/2023- Melatonin 3mg two tablets by mouth at bedtime.
Review of Resident #51's current Care Plan revealed the following:
Focus: Dx Insomnia: At risk for altered sleep pattern
Goal: Will have optimal amount of sleep this quarter
Intervention/Tasks: medications should be administered as ordered.
Review of Resident #51's MAR and Administration Notes from 08/01/2023 to 09/07/2023 revealed the following:
Amitriptyline 25 mg one tablet by mouth at bedtime
08/04/2023 8:00 p.m. - Administered 9:33 p.m.
08/09/2023 8:00 p.m. - Administered 9:41 p.m.
08/12/2023 8:00 p.m. - Administered 10:58 p.m.
08/14/2023 8:00 p.m. - Administered 9:37 p.m.
08/15/2023 8:00 p.m. - Administered 10:04 p.m.
08/19/2023 8:00 p.m. - Administered 9:58 p.m.
08/23/2023 8:00 p.m. - Administered 9:50 p.m.
08/27/2023 8:00 p.m. - Administered 10:17 p.m.
08/30/2023 8:00 p.m. - Administered 10:12 p.m.
09/01/2023 8:00 p.m. - Administered 10:07 p.m.
09/02/2023 8:00 p.m. - Administered 10:24 p.m.
Melatonin 3mg two tablets by mouth at bedtime
08/04/2023 8:00 p.m. - Administered 9:33 p.m.
08/09/2023 8:00 p.m. - Administered 9:41 p.m.
08/12/2023 8:00 p.m. - Administered 10:58 p.m.
08/14/2023 8:00 p.m. - Administered 9:37 p.m.
08/15/2023 8:00 p.m. - Administered 10:04 p.m.
08/19/2023 8:00 p.m. - Administered 9:58 p.m.
08/23/2023 8:00 p.m. - Administered 9:50 p.m.
08/27/2023 8:00 p.m. - Administered 10:17 p.m.
08/30/2023 8:00 p.m. - Administered 10:12 p.m.
09/01/2023 8:00 p.m. - Administered 10:07 p.m.
09/02/2023 8:00 p.m. - Administered 10:24 p.m.
On 09/06/2023 at 9:11 a.m., an interview was conducted with Resident #51. Resident #51 stated she had issues with receiving her medications late. Resident #51 stated she received medications for insomnia to help her sleep. Resident #51 stated she had received her sleeping medications after 11:00 p.m. on one occasion. Resident #51 stated this usually occurred when the Rent a Nurse worked. Resident #51 stated she became anxious and restless when she did not receive her medications as scheduled.
Resident #267
Review of Resident #267's clinical record revealed he was admitted on [DATE] with diagnoses which included Parkinson's disease, Schizoaffective Disorder, Generalized Anxiety Disorder, Pain Unspecified, Generalized Muscle Weakness, Difficulty in Walking, and Need for Assistance with Personal Care.
Review of Resident # 267's MDS with an ARD of 08/15/2023 revealed the resident had a BIMS of 15, which indicated intact cognition.
Review of Resident 267's current Physician's Orders revealed the following:
Start Date: 08/10/2023- Mirapex 0.25mg one tablet by mouth three times a day
Start Date: 08/10/2023- Amantadine 100mg one capsule by mouth three times a day
Review of Resident 267's MAR and Administration Notes from 08/01/2023 to 08/31/2023 revealed the following:
Mirapex 0.25mg one tablet by mouth three times daily
08/12/2023 08:00 p.m. - Administered 11:08 p.m.
08/13/2023 08:00 p.m. - Administered 9:19 p.m.
08/14/2023 08:00 p.m. - Administered 10:29 p.m.
08/15/2023 08:00 p.m. - Administered 11:16 p.m.
08/17/2023 01:00 p.m. - Administered 2:34 p.m.
08/19/2023 01:00 p.m. - Administered 3:06 p.m.
08/19/2023 08:00 p.m. - Administered 10:49 p.m.
08/21/2023 08:00 a.m. - Administered 9:27 a.m.
08/21/2023 08:00 p.m. - Administered 10:33 p.m.
08/22/2023 01:00 p.m. - Administered 2:39 p.m.
08/23/2023 08:00 p.m. - Administered 12:38 p.m.
08/24/2023 08:00 p.m. - Administered 10:07 p.m.
08/25/2023 08:00 a.m. - Administered 9:28 a.m.
08/27/2023 01:00 p.m. - Administered 2:39 p.m.
08/27/2023 08:00 p.m. - Administered 10:07 p.m.
08/28/2023 01:00 p.m. - Administered 2:58 p.m.
08/28/2023 08:00 p.m. - Administered 9:35 p.m.
08/29/2023 08:00 p.m. - Administered 10:25 p.m.
08/30/2023 01:00 p.m. - Administered 2:38 p.m.
08/30/2023 08:00 p.m. - Administered 10:38 p.m.
08/31/2023 08:00 a.m. - Administered 9:52 a.m.
08/31/2023 08:00 p.m. - Administered 1:00 a.m.
Amantadine 100mg one capsule by mouth three times daily
08/12/2023 08:00 p.m. - Administered 11:08 p.m.
08/13/2023 08:00 p.m. - Administered 9:19 p.m.
08/14/2023 08:00 p.m. - Administered 10:29 p.m.
08/15/2023 08:00 p.m. - Administered 11:16 p.m.
08/17/2023 01:00 p.m. - Administered 2:34 p.m.
08/19/2023 01:00 p.m. - Administered 3:06 p.m.
08/19/2023 08:00 p.m. - Administered 10:49 p.m.
08/21/2023 08:00 a.m. - Administered 9:27 a.m.
08/21/2023 08:00 p.m. - Administered 10:33 p.m.
08/22/2023 01:00 p.m. - Administered 2:39 p.m.
08/23/2023 08:00 p.m. - Administered 12:38 p.m.
08/24/2023 08:00 p.m. - Administered 10:07 p.m.
08/25/2023 08:00 a.m. - Administered 9:28 a.m.
08/27/2023 01:00 p.m. - Administered 2:39 p.m.
08/27/2023 08:00 p.m. - Administered 10:07 p.m.
08/28/2023 01:00 p.m. - Administered 2:58 p.m.
08/28/2023 08:00 p.m. - Administered 9:35 p.m.
08/29/2023 08:00 p.m. - Administered 10:25 p.m.
08/30/2023 01:00 p.m. - Administered 2:38 p.m.
08/30/2023 08:00 p.m. - Administered 10:38 p.m.
08/31/2023 08:00 a.m. - Administered 9:52 a.m.
08/31/2023 08:00 p.m. - Administered 1:00 a.m.
On 09/06/2023 at 9:32 a.m., an interview was conducted with Resident #267. Resident #267 stated he suffered from Parkinson's disease which required him to take medications three times daily to help control symptoms related to the disease process. Resident #267 stated he received his medications from the night nurse late on numerous occasions. Resident #267 stated when he received his medications late, he exhibited increased involuntary shaking. Resident #267 stated he felt helpless and unable to maintain his independence with activities of daily living when these symptoms were present.
On 09/11/2023 at 11:34 a.m., an interview was conducted with S2DON. He confirmed medication could be given one hour before or one hour after the scheduled time. S2DON reviewed and confirmed the documentation from Resident #51's medication audit report revealed Melatonin 3 mg and Amitriptyline 25 mg were administered late on the aforementioned dates. He reviewed and confirmed the documentation from Resident #267's medication audit report revealed Mirapex 0.25 mg and Amantadine 100mg were administered late on the aforementioned dates. S2DON further confirmed medications should be administered in a timely manner and as ordered by the physician, and this had not been done.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0761
(Tag F0761)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations and interviews, the facility failed to ensure that drugs were stored and labeled properly in accordance wi...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations and interviews, the facility failed to ensure that drugs were stored and labeled properly in accordance with current accepted professional principles. The facility failed to ensure:
1.
Expired medications were not available for administration to residents in Medication Storage room [ROOM NUMBER] and Medication Storage room [ROOM NUMBER];
2.
Medications were labeled with an open date for medication on Carts A, B, C, and D; and
3.
Medication Cart B was locked when unattended.
Findings:
Review of the facility's policy titled Medication Labeling and Storage, revealed, in part, the following:
Policy Statement
The facility stores all medications and biologicals in locked compartments under proper temperature, humidity and light controls. Only authorized personnel have access to keys.
Policy Interpretation and Implementation
Medication Storage
1. Medications and biologicals are stored in the packaging, containers or other dispensing systems in which they are received. Only the issuing pharmacy is authorized to transfer medications between containers.
Medication Labeling
5. Multi-dose vials that have been opened or accessed (e.g., needle punctured) are dated and discarded within 28 days unless the manufacturer specifies a shorter or longer date for the open vial.
Review of the facility's policy titled Administering Medications, revealed, in part, the following:
Policy Statement
Medications are administered in a safe and timely manner, and as prescribed.
Policy Interpretation and Implementation
19. During administration of medications, the medication cart is kept closed and locked when out of sight of medication nurse or aide .The cart must be clearly visible to the personnel administering medications, and all outward sides must inaccessible to residents or others passing by.
1.
On 09/06/2023 at 9:21 a.m., a review of medications in Medication room [ROOM NUMBER] with S11Data revealed the Emergency kit contained the following:
5-vials of Zofran 4mg/2mL with an expiration date of 07/2023.
The refrigerator revealed the following expired medications:
4-Tylenol 650 mg suppositories with an expiration date of 07/2023.
4-Biscolax 10 mg suppositories with an expiration date of 10/2022.
1-bottle of Vancomycin 50 mg/mL solution was undated with an expiration date of 07/24/2023.
On 09/06/2023 at 9:24 a.m., a review of medications in Medication room [ROOM NUMBER] with S17LPN revealed the following:
4-Preparation-H suppositories with an expiration date of 07/2023.
4-Biscolax 10 mg suppositories with an expiration date of 10/2021.
ER Box revealed:
3-vials of Zofran 4mg/2mL with an expiration date of 07/2023.
1-5 mL syringe of injectable Heparin with an expiration date of 06/2022, and was also not on the Emergency kit provided list.
2.
On 09/06/2023 at 8:40 a.m., a review of medications on Cart B with S8LPN revealed the following:
3-vials of Lantus insulin were opened and undated.
2-vials of Humalog 100 insulin were opened and undated.
1-vial of Novolog 100 insulin was opened and undated.
1-vial of Humulin-R 100 insulin was opened and undated.
On 09/06/2023 at 9:17 a.m., a review of medication on Cart C with S10LPN revealed:
1-vial of Lantus insulin was opened and undated.
On 09/06/2023 at 9:21 a.m., a review of medications on Cart A with S11Data revealed the following:
3-vials of Lantus insulin were opened and undated.
3-vials of Humulin-R were opened and undated.
1-bottle of Azelastine 0.1% eye drops was opened and undated.
1-bottle of Ipratropium 0.06% nasal spray was opened and undated.
1-bottle of artificial tears eye drops was opened and undated.
On 09/06/2023 at 9:24 a.m., a review of medications in Medication room [ROOM NUMBER] with S17LPN revealed the following:
1-vial of Aplisol solution was filled on 06/26/2023 and was opened, undated, and the label read discard 30 days after opening.
A review of medications on Cart D with S17LPN revealed the following:
3-vials of Lantus insulin were opened and undated.
1-Breztri/Aerosphere inhaler was opened and undated, and there was no carton with the manufacturer's expiration date.
1-vial of Humalog-U100 was opened and undated.
1-vial of Humulin-R was opened and undated
1-bottle of Ear Drops 6.5% was opened and undated.
1-vial of Levemir insulin was opened and undated.
1-bottle of Lubricant eye drops 0.3-0.4% was opened and undated.
On 09/06/2023 at 9:21 a.m., a review of medications in Medication room [ROOM NUMBER] with S11Datat revealed the following:
The Emergency kit contained one round white loose pill in the bottom of the container
The refrigerator revealed the following:
1-vial of Procrit 10,000 units/mL 6mg subcutaneous weekly was opened and undated.
2-vials of Tuberculin intradermal solution were opened and undated.
On 09/06/2023 at 9:00 a.m., an interview was conducted with S8LPN. She confirmed the insulin should have been dated when it was opened and it expired 28 days after opening.
On 09/06/2023 at 9:09 a.m., an interview was conducted with S2DON. S2DON confirmed the insulin should be dated after opening and it expired 28 days after opening.
On 09/06/2023 at 9:19 a.m., an interview was conducted with S10LPN. She confirmed the insulin should be dated when it is opened and it expired 28 days after opening.
On 09/06/2023 at 9:22 a.m., an interview was conducted with S11Data. She confirmed the insulin should be dated when it is opened and it expired 28-30 days after opening. She verified that eye drops and nasal sprays should be dated when they are opened.
On 09/06/2023 at 9:23 a.m., an interview was conducted with S2DON. He confirmed that all medications in boxes should be dated when opened and kept in original containers. S2DON also confirmed the Emergency kit contained one round white loose pill in the bottom of the container and 5-vials of Zofran 4mg/2mL with an expiration date of 07/2023. S2DON confirmed inhalers, eye drops, and nasal sprays should have been kept in the original boxes and dated with the date it was opened.
On 09/06/2023 at 9:25 a.m., an interview was conducted with S17LPN. She confirmed the insulin should be dated when it is opened and it expired 28 days after opening.
On 09/06/2023 at 9:28 a.m., an interview was conducted with S3ADON. He confirmed that nurses were expected to label the date on medication when it was opened. He verified the vials and the suppositories which were expired had not been labeled when opened, and should have been. He also confirmed the Tylenol suppositories should have been bagged and labeled by the pharmacy. S3ADON verified the inhaler did not have an expiration date and the inhaler should have remained the box.
3.
On 09/06/2023 at 8:20 a.m., an observation was made of Cart B unlocked and unattended on the hall.
On 09/06/2023 at 8:24 a.m., an interview was conducted with S8LPN. She confirmed Cart B should be locked when unattended.
On 09/06/2023 at 11:11 a.m., an observation was made of Cart B unattended and unlocked.
On 09/06/2023 at 11:13 a.m., an observation was made of Cart B unattended, unlocked, while a resident passed by.
On 09/06/2023 from 11:39 - 11:42 a.m., an observation was made of Cart B unattended and unlocked.
On 09/06/2023 from 12:01-12:03 p.m., an observation was made of S8LPN walking away from Cart B leaving the cart unattended and unlocked with cart keys still in locking mechanism.
On 09/06/2023 from 12:12 p.m.-12:15 p.m., an observation was made of Cart B unattended and unlocked.
On 09/06/2023 at 12:17 p.m., an interview was conducted with S8LPN. She confirmed the medication Cart B should be locked when unattended.
09/07/2023 at 4:12 p.m., an interview was conducted with S2DON. He confirmed nurses should lock the medication cart and put keys in their pocket when they leave the cart.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Medical Records
(Tag F0842)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews and interviews, the facility failed to maintain accurate records in accordance with accepted professiona...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews and interviews, the facility failed to maintain accurate records in accordance with accepted professional standards and practices for 3 (#F52, #RF3 and #RF4) of 3 (#F52, #RF3 and #RF4) sampled residents reviewed for falls. The facility failed to accurately document residents' fall intervention tasks every shift.
Findings:
Review of the facility's policy titled Charting and Documentation revealed the following:
Policy Statement: All services provided to the resident, progress towards the care plan goals, or any changes in the resident's medical, physical, functional or psychosocial condition, shall be documented in the resident's medical record.
Policy Interpretation and Implementation:
3. Documentation in the medical record will be ., complete, and accurate.
Resident #F52
Review of Resident #F52's clinical record revealed he was admitted to the facility on [DATE] with diagnoses which included Parkinson's disease, Alzheimer's disease, Vascular Dementia Unspecified Severity without Behavioral Disturbance, and Morbid Severe Obesity due to Excess Calories.
Review of Resident #F52's current care plan revealed the following, in part:
Focus: Potential for falls related to history of falls, decreased mobility, medication effects and confusion; Fall 08/19/2023.
Interventions/Tasks: 08/21/2023- monitor resident every 90 minutes.
Review of Resident #F52's fall intervention task for 90 minute rounding revealed no documentation the task was completed each shift on 10/01/2023, 10/04/2023, 10/05/2023, 10/09/2023, 10/10/2023, 10/11/2023, 10/13/2023, 10/14/2023, 10/19/2023, and 10/23/2023.
On 11/01/2023 at 8:22 a.m., an interview was conducted with S5LPN. She said after a resident had a fall, the CNAs were scheduled fall intervention tasks in the computer to document on every shift. She said the CNAs were responsible for documenting the assigned fall intervention tasks each shift. She said Resident #F52 was a fall risk, and to prevent falls, the CNAs were to monitor him every 90 minutes.
On 11/02/2023 at 12:10 p.m., an interview was conducted with S6CNA. She said she was assigned to Resident #F52 often and he was a fall risk. She said there was a task assigned in the computer to monitor Resident #F52 every 90 minutes to prevent falls. She said the CNAs were responsible for documenting this task every shift for Resident #F52. She said the CNAs should document the assigned tasks, including fall interventions every shift.
Resident #RF3
Review of Resident #RF3's clinical record revealed he was admitted to the facility on [DATE] with diagnoses which included Alzheimer's disease, Hemiplegia and Hemiparesis Following Cerebral Infarction Affecting Right Dominant Side, Contracture Right Hand, and Unspecified Pain.
Review of Resident #RF3's current care plan revealed the following, in part:
Focus: Potential for falls related to history of falls, decreased mobility related to hemiplegia; Fall 10/03/2023.
Interventions/Tasks: 10/03/2023-Fall: Make sure bed is locked when making resident rounds in room every shift and prn.
Review of Resident #RF3's fall intervention task for making sure his bed was locked revealed no documentation the task was completed each shift on 10/08/2023 and 10/16/2023.
On 11/01/2023 at 11:30 a.m., an interview was conducted with S7CNA. She said she assigned to Resident #RF3 often and he was a fall risk. She said there was an intervention assigned to the CNAs in the computer to ensure Resident #RF3's bed was locked every shift to prevent falls. She said the CNAs were responsible for documenting the assigned fall intervention tasks every shift. She said the CNAs should document the assigned tasks, including fall interventions every shift.
On 11/01/2023 at 11:35 a.m., an interview was conducted with S8CNA. She said she was assigned to Resident #RF3 and he was a fall risk. She said there was an intervention assigned to the CNAs in the computer to ensure Resident #RF3's bed was locked every shift to prevent falls. She said the CNAs were responsible for documenting the assigned fall intervention tasks every shift. She said the CNAs should document the assigned tasks, including fall interventions every shift.
Resident #RF4
Review of Resident #RF4's clinical record revealed she was admitted on [DATE] with diagnoses which included Unspecified Dementia, Unspecified Severity, without Behavioral Disturbance, History of Falling, and Hereditary and Idiopathic Neuropathy.
Review of Resident #RF4's current care plan revealed the following, in part:
Focus: Potential for falls related to decreased mobility, medication effects and confusion; Fall 10/09/2023.
Interventions/Tasks: 10/09/2023-Fall: Assist resident with transferring needs. Anticipate need for getting in and out of the bed from wheelchair every shift and as needed.
Review of Resident #RF4's fall intervention task for assisting with transfers revealed no documentation the task was completed each shift from 10/09/2023 through 10/19/2023, 10/22/2023, 10/25/2023, 10/28/2023, and 10/29/2023.
On 11/02/2023 at 11:48 a.m., an interview was conducted with S9CNA. She said she was assigned to Resident #RF4 and she was a fall risk. She said there was an intervention assigned to the CNAs in the computer each shift to assist Resident #RF4 with transferring to prevent falls. She said the CNAs were responsible for documenting the assigned fall intervention tasks every shift. She said the CNAs should document the assigned tasks, including fall interventions every shift.
On 11/01/2023 at 11:56 a.m., an interview was conducted with S10LPN. She said after a resident had a fall, the CNAs were scheduled fall intervention tasks in the computer to document on every shift. She said the CNAs were responsible for documenting the assigned fall intervention tasks each shift.
On 11/02/2023 at 9:20 a.m., an interview was conducted with S4ADON. He said he was responsible for monitoring the CNAs and their documentation. He said getting the CNAs to complete their documentation timely or at all, had been a chore. He said if the fall intervention tasks were not documented, there was no way to confirm they were done. He reviewed the care plans and CNA documentation dated October 2023 for Resident's #F52, #RF3, and #RF4 and confirmed the above missing documentation. He said he had been monitoring the CNAs facility wide documentation not resident specific documentation. He said he had not monitored Resident's #F52, #RF3, or #RF4 to ensure the CNAs had documented the assigned fall intervention tasks. He confirmed the CNAs were not documenting the assigned fall intervention tasks for Resident's #F52, #RF3, or #RF4 and should have been.
On 11/02/2023 at 9:58 a.m., an interview was conducted with S3CN. She said S4ADON was responsible for ensuring the CNAs were documenting assigned interventions in the computer. She reviewed the care plans and CNA documentation dated October 2023 for Resident's #F52, #RF3, and #RF4 and confirmed the above missing documentation. She said if the interventions assigned were not documented there was no proof the CNA completed the intervention. She confirmed the CNAs were not documenting the assigned fall intervention tasks for Resident's #F52, #RF3, or #RF4 and should have been. She confirmed the CNAs should document the assigned tasks, including fall interventions every shift. She said the CNAs documentation had not been monitored like it should have been.
On 11/02/2023 at 10:20 a.m., an interview was conducted with S2DON. He said CNA tasks including fall interventions should be scheduled on their ADL tasks. He said the CNAs were monitored by S4ADON, who spot checked their documentation at no set frequency. He said the facility was aware there were documentation issues. He reviewed the care plans and CNA documentation dated October 2023 for Resident's #F52, #RF3, and #RF4 and confirmed the above missing documentation. He said he entered Resident #RF4's post fall intervention task, it was his user error as he did not add the intervention correctly in the computer for the CNAs to document on. He said he did not catch the mistake and assign the task correctly until 10/17/2023. He confirmed the CNAs were not documenting the assigned fall intervention tasks for Resident's #F52, #RF3, or #RF4 and should have been. He said S4ADON had been monitoring the CNAs documentation, but it was not resident specific. He said there had been no specific monitoring to ensure the CNAs documented interventions initiated for resident falls and there should have been.
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 interviews, observations, and record reviews, the facility failed to maintain an infection control program designed to provide a safe, sanitary environment, and to help prevent the developmen...
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Based on interviews, observations, and record reviews, the facility failed to maintain an infection control program designed to provide a safe, sanitary environment, and to help prevent the development and transmission of communicable diseases and infections for 4 of 4 (Resident #10, Resident #39, Resident #46, and Resident #67) residents observed for blood glucose monitoring.
Findings:
Review of the facility's policy titled Obtaining a Fingerstick Glucose Level revealed in part, the following:
Purpose
The purpose of this procedure is to obtain a blood sample to determine the resident's blood glucose level.
Steps in the Procedure
18. Clean and disinfect reusable equipment between uses according to the manufacturer's instructions and current infection control standards of practice.
On 09/06/2023 at 11:20 a.m., an observation was made of S8LPN performing glucometer checks on Resident #39, Resident #10, Resident #46, and Resident #67. S8LPN walked into Resident #39's room, performed glucometer check on Resident #39, walked out of the resident's room, placed the glucometer on the medication cart without cleaning the glucometer. She then walked into Resident #10's room, performed glucometer check on Resident #10, walked out of the resident's room, and placed the glucometer on the medication cart without cleaning the glucometer. She then walked into Resident #46's room performed glucometer check on Resident #46, walked out of the resident's room, and placed the glucometer on the medication cart without cleaning the glucometer. She then walked into Resident #67's room, performed glucometer check on Resident #67, walked out of the resident's room, and placed the glucometer on the medication cart without cleaning the glucometer.
On 09/06/2023 at 12:17 p.m., an interview was conducted with S8LPN. She verified the glucometer should be cleaned/disinfected between each resident and she did not.
09/07/2023 at 4:12 p.m., an interview was conducted with S2DON. He confirmed glucometers should be cleaned/disinfected before and after each use.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Food Safety
(Tag F0812)
Could have caused harm · This affected most or all residents
Based on observations and interview, the facility failed to store, prepare, and distribute foods under sanitary conditions. The facility failed to ensure:
1.
Food was properly sealed and dated after ...
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Based on observations and interview, the facility failed to store, prepare, and distribute foods under sanitary conditions. The facility failed to ensure:
1.
Food was properly sealed and dated after opening;
2.
Presence of expired food intended for use; and
3.
Dietary staff wore a beard restraint while preparing food.
There were a total of 109 out of 112 facility residents who were provided meals and beverages from the facility's kitchen.
Findings:
Review of the facility policy titled, Food Receiving and Storage revealed the following, in part;
Policy: Food shall be received and stored in a manner that complies with safe food handling practices.
Refrigerated/Frozen Storage
1. All foods stored in refrigerator or freezer are covered, labeled, and dated.
7. Refrigerated foods are labeled, dated and monitored so they are used by their use-by date, frozen, or discarded.
Review of the facility policy titled, Food Preparation and Service revealed the following, in part;
Policy: Food and nutrition services employees prepare, distribute, and serve food in a manner that complies with safe food handling practice.
Food Distribution and Service
8. Food and nutrition services staff wear hair restraints (hair net, hat, beard restraint, etc.) so that hair does not contact food.
During the initial tour of the facility's kitchen on 09/05/2023 at 8:50 a.m., the following observations were made:
Walk in Freezer:
-1 bag of green peas opened and undated.
-1 bag of French fries opened and undated.
-1 bag of 18 dinner rolls opened and undated.
-1 bag of chicken patties opened and undated.
-1 bag of 6 biscuits opened, undated, and unsealed.
-1 box of corn dogs opened, undated, and unsealed.
-1 box of hamburger patties unsealed and opened to air.
-1 box of sausage patties unsealed and opened to air.
-1 large brown cylinder of ice cream unsealed and opened to air.
-6 loaves of bread undated.
Walk in Refrigerator:
-1 bottle of Rum opened and undated.
-2 bags of mini marshmallows opened and undated.
-1 bag of lettuce opened and undated.
- 4 boxes of apple juice expired on 07/13/2023.
-1 bag of hash browns opened, undated, and unsealed.
-1 bag of pork chops opened, undated, and unsealed.
Pantry:
-2 boxes of thicken water expired 09/04/2023.
-10 small containers of lemon flavored water expired on 08/22/2023.
-1 container of Black pepper opened and undated.
-1 pack of popcorn in zip lock bag undated.
On 09/05/2023 at 8:50 a.m., an interview was conducted with S14DS during the initial tour of the kitchen. She verified the above observations and acknowledged the facility failed to store foods properly. She confirmed all opened food products should have been labeled with the date opened. S14DS confirmed she was responsible for ensuring all food was labeled and sealed after opening.
On 09/05/2023 at 11:50 a.m., an observation was made of S15DS standing near the food serving line with uncovered facial hair.
On 09/05/2023 at 11:51 a.m., S14DS confirmed all dietary staff must wear hair restraints and/or beard restraints to prevent hair from contacting food. She stated she ordered beard guards but until they come in he should be wearing a mask at all times.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
QAPI Program
(Tag F0867)
Could have caused harm · This affected most or all residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews and interviews, the facility failed to implement and monitor appropriate plans of action to correct iden...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews and interviews, the facility failed to implement and monitor appropriate plans of action to correct identified quality deficiencies. The facility failed to ensure:
1. CNA staff documented fall intervention tasks for 3 (#F52, #RF3 and #RF4) of 3 (#F52, #RF3 and #RF4) sampled residents reviewed for falls; and
2. Residents were free of significant medication errors for 1 (#F267) of 3 (#F89, #RF4 and #F267) residents reviewed for medication administration.
Findings:
1.
Review of the facility's policy titled, Quality Assurance and Performance Improvement (QAPI) Program revealed the following, in part:
Policy Statement: The facility shall develop, implement, and maintain an ongoing, facility-wide Quality Assurance and Performance Improvement (QAPI) program that builds on the Quality Assessment and Assurance Program to actively pursue quality of care and quality of life goals.
Policy Interpretation and Implementation: The primary purpose of the Quality Assurance and Performance Improvement Program is to establish data-driven, facility-wide processes that improve the quality of care, quality of life and clinical outcomes for our residents.
Five Strategic Elements:
2. Governance and leadership:
c. Members of the facility leadership are accountable for QAPI efforts.
3. Feedback, data systems, and monitoring:
a. Systems are in place to monitor care and services.
c. Care processes and outcomes are monitored using performance indicators.
e. Action plans are implemented to prevent recurrence of adverse events.
Review of facility's Plan of Correction revealed the following, in part:
1. On 09/07/2023, a task to round on Resident #52 every 90 minutes was assigned to ensure staff is aware of the intervention to reduce the risk of falls and documents the task as completed.
2. This facility will ensure a task is assigned to a resident following an intervention for falls, as applicable, to ensure the staff is aware of and documents the task is completed.
3. Staff in-service initiated on 10/03/2023 to include:
1. A task may need to be assigned to a resident following an intervention for a fall to ensure the staff is aware of and documents the task is completed, when applicable.
4. DON/designee will review all resident falls in the facility weekly for 3 weeks to ensure a task is assigned to a resident following an intervention for falls, as applicable, to ensure the staff is aware of and documents the task is completed. If problems are identified, one on one education will be provided.
5. Substantial compliance will be achieved by 10/26/2023.
Resident #F52
Review of Resident #F52's clinical record revealed he was admitted to the facility on [DATE] with diagnoses which included Parkinson's disease, Alzheimer's Disease, Vascular Dementia Unspecified Severity without Behavioral Disturbance, and Morbid Severe Obesity due to Excess Calories.
Review of Resident #F52's current care plan revealed the following, in part:
Focus: Potential for falls related to history of falls, decreased mobility, medication effects and confusion; Fall 08/19/2023.
Interventions/Tasks: 08/21/2023- monitor resident every 90 minutes.
Review of Resident #F52's fall intervention task for 90 minute rounding revealed no documentation the task was completed each shift on 10/01/2023, 10/04/2023, 10/05/2023, 10/09/2023, 10/10/2023, 10/11/2023, 10/13/2023, 10/14/2023, 10/19/2023, and 10/23/2023.
Resident #RF3
Review of Resident #RF3's clinical record revealed he was admitted to the facility on [DATE] with diagnoses which included Alzheimer's Disease, Hemiplegia and Hemiparesis Following Cerebral Infarction Affecting Right Dominant Side, Contracture Right Hand, and Unspecified Pain.
Review of Resident #RF3's current care plan revealed the following, in part:
Focus: Potential for falls related to history of falls, decreased mobility related to hemiplegia; Fall 10/03/2023.
Interventions/Tasks: 10/03/2023-Fall: Make sure bed is locked when making resident rounds in room every shift and prn.
Review of Resident #RF3's fall intervention task for making sure his bed was locked revealed no documentation the task was completed each shift on 10/08/2023 and 10/16/2023.
Resident #RF4
Review of Resident #RF4's clinical record revealed she was admitted on [DATE] with diagnoses which included Unspecified Dementia, Unspecified Severity, without Behavioral Disturbance, History of Falling, and Hereditary and Idiopathic Neuropathy.
Review of Resident #RF4's current care plan revealed the following, in part:
Focus: Potential for falls related to decreased mobility, medication effects and confusion; Fall 10/09/2023.
Interventions/Tasks: 10/09/2023-Fall: Assist resident with transferring needs. Anticipate need for getting in and out of the bed from wheelchair every shift and as needed.
Review of Resident #RF4's fall intervention task for assisting with transfers revealed no documentation the task was completed each shift from 10/09/2023 through 10/19/2023, 10/22/2023, 10/25/2023, 10/28/2023, and 10/29/2023.
2.
Review of the facility's policy titled, Administering Medications revealed the following, in part:
4.) Medications are administered in accordance with prescriber orders, including any required time frame.
7.) Medications are administered within one hour of their prescribed time, unless otherwise specified (for example, before and after meal orders.)
21.) If a drug is withheld, refused, or given at a time other than the scheduled time, the individual administering the medication shall initial and circle the MAR space provided for that drug and dose.
Review of facility's Plan of Correction revealed the following, in part:
3. Staff for Resident #267 were in-serviced on 10/03/2023 that Medications must be administered timely and as ordered.
4. Staff in-service initiated on 10/03/2023 to include:
1. Medications must be administered as ordered.
2. Medications must be administered timely.
3. MARs should always be electronically signed when the medication is administered to the resident, not when you complete your med pass and sit down at the nurses' station. The time you electronically sign the MAR indicates the time you administered the medication.
4. DON/designee will randomly observe med pass for 5 residents per week for 3 weeks to ensure all medications are available and administered as ordered, within the correct time frames. If problems are identified, one on one education will be provided.
5. Substantial compliance projected date: 10/26/2023.
Resident #F267
Review of Resident #F267's clinical record revealed he was admitted to the facility on [DATE] with diagnoses which included Parkinson's Disease.
Review of Resident #F267's Physician's Orders dated October and November 2023 revealed the following, in part:
Start Date: 08/10/2023-, End Date: 10/11/2023: Mirapex Oral Tablet 0.25mg- Give one tablet by mouth TID related to Parkinson's Disease. Scheduled at 8:00 a.m., 1:00 p.m., and 8:00 p.m.
Start Date: 10/11/2023-Current: Mirapex Oral Tablet 0.25mg- Give one tablet by mouth TID related to Parkinson's Disease. Scheduled at 7:00 a.m., 1:00 p.m., and 7:00 p.m.
Start Date: 09/15/2023- End Date: 10/04/2023: Amantadine HCL 100mg- Give two capsules by mouth TID related to Parkinson's Disease. Scheduled at 8:00 a.m., 1:00 p.m. and 8:00 p.m.
Start Date: 10/04/2023- 10/09/2023 Amantadine HCL 100mg- Give two capsules by mouth by mouth TID related to Parkinson's Disease. Scheduled at 7:00 a.m., 1:00 p.m., and 7:00 p.m.
Start Date: 10/09/2023-Current Amantadine HCL 100mg- Give one tablet by mouth BID related to Parkinson's Disease. Scheduled at 7:00 a.m. and 7:00 p.m.
Review of Resident #F267's MAR and Administration Notes from 10/01/2023 to 10/31/2023 revealed in part, a check mark and initials on the following dates and times, which indicated the medication was administered:
Start date: 08/10/2023, Discontinue date: 10/11/2023 - Mirapex oral tablet 0.25mg give one tablet by mouth TID at 8:00 a.m., 1:00 p.m., and 8:00 p.m.:
10/01/2023 scheduled at 1:00 p.m., administered at 3:29 p.m.
10/01/2023 scheduled at 8:00 p.m., administered at 11:09 p.m.
10/04/2023 scheduled at 8:00 p.m., administered at 10:05 p.m.
10/09/2023 scheduled at 8:00 p.m., administered on 10/10/2023 2:58 a.m.
Start date: 10/11/2023 - Mirapex oral tablet 0.25mg give one tablet by mouth TID at 7:00 a.m., 1:00 p.m., and 7:00 p.m.:
10/12/2023 scheduled at 7:00 p.m., administered at 10:35 p.m.
10/16/2023 scheduled at 1:00 p.m., administered at 3:02 p.m.
10/18/2023 scheduled at 7:00 p.m., administered at 10:11 p.m.
10/23/2023 scheduled at 1:00 p.m., administered at 2:57 p.m.
10/25/2023 scheduled at 7:00 p.m., administered at 8:48 p.m.
Start date: 09/15/2023, Discontinue date: 10/04/2023 - Amantadine HCL 100mg give two capsules by mouth TID at 8:00 a.m., 1:00 p.m., and 8:00 p.m.:
10/01/2023 scheduled at 1:00 p.m., administered at 3:29 p.m.
10/03/2023 scheduled at 7:00 p.m., administered at 11:30 p.m.
Start date: 10/04/2023, Discontinue date: 10/09/2023 - Amantadine HCL 100mg give two capsules by mouth TID at 7:00 a.m., 1:00 p.m., and 7:00 p.m.:
10/04/2023 scheduled at 7:00 p.m., administered at 10:05 p.m.
10/06/2023 scheduled at 7:00 p.m., administered at 10:22 p.m.
Start date: 10/09/2023 - Amantadine HCL 100mg give one tablet by mouth two times a day at 7:00 a.m. and 7:00 p.m.:
10/09/2023 scheduled at 7:00 p.m., administered on 10/10/2023 at 2:58 a.m.
10/12/2023 scheduled at 7:00 p.m., administered at 10:35 p.m.
10/18/2023 scheduled at 7:00 p.m., administered at 10:11 p.m.
On 11/02/2023 at 9:00 a.m., an interview was conducted with Resident #F267. He said he had Parkinson's Disease, which required him to take medications to help control symptoms related to the disease process. He said he received his medications late on numerous occasions. He said when he received his medications late, he exhibited increased involuntary shaking.
On 11/02/2023 at 2:43 p.m., an interview was conducted with S4ADON. He said S1ADM, S2DON, and S3CN were responsible for the facility's open QAPI plans. He said he was not aware when the QAPI plans were initiated, but the completion date was 10/26/2023. He said he was responsible for monitoring the CNAs and their documentation. He said he had been monitoring the CNAs facility wide documentation not resident specific documentation. He said he had not monitored Resident's #F52, #RF3, or #RF4 to ensure the CNAs had documented the assigned fall intervention tasks. He confirmed the CNAs were not documenting the assigned fall intervention tasks for Resident's #F52, #RF3, or #RF4 and should have been. He confirmed since there was incomplete charting of fall intervention tasks for the above residents, the QAPI plan was ineffective. He said he had not been involved in the facility's QAPI plan on medication administration and had not reviewed Resident #F267 for timely medication administration. He confirmed the facility should follow their policy and procedures for their QAPI process.
On 11/02/2023 at 3:06 p.m., an interview was conducted with S2DON. He said the facility's QAPI plans were initiated around 10/04/2023, with a completion date of 10/26/2023. He said the facility's QAPI plans had been a collaborative effort with the Administrative team. He said he was ultimately responsible for monitoring and managing the open/active QAPI plans for the facility. He said S1ADM had not been involved in the QAPI plans related to resident fall interventions or medication administration. He said he tracked and monitored resident falls to ensure a fall intervention task was generated when needed. He said S4ADON was responsible for monitoring CNA ADL documentation facility wide. He said no specific staff member had been monitoring residents with task generated fall interventions to ensure the CNAs documented them. He said he had not monitored Resident's #F52 #RF3, or #RF4 to ensure the fall intervention were documented on every shift and should have. He said he spot checked after the fall interventions were initiated for Resident's #F52, #RF3, and #RF4 to ensure the CNAs were implementing the interventions, but did not monitor their documentation. He verified the CNAs were not documenting the assigned fall interventions every shift. He confirmed Resident #F267 had not been receiving his Parkinson's medications timely. He confirmed he had not included Resident #F267 in the facility's QAPI plan monitoring for timely medication administration and should have. He confirmed the facility should follow their policy and procedure for their QAPI process. He confirmed since there were continued issues identified with the facility's QAPI plans, they had not been effective.
On 11/02/2023 at 3:20 p.m., an interview was conducted with S1ADM. He said he had no direct involvement in the facility's QAPI plans related to fall interventions and medication administration. He verified the facility's compliance date for the QAPI plans was 10/26/2023. He said S2DON was responsible for monitoring and managing the open/active QAPI plans for the facility. He confirmed S2DON had not tracked or monitored CNA documentation of fall intervention tasks per the QAPI plan. He confirmed the CNAs were not documenting the assigned fall intervention tasks for Resident's #F52, #RF3, or #RF4 and should have been. He said S2DON and S4ADON should have been monitoring the CNAs documentation of the fall intervention tasks. He said Resident #F267 should have been included in S2DON's monitoring for timely medication administration. He confirmed S2DON had not tracked and monitored timely administration of medications per the QAPI plan. He confirmed the facility's QA/QAPI system had not been effective.
Jul 2023
2 deficiencies
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Report Alleged Abuse
(Tag F0609)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to ensure an allegation of physical abuse was reported immediately, b...
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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 an allegation of physical abuse was reported immediately, but not later than 2 hours to the state agency for 1 (#1) of 7 (#1, #2, #3, #4, #5, R1, and R2) residents reviewed for abuse.
Findings:
Review of the facility's policy, Abuse Prevention Program revealed, in part, the following;
Policy interpretation and implementation
As part of the resident abuse prevention, the administration will:
7. Investigate and report any allegations of abuse within timeframes as required by federal requirements.
Review of the facility's policy, Abuse Investigation and Reporting revealed, in part, the following;
Reporting
1.
All alleged violations involving abuse, neglect, exploitation, or mistreatment . will be reported by the facility administrator, or his/her designee, to the following persons or agencies:
a.
The State licensing/certification agency responsible for surveying/licensing the facility.
2.
An alleged violation of abuse, neglect, exploitation, or mistreatment . will be reported immediately, but no later than:
a.
Two (2) hours if the alleged violation involves abuse .
Review of Resident #1's Clinical Record revealed she was admitted to the facility on [DATE] with a diagnosis which included Dementia.
Review of Resident #1's Yearly MDS with an ARD of 04/18/2023 revealed she had a BIMS of 3, which indicated she had severe cognitive impairment.
Review of Resident #1's Nurses Notes revealed, in part, the following:
06/18/2023 at 11:08 a.m.-This nurse was in another resident's room when S4CNA approached this nurse to let me know that resident had a skin tear to right forearm and that resident had scratched her right arm. This nurse went to assess skin tear .Upon leaving out of room to gather supplies resident's daughter arrives .Daughter approaches nurse very upset asking, what happened to my mother's arm? This nurse informed daughter that she has a skin tear to her arm and I will clean and wrap it. Daughter walks off saying My momma is not crazy. I know what's going on and me and my sister will be up here tomorrow. This nurse explains to daughter that I did not say your mom was crazy. She states I know but something has to be done. I have reported this several times.-Signed, S3LPN.
Review of Facility Investigation Report for Resident #1 revealed in part, the following:
06/18/2023- S1ADM was notified that Police were called to the facility in regards to a skin tear that occurred approximately at 7:20 a.m. S1ADM, S5SSD, and S6DON interviewed Resident #1. Resident stated everything was fine. Could not recall the event that caused the skin tear and resident was showing no signs of distress . Scheduled a meeting for 2:00 p.m. with resident's daughters on 06/19/2023. They expressed their concern with skin tear and they wanted S4CNA arrested and prosecuted .
Review of Incident Log dated June 2023 revealed Resident #1 acquired a superficial skin tear on 6/18/2023.
Review of Resident #1's Wound Assessment Report dated 06/19/2023 revealed a new wound on her right forearm identified on 06/18/2023. Measurements: 3.5 cm length, 1 cm width, and 0.10 cm depth. Drainage: small serosanguinous.
Review of the Grievance Log dated April 2023-July 2023 revealed Resident #1's daughter complained on 06/19/2023 that her mother's CNA intentionally caused a skin tear .
Review of facility's Reportable Incidents revealed no entries for Resident #1.
On 07/18/2023 at 8:52 a.m. an interview was conducted with Resident #1's daughter. She stated on the morning of 06/18/2023 she noticed a skin tear and bruising to her mother's right forearm. She stated the skin was open and bleeding. She asked S4CNA what happened because her mom was crying and her skin was open and bleeding. S4CNA stated, You should see what she did to me. She jumped me first. Resident #1's daughter stated she felt as if her mother had been assaulted after speaking to S4CNA. She stated she called the police department and filed an assault report against S4CNA. She stated the next day, she and her other two sisters met with S1ADM and S6DON. She stated she made S1ADM aware she felt like the injuries to her mother were intentional. She stated she voiced concerns to S1ADM that something very inappropriate happened, and she considered it assault due to the type of injury.
On 07/19/2023 at 10:40 a.m., an interview was conducted with S1ADM. He stated he was notified on 6/18/2023 at 4:30 p.m. police were in the building concerning an incident involving S4CNA and Resident #1's family member. He stated he spoke with police on the phone, and they stated they were called to the facility by Resident #1's family regarding the skin tear found that morning. S1ADM stated he met with Resident #1's three daughters on 06/19/2023 at 2:00 p.m. He stated during the meeting he was made aware that Resident #1's daughters thought S4CNA intentionally harmed their mother. He stated he did not report the incident to State Agency.
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
Administration
(Tag F0835)
Could have caused harm · This affected 1 resident
Based on record review and interviews, the facility failed to ensure it was administered in a manner that enabled it to use its resources effectively and efficiently to attain or maintain the highest ...
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Based on record review and interviews, the facility failed to ensure it was administered in a manner that enabled it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. The facility failed to report allegations of physical abuse to the required state agency.
Findings:
Review of the facility's policy, Abuse Prevention Program revealed, in part, the following;
Policy interpretation and implementation
As part of the resident abuse prevention, the administration will:
7. Investigate and report any allegations of abuse within timeframes as required by federal requirements.
Review of the facility's policy, Abuse Investigation and Reporting revealed, in part, the following;
Reporting
1.
All alleged violations involving abuse, neglect, exploitation, or mistreatment . will be reported by the facility administrator, or his/her designee, to the following persons or agencies:
a.
The State licensing/certification agency responsible for surveying/licensing the facility.
2.
An alleged violation of abuse, neglect, exploitation, or mistreatment . will be reported immediately, but no later than:
a.
Two (2) hours if the alleged violation involves abuse .
Review of Facility's Investigation Report for Resident #1 revealed in part, the following:
06/18/2023 - S1ADM was notified that Police were called to the facility in regards to a skin tear that occurred approximately at 7:20 a.m.S1ADM scheduled a meeting with resident's daughters on 06/19/2023. They expressed their concern with skin tear and they wanted S4CNA arrested and prosecuted .
Review of the Grievance Log dated 06/19/2023 revealed the following:
Complainant: Resident #1's daughter
Complaint: Daughter stated mother's CNA intentionally caused a skin tear.
Review of Facility's Reportable Incidents revealed no entries for Resident #1.
Review of In-service Training dated 06/14/2023 revealed S1ADM and S6DON received training by S7CORP. Further review revealed the following:
All alleged violations involving abuse, neglect, exploitation or mistreatment (including injuries of unknown source and misappropriation of resident property) must be reported to the State Survey Agency via SIMS immediately, but not later than 2 hours after the allegation is made, if the events that caused the allegation involved abuse or result in serious bodily injury, or not later than 24 hours if the events that caused the allegation do not involve abuse and do not result in serious bodily injury .
On 07/18/2023 at 8:52 a.m. an interview was conducted with Resident #1's daughter. She stated on 06/18/2023 she noticed a skin tear and bruising to her mother's right forearm. She stated the skin was open and bleeding. She asked S4CNA what happened because her mom was crying and her skin was open and bleeding. S4CNA stated, You should see what she did to me. She jumped me first. Resident #1's daughter stated she felt as if her mother had been assaulted after speaking to S4CNA. She stated she called the police department and filed an assault report against S4CNA. She stated the next day, she and her other two sisters met with S1ADM and S6DON. She stated she made S1ADM aware she felt like the injuries to her mother were intentional. She stated she voiced concerns to S1ADM that something very inappropriate happened, and she considered it assault due to the type of injury.
On 07/19/2023 at 10:15 a.m., an interview was conducted with S6DON. He stated S7CORP completed an in-service training with himself and S1ADM on 06/14/2023 regarding reportable incidents and their required reporting timeframe to State Agency.
On 07/19/2023 at 10:40 a.m., an interview was conducted with S1ADM. He stated he was notified on 6/18/2023 at 4:30 p.m. police were in the building concerning an incident that morning involving S4CNA and Resident #1's family member. He stated he spoke with police on the phone, and they stated they were called to the facility by Resident #1's family regarding the skin tear found that morning. S1ADM stated he met with Resident #1's three daughters on 06/19/2023 at 2:00 p.m. He stated during the meeting he was made aware that Resident #1's daughters thought S4CNA intentionally harmed their mother. He stated he did not report the incident to Reporting State Agency.
Jun 2023
2 deficiencies
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Report Alleged Abuse
(Tag F0609)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, and interviews, the facility failed to report an incident of neglect, which resulted in elo...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, and interviews, the facility failed to report an incident of neglect, which resulted in elopement, to the State Survey Agency for 1 (#1) of 2 (#1 and #2) residents reviewed for wandering.
Finding:
Review of the facility's policy titled Abuse Investigation and Reporting revealed the following, in part:
Policy Statement: All reports of resident abuse, neglect, exploitations, misappropriation of resident property, mistreatment and/or injuries of unknown source shall be promptly reported to local, state and federal agencies and thoroughly investigated by facility management.
Role of the Investigator:
Reporting: a. The State licensing/certification agency responsible for surveying/licensing the facility.
Review of Resident #1's clinical record revealed she was admitted to the facility on [DATE] with diagnoses which included Dementia, Major Depressive Disorder, Anxiety Disorder and on 02/16/2023, Urinary Tract Infection.
Review of Resident #1's MDS with an ARD of 12/28/2022 revealed a BIMS of 12, which indicated the resident had moderate cognitive impairment.
Review of the facility's Incident Investigation dated 02/18/2023 for Resident #1 revealed the following, in part:
Narrative: It was reported to the nurse that Resident #1was found outside and was brought back in the building by staff. Resident #1 stated she wanted to go outside and walk around.
Review of Resident #1's Nurse's Note dated 02/18/2023 revealed the following, in part:
At 4:48 p.m., writer was called to the front of the building by CNA stating resident was seen outside. When writer arrived at the front door, resident was being brought back into the building by the CNA's. Resident stated she wanted to go outside and walk around but she had been informed she could not be outside by herself. The resident stated she would not try it again. Writer assessed resident and found no injuries. Signed by S6LPN.
An observation was made of Resident #1 on 06/12/2023 at 8:50 a.m. She was observed in the secured unit sitting in the dining room conversing with other residents. She agreed to walk to her room for an interview. She used a walker with ambulation.
An interview was conducted on 06/12/2023 at 9:00 a.m. with Resident #1. Resident #1 said she had been residing in the facility for 6 months. She said she recalled one Saturday evening a few months ago, she walked out of the front doors of the facility by herself. She said her intention was to walk alongside the road attempting to get to the church. She said she now resided in a different room which she prefers. Resident #1 was alert and oriented to her birthdate and name only.
An interview was conducted on 06/12/2023 at 2:00 p.m. with S2DON. He confirmed he was aware Resident #1 left the facility unsupervised on 02/18/2023. He said S1ADM was responsible for reporting incidences of elopement to the State Survey Agency.
An interview was conducted on 06/12/2023 at 3:45 p.m. with S7CN. He said he was contacted by S1ADM on 02/18/2023 regarding Resident #1's elopement from the facility. He said Resident #1 was immediately returned inside the facility by CNA staff and assessed for injuries. He confirmed the incident was not reported to the State Survey Agency and should have been.
An interview was conducted on 06/14/2023 at 3:00 p.m. with S1ADM. He said on 02/18/2023 at 4:50 p.m., he was notified by S6LPN that Resident #1 had eloped from the facility. He said Resident #1 was found outside of the front of the facility. He said two CNA staff members escorted Resident #1 back into the facility. He confirmed he did not initiate a SIMS report to the State Survey Agency for Resident #1's elopement and should have.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0658
(Tag F0658)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to ensure services were provided to meet quality professional standar...
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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 services were provided to meet quality professional standards for 1(#1) of 5(#1, #2, #3, #4 and #5) residents reviewed. The facility failed to ensure Resident #1 received medications ordered by the Physician timely.
Findings:
Review of Resident #1's clinical record revealed the resident was admitted to the facility on [DATE] with diagnoses which included Dementia, Major Depressive Disorder, Anxiety Disorder and Urinary Tract Infection.
Review of Resident #1's Nurses' Notes dated February 2023 revealed the following, in part:
02/13/2023 at 11:56 a.m. Call made to daughter in regards to resident's increased confusion. Resident's daughter voiced concerns she noticed this last week when she visited her. Advised her we can check her urine to make sure nothing is going on. Urinalysis will be collected according to standing orders. Signed S3LPN.
02/16/2023 at 10:20 a.m. Received Fax order from Resident #1's physician for Macrobid 100mg one capsule BID for 7 days for UTI. Signed S4LPN.
Review of Resident #1's lab results dated February 2023 revealed the following, in part:
02/15/2023 at 12:00 p.m. revealed urine culture positive for Enterococcus Faecalis in the urine confirming the specimen sample was positive for a UTI.
Review of Resident #1's Physician Orders dated February 2023 revealed the following, in part:
02/16/2023 Macrobid 100mg 1 capsule by mouth BID for 7 days. Diagnosis: UTI.
Review of Resident #1's current Care Plan revealed the following, in part:
08/09/2022 Problem: History of UTIs
Approaches: Observe for signs and symptoms of UTI, provide good peri-care, 02/16/2023 Macrobid 100mg bid for 7 days.
Review of Resident #1's Medication Administration Record dated February 2023 revealed the following, in part:
Order date: 02/20/2023 Macrobid 100mg capsule- take one capsule by mouth twice a day for 7 days. Further review revealed Resident #1 received her first dose of Macrobid 100mg capsule on 02/20/2023.
An interview was conducted on 06/14/2023 at 10:00 a.m. with the Facility's Pharmacist. She verified on 02/16/2023 at 10:22 a.m., she received an order for Macrobid 100mg capsules for 7 days to treat a UTI for Resident #1. She confirmed the medication was delivered to the facility on [DATE] at 5:30 p.m.
An interview was conducted on 06/14/2023 at 10:15 a.m. with S5DE. She said she was responsible for ensuring all Physicians' Orders were correctly entered in the Electronic Medical Record. She said on 02/17/2023, she was unable to perform her job duties as a Data Entry staff because she was assigned to provide care to the residents on Hall A from 7:00 p.m.-7:00 a.m. She said when she returned to work on 02/20/2023 at 7:00 a.m., S4LPN had already entered the missed order at 6:30 a.m. in Resident #1's Electronic Medical Record. She said when she was not working her job as a Data Entry staff, no one else performed her duties. She said if an order was missed by a staff nurse, it would not be reconciled until she returned to her regular duty as a Data Entry staff.
An interview was conducted on 06/14/2023 at 2:00 p.m. with S4LPN. She confirmed she provided care to Resident #1. She stated she could not recall the details of the incident for a missed entry in Resident #1's electronic medical record. She confirmed the nurse that received a new Physician Order was responsible for entering it into the resident's Electronic Medical Record.
An interview was conducted on 06/14/2023 at 3:00 p.m. with S2DON. He verified on 02/16/2023 at 7:05 a.m., S4LPN received an order for Macrobid 100mg capsule with administration instructions of one capsule twice a day by mouth for 7 days to treat a Urinary Tract Infection for Resident #1. He said the pharmacy delivered the medication to the facility on [DATE] at 5:30 p.m. He said because S4LPN failed to enter the order into Resident #1's Electronic Medical Record, she had not received the ordered medication until it was discovered on 02/20/2023. He said S4LPN entered the medication in the Electronic Medical Record on 02/20/2023 when she realized she had failed to enter it on 02/16/2023. He confirmed the first dose of Macrobid 100mg was administered to Resident #1 at 7:00 a.m. on 02/20/2023 by S4LPN. He confirmed when S5DE was assigned as a staff nurse to work the halls, there was no one else to perform her duties. He said the facility needed a revised process for reconciling Physicians' Orders when S5DE was not available to perform her job duties as a Data Entry staff. He said if S5DE had been performing her regular duties as a Data Entry staff, she would have identified the missed entry, and Resident #1 would have received her medication timely.
Apr 2023
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 F0919
(Tag F0919)
Could have caused harm · This affected multiple residents
Based on observations and interview, the facility failed to ensure it was adequately equipped to allow residents to call for staff assistance, as evidenced by failing to ensure the call light system a...
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Based on observations and interview, the facility failed to ensure it was adequately equipped to allow residents to call for staff assistance, as evidenced by failing to ensure the call light system at the bed side and bathroom functioned for 6 (#1, R1, R2, R3, R4, R5) of 10 (#1, #2, #3, #4, #5, R1, R2, R3, R4, R5) sampled residents.
Findings:
Rm c
On 04/12/2023 at 12:01 p.m., an interview was conducted with Resident #1. Resident #1 stated his call light had not been working for about 2 weeks. The call light was tested and was observed not to function or illuminate outside of the room. An observation was made of the bathroom call light and Resident R5's call light. Both were found not to function or illuminate outside of the room.
On 04/12/2023 at 2:08 p.m., an observation of Rm c's call lights were made with S2M. S2M confirmed the call lights did not function or illuminate outside of the room for Resident #1, Resident R5, or the bathroom.
On 04/12/2023 at 4:30 p.m., an interview was conducted with Resident R5. Resident R5 stated his call light did not work and had not worked for two of weeks.
Rm b
On 04/12/2023 at 12:13 p.m., an observation of Rm b's call lights were made with S2M. S2M confirmed the call lights did not function or illuminate outside of the room for Resident R3, Resident R4, or the bathroom.
On 04/12/2023 at 4:21 p.m., an interview was conducted with Resident R3. Resident R3 stated her call light did not work.
Rm a
On 04/12/2023 at 12:14 p.m., an observation of Rm a's call lights were made with S2M. S2M confirmed the call lights did not function or illuminate outside of the room for Resident R1, Resident R2, or in the bathroom. S2M stated he was not aware the call lights were not working in Rm a, Rm b, and Rm c until now.
On 04/12/2023 at 4:10 p.m., an interview was conducted with S1ADM. S1ADM stated he was not aware the call lights in Rm a, Rm b, and Rm c were not functioning prior to the aforementioned observations. S1ADM stated he did not know the call lights were not functioning.
Oct 2022
7 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Safe Environment
(Tag F0584)
Could have caused harm · This affected 1 resident
Based on observations and interviews, the facility failed to ensure the residents had a safe, clean, comfortable homelike environment by failing to maintain a clean environment in resident's room. Thi...
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Based on observations and interviews, the facility failed to ensure the residents had a safe, clean, comfortable homelike environment by failing to maintain a clean environment in resident's room. This failed practice affected 2 (#80, #90) out of 5 residents in the facility that received tube feedings per the facility's 671.
Findings:
Resident #80
An observation was made on 10/17/2022 at 9:40 a.m. in the Resident #80's room. Dried brown substance was located on the floor, on the feeding pump, on the side rails of the resident's bed, on the rolling pole and base, on the night stand, and on the wall.
An observation was made on 10/18/2022 at 1:35 p.m. in Resident #80's room. Dried brown substance was located on the floor, on the feeding pump, on the side rails of the resident's bed, on the rolling pole and base, on the night stand, and on the wall.
An observation was made on 10/19/2022 at 9:15 a.m. in Resident #80's room. Dried brown substance was located on the floor, on the feeding pump, on the side rails of the resident's bed, on the rolling pole and base, on the night stand, and on the wall.
An observation was made on 10/20/2022 at 12:46 p.m. in Resident #80's room. Dried brown substance was located on the floor, on the feeding pump, on the side rails of the resident's bed, on the rolling pole and base, on the night stand, and on the wall.
An interview was conducted on 10/20/2022 at 12:46 p.m. with S3ADON in the Resident #80's room. She stated it is housekeeping and nurses' job to ensure feeding pumps, rolling poles, and surrounding areas cleanliness. She confirmed there was dried feeding solution on the feeding pump, rolling pole, pole base, floor, night stand, and wall. She stated this should have been cleaned by housekeeping or nursing staff.
Resident #90
An observation was made on 10/19/2022 at 9:03 a.m. in Resident #90's room. Dried brown substance was located on the feeding pump rolling pole and base.
An observation was made on 10/20/2022 at 12:45 p.m. in Resident #90's room. Dried brown substance was located on the feeding pump rolling pole and base.
An interview was conducted on 10/20/2022 at 12:49 p.m. with S3ADON in the Resident #90's room. S3ADON confirmed the dried brown substance on the pole and base was feeding solution and should not have been present.
An interview was conducted on 10/20/2022 at 2:36 p.m. with S2DON. He stated the dried feeding solution on the feeding pump and on the surrounding areas was unacceptable. He stated housekeeping and nurses should have ensured this was cleaned when it occurred.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Comprehensive Care Plan
(Tag F0656)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to implement a person-centered care plan by failing to...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to implement a person-centered care plan by failing to apply an abdominal binder as ordered for 1 (#93) of 3 (#80, #90, #93) residents reviewed with PEG Tubes.
Findings:
Review of the clinical record for Resident #93 revealed the resident was admitted to the facility on [DATE] with diagnoses that included, Encounter for Attention to Gastrostomy, Unspecified Protein-Calorie Malnutrition, Iron Deficiency and Alzheimer's disease.
Review of the telephone orders for Resident #93 revealed the following:
10/17/2022- Abdominal Binder to be worn at all times, can be removed for bathing and feeding.
Review of the Nurses notes for Resident #93 revealed the following:
10/12/2022 at 3:48 p.m. - CNA called nurse to resident's room because he pulled his PEG tube out, Nurse placed Foley catheter in to keep it patent, instructed the resident to not pull it out.
10/13/2022 at 8:40 a.m. - Resident going to hospital to get PEG tube replaced.
10/13/2022 at 11:45 a.m. - Resident back from hospital with new PEG in place.
10/17/2022- Received new orders for Resident to wear abdominal binder at all times, can be removed for bathing and feeding, will continue to monitor.
An interview was held with S4LPN on 10/19/2022 at 10:15 a.m. She confirmed she was the nurse assigned to Resident #93 today. When asked if the resident had an order to wear an abdominal binder, she was unable to confirm if there was a current order. She confirmed she did not see an abdominal binder applied to the resident during his morning medication administration. She confirmed she administered his medications through his PEG tube earlier that morning.
An observation was made of Resident #93 on 10/19/2022 at 10:20 a.m. The resident was observed lying in bed, there was no abdominal binder in place on the resident. The resident proceeded to grab this PEG tube, shake it and request that it be removed. S4LPN entered the room and was observed looking in the resident's drawers and closet. S4LPN pulled an abdominal binder out of the closet and applied it to the resident.
An interview was held with S6LPN on 10/20/22 at 1:17 p.m. in Resident's #93's room. She confirmed Resident #93 was supposed to wear an abdominal binder. She stated when she rounded on him earlier that morning, she found the abdominal binder by the resident's head. She stated she had to reapply it.
An observation was made of Resident #93 on 10/20/2022 at 1:20 p.m. The resident was lying in bed and the abdominal binder was observed by the resident's head and was not secured around the abdomen. S6LPN was observed applying the abdominal binder to the resident at that time.
An interview was held with S2DON on 10/20/2022 at 2:18 p.m. He confirmed he was aware Resident #93 had a history of removing his PEG tube. He confirmed if there was a current physician order for the abdominal binder to be applied to the resident, then it should have been in place as ordered.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0658
(Tag F0658)
Could have caused harm · This affected 1 resident
Based on record reviews and interviews the facility failed to provide services to meet professional standards for 1(#1) of 3 (#1, #14, and #59) residents sampled for receiving pain medication. The fac...
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Based on record reviews and interviews the facility failed to provide services to meet professional standards for 1(#1) of 3 (#1, #14, and #59) residents sampled for receiving pain medication. The facility failed to ensure the following:
1. Physician's orders, administered controlled medication doses, and resident responses to administered as needed medication were documented on the Medication Administration Record (MAR) and
2. Physician's orders were placed on the resident's chart.
Findings:
Review of the facility's policy Documentation of Medication Administration revealed the following, in part:
Policy Statement
The facility shall maintain a medication administration record to document all medications administered.
Policy Interpretation and Implementation
1. A nurse shall document all medications administered to each resident on the resident's medication administration record (MAR).
2. Administration of medication must be documented immediately after (and never before) it is given.
3. Documentation must include, as a minimum:
a. Name and strength of the drug;
b. Dosage;
c. Method of administration (e.g., oral, injection (and site), etc.);
d. Date and time of administration;
f. Signature and title of the person administering the mediation; and
g. Resident response to the medication, if applicable (e.g., PRN, pain medication, etc.).
Review of Resident #1's medical record revealed an admit date of 09/02/2020 with diagnoses, which included Pain Unspecified, Acquired Absence of Right and Left leg Above the Knee, Peripheral Vascular Disease, Phantom Limb Syndrome with Pain.
Review of Quarterly MDS with ARD of 10/02/2022 revealed a BIMS of 15 which indicated Resident # 1 was cognitively intact.
Review of the current Physician's Orders dated 07/01/2022-10/17/2022 revealed the following, in part:
Percocet 10-325 mg tablet by mouth every 6 hour as needed for pain
Review of Resident #1's Care Plan revealed the following, in part:
Potential for pain/discomfort related to phantom pain to bilateral lower extremity, mono-neuropathy, and muscle spasm.
-Pain will be managed daily
Interventions:
-Assess level of pain
-MD notified as needed
-Medication as ordered
Review of the MAR dated 08/01/2022-10/14/2022 revealed the following, in part:
Percocet 10/325 mg take one tablet by mouth every six hours as needed for pain.
08/20/2022 at 6:07 pm
09/13/2022 at 6:08 pm
10/05/2022 at 8:01 p.m.
10/06/2022 at 10:06 p.m.
10/10/2022 at 7:43 p.m.
10/11/2022 at 8:16 a.m. and 8:45 p.m.
10/14/2022 at 6:30 p.m.
Review of the Narcotic Log dated 08/01/2022-10/14/2022 revealed the following (39 doses given):
Percocet 10/325 mg 5 doses carried over and received from pharmacy on 07/28/2022
Dates/Time administered:
08/01/2022 at 8:00 p.m. 1 given
Oxycodone 5/325 mg oral, 28 doses received from pharmacy on 08/17/2022
Dates/Time administered:
08/17/2022 at 7:00 p.m. 1 given
08/18/2022 at 7:00 p.m. 1 given
08/19/2022 at 7:00 p.m. 1 given
08/20/2022 at 7:00 p.m. 1 given
08/21/2022 at 7:00 p.m. 1 given
08/23/2022 at 7:00 p.m. 1 given
08/24/2022 at 6:45 1 given
08/25/2022 at (unable to read time)
08/26/2022 at 7:00 p.m. 1 given
08/27/2022 at 7:00 p.m. 1 given
08/28/2022 at 7:00 p.m. 1 given
08/29/2022 at 7:00 p.m. 1 given
08/30/2022 at 7:00 p.m. 1 given
08/31/2022 at 8:00 p.m. 1 given
09/01/2022 at 8:00 p.m. 1 given
09/02/2022 at 8:00 p.m. 1 given
09/03/2022 at 8:00 p.m. 1 given
09/04/2022 at 8:00 p.m. 1 given
09/05/2022 at 8:00 p.m. 1 given
09/06/2022 at 8:00 p.m. 1 given
09/07/2022 at 8:00 p.m. 1 given
09/08/2022 at 8:00 p.m. 1 given
09/09/2022 at 8:00 p.m. 1 given
09/10/2022 at 7:00 p.m. 1 given
09/11/2022 at 7:00 p.m. 1 given
09/12/2022 at 7:00 p.m. 1 given
09/13/2022 at 6:00 p.m. 1 given
Oxycodone 10/325 mg oral 28 doses received from pharmacy on 10/05/2022
Dates/Time administered:
10/05/2022 at 8:00 p.m. 1 given
10/06/2022 at 10:00 p.m. 1 given
10/07/2022 at 8:00 p.m. 1 given
10/08/2022 at 8:00 p.m. 1 given
10/09/2022 at 8:00 p.m. 1 given
10/10 2022 at 8:00 p.m. 1 given
10/11/2022 at 8:00 a.m. 1 given
10/11/2022 at 8:00 p.m. 1 given
10/12/2022 at 8:00 p.m. 1 given
10/13/2022 at 8:00 p.m. 1 given
10/14/2022 at 8:00 p.m. 1 given
On 10/19/2022 at 10:37 a.m. an interview was conducted with S8LPN. She stated narcotic medications were supposed to be signed out on the narcotic log and documented on the Electronic Medication Administration Record (EMAR) when administered to a resident. She further stated she would evaluate how the resident responded to the medication and document the response in the EMR. S8LPN stated when medications were received from pharmacy, the order was supposed to be entered in the MAR and placed on the chart. She confirmed there was no order in the chart for Percocet 5/325 mg.
On 10/20/2022 at 11:20 a.m. an interview was conducted with S2DON. He stated when a provider wrote an order to change the dosage of a medication, an order should be written to discontinue the previous medication order and a new order written to begin the new medication dose and should be placed on the chart. He stated the EMAR should also be updated to reflect the new dose. S2DON confirmed there was no order on the chart to discontinue Percocet 10/325 mg every 6 hours as needed, or to change the dose to Percocet 5/325 mg every 6 hours as needed beginning 08/17/2022. S2DON also confirmed the EMAR had not been updated to reflect the change in the medication dosage. He stated nurses should document all medications given in the EMAR. He confirmed all doses signed out on Resident #1's narcotic log were not documented in the EMAR and should have been.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Pharmacy Services
(Tag F0755)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews the facility failed to provide pharmaceutical services, including services that include t...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews the facility failed to provide pharmaceutical services, including services that include the accurate acquiring, receiving, dispensing and administering of all drugs and biologicals to meet the needs of each resident. The facility failed to ensure a controlled medication (Percocet) was available for 1 (#1) of 3 (#1, #14, and #59) residents sampled for pain.
Findings:
Review of the facility's policy titled Administering Medications revealed the following, in part:
Policy Statement
Medications are administered in a safe and timely manner, and as prescribed.
Review of the clinical record revealed Resident #1 was admitted to the facility on [DATE]. Resident #1 had the following diagnoses, in part:
Pain, unspecified, Acquired Absence of Right and Left leg Above the Knee, Peripheral Vascular Disease, Phantom Limb Syndrome with Pain
Review of Quarterly MDS with ARD of 10/02/2022 revealed a BIMS of 15 which indicated Resident # 1 was cognitively intact.
Review of the current Physician's Orders dated 07/01/2022-10/17/2022 revealed the following, in part:
9/13/2022 Percocet 10-325 mg tablet by mouth every 6 hour as needed for pain
Review of Care Plan revealed appropriate problems, goals, and interventions related to Resident 1's condition and diagnosis:
Potential for pain/discomfort related to phantom pain to bilateral lower extremity, mono-neuropathy, and muscle spasm.
-Pain will be managed daily 01/09/2023
Interventions:
-Medication as ordered
Review of the MAR dated 08/01/2022-10/14/2022 revealed the following:
Percocet 10-325 mg take one tablet by mouth every six hours as needed for pain.
Review of the Nurses' Notes dated 07/01/2022-10/17/2022 revealed the following, in part:
10/02/2022 at 8:21 p.m. Resident rated pain 8/10. Nurse requested Percocet to be refilled. No response yet from S14MD. Tylenol650 mg given. Resident states it does not help.
10/03/2022 at 7:49 p.m. Resident with no acute distress noted. Patient complains of not having his prn pain pill prescription refilled despite notifying the physician.
On 10/17/2022 at 1:30 p.m. an interview was conducted with Resident # 1 in his room. He stated sometimes he had to wait for S12MD to reorder his pain medications and doesn't have it available when he feels like he needs it. He stated last month it took 3 weeks before Percocet was reordered and he received it. Resident #1 stated he took the pain medication once per day, usually in the evenings when his pain was worse. He stated if he asked for pain medication more than once per day when it was available, he would get it.
On 10/19/2022 at 10:37 a.m., an interview was conducted with S8LPN. She stated she was aware of one incident when Resident #1 was out of his pain medication.
On 10/19/2022 at 11:50 a.m., an interview was conducted with S3ADON. She stated that the provider was trying to adjust Resident #1's pain medications because he had been taking them so often. She further stated the doctor had to have prior authorization completed to reorder the medication due to it being a narcotic. S3ADON stated the nurse should follow up daily with the doctor or pharmacy to obtain orders for medications or if refills were not available.
On 10/19/2022 at 1:00 p.m., an interview with S13NP was conducted. She stated she remembered a pain management referral had been ordered at one time within the last year for Resident # 1, but he had refused to go. She stated pain management had been discussed with Resident #1 since then, but he continued to refuse this option. She stated she was unaware Resident #1 was without pain medication between the dates of 08/02/2022-08/16/2022, and 09/14/2022-10/4/2022 and was unaware why that would have occurred. She confirmed the 09/13/2022 order for Percocet 10-325 mg tablet by mouth every 6 hours as needed for pain was on the chart. S13NP stated she would have expected Resident #1 to have pain medication available if a current order was in place.
On 10/19/2022 at 1:40 p.m., an interview was conducted with the local contracted Pharmacy Technician. She stated on 09/08/2022 a request to reorder Oxycodone 5 mg was faxed by the pharmacy to S12MD's office. She further stated a reply was entered in the computer which denied the pain medication reorder and indicated an appointment with Resident #1 was needed. She stated there was no further response received at that time.
On 10/19/2022 at 3:30 p.m., an interview was conducted with the local contracted Pharmacist. She confirmed no narcotic pain medication was filled for Resident #1 in September 2022.
On 10/19/2022 at 3:43 p.m. an interview was conducted with S12MD. He stated Resident #1 was on a lot of medications and he was trying to wean him off pain medication due to possible interactions with other medications he had been taking. He stated Resident #1 was taking the pain medication often during the day. He stated he was unaware Resident #1 was without pain medication between the dates of 08/02/2022-08/16/2022, and 09/14/2022-10/4/2022.
On 10/20/2022 at 1:26 p.m., an interview was conducted with S7LPN. She stated she was aware of Resident #1 not having ordered Percocet available previously.
On 10/20/2022 at 2:07 p.m., an interview was conducted with S2DON. S2DON stated if the current prescription needed to be refilled, the nurse would fax a refill request to the pharmacy. He further stated if medication was not filled, or no response was received, the nurse should call the pharmacy and the S12MD once or twice per day to follow up on the status of the order or refill. He stated each communication between the nurse and the doctor or the pharmacy should be documented in the nurses' notes, and he confirmed it was not. He further stated if a medication order was active, the ordered medication should be available.
.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Medical Records
(Tag F0842)
Could have caused harm · This affected 1 resident
Based on interviews and record reviews, the facility failed to maintain accurate documentation for 1 (#80) of 3 (#13, #80, #93) residents reviewed for pressure ulcers. The facility failed to document ...
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Based on interviews and record reviews, the facility failed to maintain accurate documentation for 1 (#80) of 3 (#13, #80, #93) residents reviewed for pressure ulcers. The facility failed to document accurate pressure ulcer staging and assessments for Resident #80.
Findings:
Review of Wound Assessment Report for Resident #80 revealed the following:
Date of Assessment: 06/15/2022. Stage: Unstageable due to slough/eschar. Measurements: 2cm length, 1.5cm width, 0.5cm depth. Wound Bed: Granulation Tissue 100%. Date Electronically Signed: 06/16/2022 by S5LPN and 06/20/2022 by S2DON.
Review of Wound Assessment Report for Resident #80 revealed the following:
Date of Assessment: 06/20/2022. Stage: Unstageable due to slough/eschar. Measurements: 1.5cm length, 1.5cm width, 0.3cm depth. Wound Bed: Granulation Tissue 100%. Date Electronically Signed: 06/22/2022 by S5LPN and 07/01/2022 by S2DON.
Review of Wound Assessment Report for Resident #80 revealed the following:
Date of Assessment: 06/27/2022. Stage: Unstageable due to suspected deep tissue injury. Measurements: 1.5cm length, 2cm width, 0.3cm depth. Wound Bed: Granulation Tissue (Blank). Date Electronically Signed: 06/29/2022 by S5LPN and 07/01/2022 by S2DON.
An interview was conducted on 10/20/2022 at 10:50 a.m. with S5LPN. She stated she was notified of Resident #80's wound on 06/15/2022. She stated at the time it looked like a blister with a lot of bruising. She stated the Hospice RN was notified and came to assess the resident. She stated after the Hospice RN cleaned the wound, the granulation tissue was visualized. She stated S2DON also assessed the wound. She stated after this assessment, she still staged the wound as unstageable because the depth of the bruising was unknown. She stated she should have staged it correctly from the initial assessment.
An interview was conducted on 10/20/2022 at 1:25 p.m. with S5LPN. She stated she received wound care training in-house and online. She stated S2DON rounds with her once a week to assess wounds. She stated granulation tissue would be beefy red without slough. She stated on an unstageable wound, you would not be able to determine the depth. She stated granulation tissue is not tissue damage. She confirmed her documentation of the stage and description of the wound on 06/16/2022 was documented incorrectly.
An interview was conducted on 10/20/2022 at 2:19 p.m. with S2DON. He stated an unstageable wound would be described as no granulation tissue present with slough present. He stated granulation tissue looks pinkish/red in color. He stated you could not have 100% granulation on an unstageable wound. He reviewed the Wound Assessment Report dated 06/16/2022 and confirmed the stage and description of the wound was inaccurate and contained conflicting documentation. He confirmed he assessed the wound, but could not recall the exact description of the wound. He stated based on the documentation he would not be able to accurately describe the wound. He confirmed it was documented inaccurately and would have expected staff to document accurate assessments.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews the facility failed to implement appropriate infection control practices d...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews the facility failed to implement appropriate infection control practices during resident care as evidence by failing to ensure:
1. S11CNA implemented proper hand hygiene and glove usage during incontinence care for 1 (#46) of 2 (#46 and #90) residents reviewed for hospitalizations.
2. S5LPN implemented proper hand hygiene and glove usage during wound care for 1 (#85) of 2 (#80 and #85) residents reviewed for wound care.
Findings:
1.
Review of the policy titled Perineal Care included the following:
Steps in the Procedure:
2. Wash and dry your hands thoroughly.
4. Put on gloves.
For a female resident:
a. Wipe perineal area
c. Wipe/Wash rectal area
9. Discard disposable items into designated containers.
10. Remove gloves and discard in designated containers.
11. Wash and dry your hands thoroughly.
12. Reposition the bed covers. Make the resident comfortable.
Review of Resident #46's medical record revealed an admit date of 08/22/2001. Resident #46 had diagnoses which included Type II Diabetes Mellitus with Diabetic Neuropathy, Functional Urinary Incontinence, and Personal History of Urinary Tract Infections.
Review of Resident #46's MDS with an ARD of 08/29/2022 revealed a BIMS of 10 which indicated the resident had moderate cognitive impairment. Resident #46 required extensive one person physical assistance with bed mobility and toileting.
On 10/17/2022 at 9:54 a.m., an observation was made of Resident #46 receiving incontinent care from S11CNA. S11CNA entered the room, explained the care to be provided, donned gloves, and pulled the curtain. Hand hygiene was not performed. The wall dispenser for alcohol based hand rub was noted to be missing the sanitizing solution and the front face of the device. S11CNA removed two briefs and wipes from the resident's drawer. S11CNA stated it was Resident #46's preference to wear 2 briefs. Resident #46 confirmed this statement by saying she likes 2 briefs because she pees a lot. S11CNA set briefs, a jar of ointment/cream, and wipes next to the bed on the bedside table. S11CNA unfastened the 2 briefs from the resident and pushed them down between the resident's thighs. S11CNA then assisted Resident #46 onto her right side. S11CNA used the soiled brief to remove bowel movement from the resident. S11CNA utilized wipes to clean bowel movement from the resident's buttocks. S11CNA rolled the soiled briefs and bed pad under the resident's right hip. S11CNA retrieved the clean briefs and placed them under the resident. CNA continued to wipe bowel movement from the resident's groin, vagina, and inner thigh. S11CNA then unscrewed the lid from the jar of ointment/cream, stuck her hand into the jar and applied the ointment on the resident. S11CNA screwed the lid back on the jar and placed it on the resident's beside table. S11CNA removed the soiled briefs and linen pad from the resident's bed and placed the items in bags. S11CNA assisted Resident #46 on her back and fastened the 2 new briefs on the resident. S11CNA adjusted the resident's clothing, placed the blanket over the resident, retrieved the bed control to adjust the bed, and finally handed Resident #46 the call light. S11CNA removed the jar of ointment/cream from the bedside table, placed it on top of the residents' personal refrigerator and moved the bedside table next to the resident. S11CNA finally removed a sheet from Resident #46's wheelchair and placed it in the bag with the soiled linens. S11CNA retrieved the bags of soiled linens and briefs, pushed back the privacy curtain, opened the door to the room by the handle, and exited the room. S11CNA walked down the hall, opened the door to the utility room, discarded the soiled linens and briefs, removed/discarded her gloves, exited the utility room and performed hand hygiene with hand sanitizer from a pocket. The entire observation occurred with S11CNA using one pair of gloves.
On 10/17/2022 at 10:07 a.m., an interview was conducted with S11CNA. S11CNA confirmed the aforementioned observation. S11CNA confirmed she did not sanitize her hands before putting on gloves. S11CNA stated hand hygiene was not performed because there was no sanitizer in Resident #46's room. S11CNA confirmed only one pair of gloves were used during the entire observation. S11CNA confirmed the gloves for incontinence care were not removed until the soiled linens and briefs were discarded in the utility room.
On 10/20/2022 at 2:26 p.m., an interview was conducted with S2DON. S2DON stated hand hygiene should be performed before glove application. S2DON stated gloves should be removed/discarded and hand hygiene should be performed after the soiled items are removed from the resident. S2DON was informed of the aforementioned observation and confirmed it was unacceptable.
2.
Review of the medical records for Resident #85 revealed the resident was admitted to the facility on [DATE] with diagnoses, which included in part: Right Lung Cancer, Left Breast Cancer, Diabetes Mellitus II Uncontrolled, Left Below the Knee Amputation, Local Infection Due to central venous catheter.
Review of the MDS with an ARD of 09/19/2022 revealed Resident #85 had a BIM of 15, which indicated the resident was cognitively intact.
Review the facility's policy titled Wound Care revealed, in part Steps in the Procedure:
4. Put on exam glove. Loosen tape and remove dressing.
5. Pull glove over dressing and discard into appropriated receptacle. Wash and dry your hands thoroughly.
6. Put on gloves. Gowns will only be necessary if soiling your skin or clothing with blood, urine, feces, or other body liquids is likely. Masks and eyewear will only be necessary if splashing of blood or other body fluids into your eyes or mouth is likely.
11. Apply treatments as indicated.
On 10/17/2022 at 12:56 p.m., an observation was made of Resident #85 in his room with a dressing on his upper right chest. Resident #85 said the wound dressing to his right chest was from an infection where a chemo port was removed.
On 10/18/2022 at 2:02 p.m., an observation was made of S5LPN. S5LPN completed wound care to Resident #85's right upper chest wound. S5LPN sanitized her hands then applied two pairs of gloves, one on top of the other. S5LPN removed the dirty dressing and cleaned the wound. S5LPN, then removed the first layer of gloves and continued to apply the clean dressing. S5LPN did not re-sanitize her hands or apply a fresh pair of gloves after removing the dirty dressing, cleaning the wound, or reapplying a clean dressing.
On 10/19/2022 at 9:05 a.m., an interview was conducted with S3ADON. S3ADON said the any nurses providing wound care should sanitize their hands at the beginning of the procedure, apply two to three pairs of gloves, remove dirty dressing, shed one pair of gloves, clean the wound, remove the dirty gloves, sanitize hands and then put on clean gloves to apply clean dressing. S3ADON confirmed, that S5LPN should have removed her dirty gloves after removing the dirty dressing, sanitized hands and put on clean gloves before applying the clean dressing.
On 10/19/2022 at 9:25 a.m., an interview was conducted with S2DON. S2DON confirmed S5LPN should have sanitized her hands and put clean gloves on before applying the clean dressing on Resident #85.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Respiratory Care
(Tag F0695)
Could have caused harm · This affected multiple residents
Based on observations and interviews, the facility failed to provide necessary care and services for the provision of respiratory care in accordance with professional standards of practice. The facili...
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Based on observations and interviews, the facility failed to provide necessary care and services for the provision of respiratory care in accordance with professional standards of practice. The facility failed to properly label respiratory care equipment for 4 (#14, #59, #61, and #81) of 5 (#14, #59, #61, #81, and #298) residents investigated for respiratory care.
Findings:
Resident #14
On 10/17/2022 at 9:00 a.m. an observation was made of Resident #14 in his room. Resident #14 was seated on his bed with the nasal cannula on the bed next to him, and concentrator off. He turned on the concentrator and placed the nasal cannula on his face. The oxygen tubing was not labeled or dated.
On 10/18/2022 at 12:20 p.m. an observation was made of Resident #14 in his room with his nasal cannula in place with oxygen flowing. The oxygen tubing was not labeled or dated.
Resident #59
On 10/17/2022 at 9:00 a.m., an observation was made of Resident #59 in her room. Resident #59 was seated in her recliner with the nasal cannula in place with oxygen flowing. The oxygen tubing was labeled and dated 10/02/2022.
On 10/17/2022 at 1:38 p.m., an observation was made of Resident #59 in her room. Resident #59 was seated in her recliner with the nasal cannula in place with oxygen flowing. The oxygen tubing was labeled and dated 10/02/2022.
On 10/18/2022 at 8:30 a.m., an observation was made of Resident #59 in her room. Resident #59 was seated in her bed with her nasal cannula in place with oxygen flowing. The oxygen tubing was labeled and dated 10/02/2022.
Resident #61
On 10/17/2022 at 10:00 a.m., an observation was made of Resident #61's oxygen humidification bottle. The humidification bottle was not labeled.
On 10/18/2022 at 10:43 a.m., an observation was made of Resident #61's oxygen humidification bottle. The humidification bottle was not labeled.
Resident #81
On 10/17/2022 at 9:09 a.m., an observation was made of Resident #81 in her room. Resident #81 was seated in her chair with the nasal cannula in place with oxygen flowing. The oxygen tubing was labeled and dated 10/02/2022.
On 10/17/2022 at 3:09 a.m., an observation was made of Resident #81 in her room. Resident #81 was seated in her chair with the nasal cannula in place with oxygen flowing. The oxygen tubing was labeled and dated 10/02/2022.
On 10/18/2022 at 9:03 a.m., an observation was made of Resident #81 in her room. Resident #81 was seated in her chair with her nasal cannula in place with oxygen flowing. The oxygen tubing was labeled and dated 10/02/2022.
On 10/18/2022 at 12:45 p.m., an interview and observation was conducted with S14LPN. She stated oxygen tubing and humidification bottles were changed weekly on Sunday nights by the Registered Nurse. She observed Resident #59's and Resident #81's oxygen tubing and confirmed they were dated 10/02/2022. She verified the tubing should have been changed weekly.
On 10/18/2022 at 1:18 p.m., an interview was conducted with S7LPN. She stated humidification bottles were changed weekly on Sunday nights by the Registered Nurse. She confirmed Resident #14's oxygen tubing was not labeled or dated and Resident #61's humidification bottle was not labeled or dated and should have been.
On 10/18/2022 at 1:20 p.m. an interview was conducted with S3ADON. She stated the oxygen tubing and humidification bottles were changed by the Registered Nurse every Sunday night. She further stated both the oxygen tubing and humidification bottle should have been labeled and dated.
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
- • 44% turnover. Below Louisiana's 48% average. Good staff retention means consistent care.
Concerns
- • Multiple safety concerns identified: Federal abuse finding, 1 life-threatening violation(s), 1 harm violation(s), $53,262 in fines. Review inspection reports carefully.
- • 42 deficiencies on record, including 1 critical (life-threatening) violation. These warrant careful review before choosing this facility.
- • $53,262 in fines. Extremely high, among the most fined facilities in Louisiana. Major compliance failures.
- • Grade F (8/100). 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 Grace's CMS Rating?
CMS assigns GRACE NURSING HOME an overall rating of 2 out of 5 stars, which is considered below average nationally. Within Louisiana, this rating places the facility higher than 0% of the state's 100 nursing homes. A rating at this level reflects concerns identified through health inspections, staffing assessments, or quality measures that families should carefully consider.
How is Grace Staffed?
CMS rates GRACE NURSING HOME's staffing level at 2 out of 5 stars, which is below average compared to other nursing homes. Staff turnover is 44%, compared to the Louisiana average of 46%. This relatively stable workforce can support continuity of care.
What Have Inspectors Found at Grace?
State health inspectors documented 42 deficiencies at GRACE NURSING HOME during 2022 to 2025. These included: 1 Immediate Jeopardy (the most serious level, indicating potential for serious harm or death), 1 that caused actual resident harm, 39 with potential for harm, and 1 minor or isolated issues. Immediate Jeopardy findings are rare and represent the most serious regulatory concerns. They require immediate corrective action.
Who Owns and Operates Grace?
GRACE NURSING HOME is owned by a for-profit company. For-profit facilities operate as businesses with obligations to shareholders or private owners. The facility operates independently rather than as part of a larger chain. With 128 certified beds and approximately 119 residents (about 93% occupancy), it is a mid-sized facility located in SLAUGHTER, Louisiana.
How Does Grace Compare to Other Louisiana Nursing Homes?
Compared to the 100 nursing homes in Louisiana, GRACE NURSING HOME's overall rating (2 stars) is below the state average of 2.4, staff turnover (44%) is near the state average of 46%, and health inspection rating (2 stars) is below the national benchmark.
What Should Families Ask When Visiting Grace?
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 Grace Safe?
Based on CMS inspection data, GRACE NURSING HOME 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 1 Immediate Jeopardy citation (the most serious violation level indicating risk of serious injury or death). The facility has a 2-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 Grace Stick Around?
GRACE NURSING HOME has a staff turnover rate of 44%, 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 Grace Ever Fined?
GRACE NURSING HOME has been fined $53,262 across 2 penalty actions. This is above the Louisiana average of $33,611. Fines in this range indicate compliance issues significant enough for CMS to impose meaningful financial consequences. Common causes include delayed correction of deficiencies, repeat violations, or care failures affecting resident safety. Families should ask facility leadership what changes have been made since these penalties.
Is Grace on Any Federal Watch List?
GRACE NURSING HOME 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.