FUTURE CARE HOMEWOOD
For profit - Corporation
141 Beds
FUTURE CARE/LIFEBRIDGE HEALTH
Data: November 2025
Trust Grade
50/100
#163 of 219 in MD
Photo by FutureCare - Homewood
Photo by FutureCare - Homewood
Photo by FutureCare - Homewood
1 / 5 photos
Last Inspection: August 2022
Over 2 years since last inspection. Current conditions may differ from available data.
Overview
Future Care Homewood in Baltimore has a Trust Grade of C, which means it is average and sits in the middle of the pack among similar facilities. It ranks #163 out of 219 in Maryland, placing it in the bottom half of state facilities, and #19 out of 26 in Baltimore City County, indicating limited local options for better care. Unfortunately, the facility is worsening, with issues increasing from 15 in 2022 to 18 in 2025. Staffing is a strength, with a 4/5 rating and a turnover rate of 37%, which is below the state average, suggesting that staff are stable and familiar with the residents. There are no fines on record, which is positive, and the facility has more RN coverage than 93% of Maryland facilities, ensuring better oversight for resident care. However, there are notable concerns in care practices. For example, the facility failed to develop comprehensive care plans for several residents, meaning their unique needs were not adequately addressed. Additionally, there were issues with food safety in the kitchen, where improper storage and preparation could potentially affect all residents. Furthermore, some residents reported they were not invited to participate in their own care planning meetings, which is critical for personalized care. Overall, while there are some strengths, families should be aware of these significant weaknesses when considering this facility.
- Trust Score
- C
- In Maryland
- #163/219
- Safety Record
- Low Risk
- Inspections
- Getting Worse
- Staff Stability ○ Average
- 37% turnover. Near Maryland's 48% average. Typical for the industry.
- Penalties ✓ Good
- No fines on record. Clean compliance history, better than most Maryland facilities.
- Skilled Nurses ✓ Good
- Each resident gets 89 minutes of Registered Nurse (RN) attention daily — more than 97% of Maryland nursing homes. RNs are the most trained staff who catch health problems before they become serious.
- Violations ⚠ Watch
- 66 deficiencies on record. Higher than average. Multiple issues found across inspections.
50/100
Bottom 26%
No red flags
15 → 18 violations
★★☆☆☆
2.0
Overall Rating
★★★★☆
4.0
Staff Levels
★★★☆☆
3.0
Care Quality
★★☆☆☆
2.0
Inspection Score
↔
Stable
2022: 15 issues
2025: 18 issues
The Good
-
4-Star Staffing Rating · Above-average nurse staffing levels
-
Full Sprinkler Coverage · Fire safety systems throughout facility
-
No fines on record
-
Staff turnover below average (37%)
11 points below Maryland average of 48%
Facility shows strength in staffing levels, fire safety.
The Bad
2-Star Overall Rating
Below Maryland average (3.0)
Below average - review inspection findings carefully
Staff Turnover: 37%
Near Maryland avg (46%)
Typical for the industry
Chain: FUTURE CARE/LIFEBRIDGE HEALTH
Part of a multi-facility chain
Ask about local staffing decisions and management
The Ugly 66 deficiencies on record
May 2025
18 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 F0582
(Tag F0582)
Could have caused harm · This affected 1 resident
Deficiency Text Not Available
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Deficiency Text Not Available
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
Deficiency Text Not Available
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Deficiency Text Not Available
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0657
(Tag F0657)
Could have caused harm · This affected 1 resident
Deficiency Text Not Available
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Deficiency Text Not Available
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 F0676
(Tag F0676)
Could have caused harm · This affected 1 resident
Deficiency Text Not Available
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Deficiency Text Not Available
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
ADL Care
(Tag F0677)
Could have caused harm · This affected 1 resident
Deficiency Text Not Available
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Deficiency Text Not Available
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
Quality of Care
(Tag F0684)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on a review of the resident medical records and interviews with facility staff, it was determined that the facility failed...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on a review of the resident medical records and interviews with facility staff, it was determined that the facility failed to: 1) ensure that a resident received prescribed medication for 5 days, 2) ensure that a physician's order for a wound consultation was followed timely and 3) clarify a physician's order. This was evident for 3 (Resident # 389, #416 and #394) of 75 residents reviewed during this recertification/complaint survey.
The findings include:
Tafamidis is a medication primarily used to treat transthyretin amyloid cardiomyopathy. However Resident #389's hospital record showed that he/she had been used this medication for [name of cancer].
1) On 5/13/2025, at 12:26 PM, the surveyor investigated complaints for Resident #389. One complainant reported that facility staff did not administer prescribed medication to the resident.
A review of Resident #389's Medical Administration Record (MAR) for December 2024, conducted on 5/14/2025 at 7:58 PM, revealed the resident was prescribed Tafamidis 61mg by mouth once daily for [name of cancer] with a start date of December 12, 2024. However, the MAR documented 9 - other/see progress note from 12/12/2024, to 12/16/2024.
A review of Resident #389's progress notes on 5/14/2025, at 9:05 AM, showed that Registered Nurse (RN #33) wrote a progress note on 12/15/2024, around 3:00 PM, stating: Tafamidis not available, writer called Remedy pharmacy but they do not deliver this medication. Writer was instructed to call specialty pharmacy but they are closed until Monday. Writer informed [attending provider] about this issue. However, there was no additional documentation noted.
During an interview with the Director of Nursing (DON) on 5/14/2025, at 9:33 AM, he stated that if a resident's prescribed medication was not delivered promptly, facility staff would call a contracted pharmacy, which typically delivered medication within four hours. The DON commented, the longest excuse time will be a day.
At 11:04 AM on 5/14/2025, the DON explained that Resident #389's Tafamidis was supposed to be delivered by a specialty pharmacy. He provided a copy of a progress note dated 12/16/2024, at 2:24 PM, which stated, Spoke with pharmacy; medication must be ordered through a specialized pharmacy. When the surveyor asked the DON why this was not addressed upon admission, he did not provide a clear answer. The surveyor shared the concern that Resident #389 did not receive prescribed medication for five days, which the DON validated.
2) On 5/19/25 at 4:11 PM review of Resident #416's medical record revealed the resident was admitted to the facility on [DATE]. Further review of the medical record revealed 6 Skin and Wound Records. Review of the documentation revealed the following:
7/10/2023 14:03 Skin and Wound Record - Category: Buttocks, Right Lower
Skin Condition Type: MASD (Moisture Associated Skin Damage)
Was the skin condition acquired within the facility or prior to admission? In-House Acquired
Wound Status: New
Wound Measurements: Length- 0.9cm, Width- 0.3 cm
7/10/2023 14:07 Skin and Wound Record - Category: Groin, Right
Skin Condition Type: MASD (Moisture Associated Skin Damage)
Was the skin condition acquired within the facility or prior to admission? In-House Acquired
Wound Status: New
Wound Measurements: Length- 1.7 cm, Width- 0.2 cm
8/8/2024 15:17 Skin and Wound Record - Category: Perineum
Skin Condition Type: open area left/right buttocks redness and macerated area on vagina excoriation and sacrum
Was the skin condition acquired within the facility or prior to admission? In-House Acquired
Wound Status: New
Wound Measurements: Length- 7cm, Width- 5cm
Surrounding Skin: Maceration, Redness
Drainage: Serous - Thin, Watery, Clear
Drainage Amount: Light
8/14/2024 09:37 Skin and Wound Record - Category: Perineum
Skin Condition Type: open area left/right buttocks redness and macerated area on vagina excoriation and sacrum
Was the skin condition acquired within the facility or prior to admission? In-House Acquired
Wound Status: Weekly Update
Wound Measurements: Length- 5cm, Width- 4cm
Surrounding Skin: Maceration, Redness
Drainage: Serous - Thin, Watery, Clear
Drainage Amount: Light
10/17/2024 10:17 Skin and Wound Record - Category: Thigh, Right Lateral
Skin Condition Type: MASD (Moisture Associated Skin Damage)
Was the skin condition acquired within the facility or prior to admission? In-House Acquired
Wound Status: New
Wound Measurements: Length-6 cm, Width-3.4 cm
Surrounding Skin: Redness
On 5/20/25 at 8:29 AM, the surveyor requested all wound notes from the wound provider for Resident #416.
On 5/20/25 at 8:37 AM review of Resident #416's medical record revealed a 1/21/24 wound consult order. Further review of the medical record revealed only one note from the wound provider dated 11/13/24.
On 5/20/25 at 8:46 AM in an interview with the Regional Clinical Services Manager (RCSM #4), she provided the surveyor with one wound note from the wound provider. Additionally, the surveyor shared the 1/21/24 wound consult order for Resident #416 and requested any further documentation of when the resident was seen by the wound provider.
On 5/20/25 at 11:47 AM in an interview with the RCSM #4 she stated that Resident #416 was not seen by the wound team until 11/13/2024 as documented on the note provided to the survey team. The surveyor shared the concern about when Resident #416 was seen by the wound provider and the RCSM #4 verified and acknowledged understanding of the concern.
3) On 5/18/25 at 3:28 PM review of Resident #394's orders revealed the following order, resident has been issued a left knee hinged brace; please clarify with ortho (orthopedic) specific of use dated 12/20/23.
On 5/19/25 at 3:42 PM in an interview with the RCSM #4, she showed the surveyor a 12/18/23 Ortho Note that documented, knee brace/hinged dispensed, and stated, but no, she did not see an order or documentation of it applied. The surveyor shared the concern and the RCSM #4 confirmed and acknowledged understanding of the concern. Then, the surveyor stated there was an ortho order from 12/20/23 that the resident had been issued a left knee hinged brace and to clarify with ortho the specifics of use.
On 5/19/25 at 4:31 PM in an interview with the RCSM #4 when asked if there was documentation of where the facility clarified with ortho the specifics of use for the left knee hinged brace. She stated there was no documentation. The surveyor shared the concern, and the RCSM #4 verified and confirmed understanding.
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 F0688
(Tag F0688)
Could have caused harm · This affected 1 resident
Deficiency Text Not Available
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Deficiency Text Not Available
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Incontinence Care
(Tag F0690)
Could have caused harm · This affected 1 resident
Based on a review of the complaint and medical records, and staff interviews, it was determined that facility staff failed to provide/document appropriate and sufficient services, treatment, and care ...
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Based on a review of the complaint and medical records, and staff interviews, it was determined that facility staff failed to provide/document appropriate and sufficient services, treatment, and care for a resident with an indwelling urinary catheter. This was evident for one (Resident #288) of two residents reviewed for urinary catheter care during this recertification/complaint survey.
The findings include:
An indwelling urinary catheter (often known as a Foley catheter) is inserted similarly to an intermittent catheter but remains in place, secured in the bladder by a water-filled balloon.
A complaint review on 5/15/2025, at 5:56 PM, revealed that Resident #288's family member reported concerns in December 2022. The family stated, the resident called crying around 12 PM because his/her Foley bag had not been emptied and had been so full.
A review of Resident #288's medical records on 5/19/2025, at 7:05 AM, showed that the facility's attending provider documented in the History and Physical (H&P) on October 12, 2022, that Resident #288 had a Foley catheter draining clear urine. However, there was no initial order for Foley care upon the resident's admission. An order for Foley catheter care, stating Patient has Foley type of indwelling catheter. 16FR 10cc Balloon for obstructive uropathy. Provide catheter care every shift. -Start Date 11/10/2022, was initiated on 11/10/2022.
During an interview with the Director of Nursing (DON) on 5/19/2025, at 7:21 AM, he stated that facility nurses should monitor residents with Foley catheters each shift for urine color, bleeding, and output. The surveyor reviewed Resident #288's orders with the DON.
At 8:46 AM on 5/19/2025, the DON confirmed the absence of an order for Foley care and documentation of urine output upon Resident #288's admission. He explained that urine output monitoring was not required for recording since there was no specific order. The surveyor then informed the DON that there was no documentation indicating who emptied Resident #288's Foley bag or provided care, which the DON validated.
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
Pharmacy Services
(Tag F0755)
Could have caused harm · This affected 1 resident
Based on a review of resident medical records and interviews with facility staff, it was determined that the facility failed to ensure drug records were maintained in a manner that allowed for reconci...
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Based on a review of resident medical records and interviews with facility staff, it was determined that the facility failed to ensure drug records were maintained in a manner that allowed for reconciliation of dispensed and administered medication. This failure was evident for one resident (Resident #410) out of two residents reviewed for narcotic medication administration during this recertifiation/complaint survey.
The findings include:
Oxycodone is a narcotic medication used to treat moderate to severe pain. It carries a high risk for addiction and dependence and can cause respiratory distress and death when taken in high doses or when combined with other substances, especially alcohol or other illicit drugs such as heroin and cocaine.
A controlled medication utilization record, known as a count sheet, is a form used to document controlled medication dispensing. It records details for each instance a controlled substance amount is removed from its original containers, including the date, time, dose given, the signature of the nurse administering the medication, the amount remaining, the amount wasted, and the signature of the person who checked.
As part of the complaint investigation related to Resident #410, the surveyor reviewed the resident's medical records on 5/13/2025, at 1:40 PM. The review of the Medication Administration Record (MAR) revealed that the resident had two different orders for Oxycodone:
- Oxycodone HCl Oral Tablet 5 MG, Give 1.5 tablets by mouth every day shift for pain, 30 minutes prior to wound treatment. Start date: January 29, 2025.
- Oxycodone HCl Oral Tablet 5 MG, Give 1 tablet by mouth every 6 hours as needed for moderate to severe pain (7-10 on a pain scale). Start date: November 19, 2024.
Additionally, the surveyor reviewed Resident #410's controlled medication records from January 9, 2025, to February 26, 2025. The following discrepancies were noted:
- On 1/2/2025, the count sheet recorded 1 tablet of Oxycodone 5mg given at 9:00 AM, but there was no corresponding documentation in the MAR.
- On 1/27/ 2025, the count sheet recorded 1 tablet of Oxycodone 5mg given at 6:00 AM and 12:00 PM, but there was no corresponding documentation in the MAR.
- On 1/31/2025, the count sheet recorded 1 tablet of Oxycodone 5mg given at 1:00 PM, but there was no corresponding documentation in the MAR.
- A new order for Oxycodone 5mg was placed on 2/01/2025, to give 1.5 tablets (7.5mg) for pain, 30 minutes prior to wound treatment, scheduled during the daytime. However, the count sheet documented the administration of only 1 tablet each day from February 1, 2025, to February 11, 2025.
- On February 8, 2025, the count sheet recorded 1 tablet of Oxycodone 5mg given at 2:00 PM, but there was no corresponding documentation in the MAR.
- On February 15, 2025, the count sheet recorded 1 tablet of Oxycodone 5mg given at 12:00 AM, 6:00 AM, and 12:00 PM. However, the MAR only documented Oxycodone 7.5mg given prior to wound care at day time (without a specific scheduled time, only noting the order as 'day').
- On February 16, 2025, the MAR documented that Resident #410 received Oxycodone 5mg as needed medication at 11:05 AM, but there was no corresponding documentation in the count sheet.
- On February 24, 2025, the MAR documented that Resident #410 received Oxycodone 5mg as needed medication at 6:53 PM, but there was no corresponding documentation in the count sheet.
- On February 25, 2025, the count sheet recorded 1 tablet of Oxycodone 5mg given at 9:30 PM, but there was no corresponding documentation in the MAR.
During an interview with the Director of Nursing (DON) on May 13, 2025, at 11:13 AM, he stated that controlled medication administration should be documented in both the MAR and the count sheet.
In a follow-up interview with the DON at 2:24 PM on May 13, 2025, the surveyor reviewed Resident #410's count sheet and MAR with him. The surveyor asked how nurses were able to administer 1.5 tablets if the medication was delivered as whole tablets. The quantity documented on the attached delivery sticker in the count sheet matched the quantity nurses marked as received. The DON explained that Oxycodone 5mg half-tablets were delivered in a bubbled pack on February 18, 2025; the sticker showed a quantity of 15, but nurses documented receiving 30 half-tablets. The surveyor then showed him another count sheet dated January 28, 2025, which showed 28 quantities of Oxycodone 5mg delivered, and 28 quantities received. In that count sheet, nurses documented an amount given of 1.5 tablets for both February 17, 2025, and February 18, 2025. Regarding this, the DON stated, It should be given as whole tablets. We are not supposed to cut half-tablets of Oxycodone. The surveyor also informed him of the discrepancy between the MAR and the count sheets, and the DON validated these concerns.
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
Unnecessary Medications
(Tag F0759)
Could have caused harm · This affected 1 resident
Deficiency Text Not Available
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Deficiency Text Not Available
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 F0790
(Tag F0790)
Could have caused harm · This affected 1 resident
Deficiency Text Not Available
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Deficiency Text Not Available
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Medical Records
(Tag F0842)
Could have caused harm · This affected 1 resident
Deficiency Text Not Available
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Deficiency Text Not Available
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 F0883
(Tag F0883)
Could have caused harm · This affected 1 resident
Deficiency Text Not Available
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Deficiency Text Not Available
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 F0919
(Tag F0919)
Could have caused harm · This affected 1 resident
Based on observation and interviews, it was determined that the facility failed to ensure that every resident had access to a communication system to call for staff assistance, if needed. This is evid...
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Based on observation and interviews, it was determined that the facility failed to ensure that every resident had access to a communication system to call for staff assistance, if needed. This is evident for 3 (Resident #100, #87, #40) of 8 resident's call bell accessibility observed during the recertification/complaint survey.
Findings Included:
On 05/21/25 at 08:45 AM, a surveyor conducted an audit for call bell accessibility and function, during the audit the following concerns were identified:
In an interview with Resident #95, he/she was asked if there was any concerns about the call light system, Resident #95 stated that his/her call bell was in good working condition, but the roommate's (Resident #100) call bell stop working a while ago. Resident #100 was not present for an interview; however, the surveyor attempted to use Resident #100's call bell and it was in-operable.
At approximately 9:10 AM, the surveyor inquired with Resident #87 regarding the call light system and upon closer observation, it was noted that Resident #87's call bell was not within reach. Specifically, Resident #87's call bell was clipped to their roommate's bed (Resident #40), while Resident #40's call bell was hanging above his/her bed, rendering it out of reach for both residents. In an interview with Resident #40, he reported that the call light was broken for a long time. The surveyor inspected the hanging call bell and further observation revealed that the call bell button was observably broken. The 6th floor Unit manager #42 was notified and he stated that it will be addressed.
On 05/21/25 at 10:33 AM, in an interview with the Director of nursing (DON), he was notified of the above-mentioned findings.
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 F0947
(Tag F0947)
Could have caused harm · This affected 1 resident
Deficiency Text Not Available
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Deficiency Text Not Available
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 F0697
(Tag F0697)
Could have caused harm · This affected multiple residents
Based on observations, record reviews, and staff interviews, it was determined that the facility failed to provide appropriate pain management for residents. This was evident for 2 resident (Resident ...
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Based on observations, record reviews, and staff interviews, it was determined that the facility failed to provide appropriate pain management for residents. This was evident for 2 resident (Resident #137 and Resident #410) of 3 residents who were reviewed for pain management during the recertification/complaint survey.
The findings include:
1) During a complaint investigation on 5/12/2025, at 5:58 PM, it was revealed that in February 2025, a complainant reported Resident #410 was in constant pain from wounds and often received medication late.
On 5/13/2025, at 9:50 AM, Registered Nurse (RN #13) explained that nurses documented medication administration time when they physically handed medications to residents. The final documented time was entered after leaving the resident's room and saving the record. RN #13 stated, it should have a couple minutes gap, but not hours gap. Additionally, RN #13 explained that wound nurses communicated wound care schedules to floor nurses, enabling them to administer pain medication prior to treatment.
When interviewed on 5/13/2025, at 10:48 AM, the wound nurse (Staff #2) confirmed she informed nurses of the wound dressing schedule and provided care after medications were given. Staff #2 also confirmed that the administration time reflected the actual time care was provided, while the documented time was when the save button was pressed.
On 5/13/2025, at 11:00 AM, the surveyor reviewed Resident #410's medical records, including orders and Medication Administration Records (MAR) for February 2025. The review found an order for oxycodone HCl Oral Tablet 5 MG (Oxycodone HCl) Give 1.5 tablet by mouth every day shift for pain total 7.5mg. Give medication 30 minutes prior to wound treatment -Start Date 2/01/2025. Wound dressing orders for the resident included applying Betadine and Santyl ointment to a wound on the right great toe and to the right lateral foot.
On 5/13/2025, the surveyor requested Medication Administration documentation with time stamps for every other day in February 2025 and corresponding wound treatment records with time stamps.
However, a comparison of Oxycodone and wound dressing times in February from the Medication Administration Audit Report revealed Resident #410 did not receive appropriate pain medication prior to wound dressing. The review of every other day in February showed Oxycodone was given 3-7 hours earlier than wound care, or pain medication was given 3 hours later than wound dressing. For example:
- On February 2, 2025: Oxycodone 7.5mg administered at 9:56 AM; Santyl Ointment wound care administered at 1:49 PM.
- On February 4, 2025: Oxycodone 7.5 mg administered at 8:23 AM; Right great toe wound dressing applied at 3:14 PM.
- On February 6, 2025: Oxycodone 7.5mg administered at 8:42 AM; Santyl ointment wound care documented at 12:17 PM.
- On February 8, 2025: Oxycodone 7.5mg administered at 11:00 AM; Wound care provided at 2:23 PM.
- On February 10, 2025: Oxycodone 7.5mg administered at 10:02 AM; Wound care provided at 1:55 PM.
- On February 20, 2025: Wound care provided at 10:19 AM; Oxycodone 7.5mg administered at 1:16 PM.
During an interview with the Director of Nursing (DON) on 5/13/2025, at 11:13 AM, the surveyor reviewed Resident #410's medication audit form with him. The DON validated that Resident #410 did not receive pain medication properly before receiving wound care.
2) The medical abbreviation PRN stands for 'pro re nata' (a Latin phrase), which means the medication is taken on an as needed basis and is not prescribed to be administered at scheduled times.
The numeric rating scale (NRS) is a pain screening tool, commonly used to assess pain severity at that moment in time using a 0-10 scale, with zero meaning no pain and 10 meaning the worst pain imaginable.
On 05/20/25 at 08:16 AM, review of the medical records revealed that the resident # 137 stayed short-term at the facility and was diagnosed with chronic pain syndrome and a surgical wound.
The Resident was ordered, oxycodone HCl Oral Capsule 5 MG, give 7.5 mg by mouth every 4 hours as needed for Pain scale 4-6 on 03/23/25, and oxycodone HCl Oral Tablet 15 MG, give 1 tablet by mouth every 4 hours as needed for Pain scale 7-10 on 03/23/25.
Further medical record review revealed that on 03/23/25 at 11:28 PM, the resident # 137 complained of pain, scoring 10/10. Oxycodone 7.5 mg was administered by Registered Nurse # 40. Per the physician's orders, the resident was to receive the oxycodone 15 mg for a pain scale rating of 7-10, but received only Oxycodone 7.5 mg.
On 05/20/25 at 10:59 AM, an interview with Registered Nurse staff # 40 verified that he/she administered PRN pain medication and confirmed that the pain medication was administered outside of the physician's ordered parameters.
On 05/21/25 at 2:30 PM, the Director of Nursing (DON) validated that the medication was administered outside the parameters.
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 F0726
(Tag F0726)
Could have caused harm · This affected multiple residents
Deficiency Text Not Available
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Deficiency Text Not Available
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
Food Safety
(Tag F0812)
Could have caused harm · This affected multiple residents
Deficiency Text Not Available
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Deficiency Text Not Available
Aug 2022
15 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0561
(Tag F0561)
Could have caused harm · This affected 1 resident
Based on resident interview, family interview, staff interview, and clinical record review it was determined that the facility nursing staff failed to ensure residents received at least two showers ea...
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Based on resident interview, family interview, staff interview, and clinical record review it was determined that the facility nursing staff failed to ensure residents received at least two showers each week (#26, #31, and #102). This was evident for 3 out of the 66 residents reviewed as part of the survey process.
The findings are:
1. Resident #26 was interviewed on 7/27/22 at 9:18 AM. The resident stated that he/she was never offered a shower since admission and has only received bed baths. A review of the shower documentation for July and August in the clinical record revealed that the resident has only received a shower on 7/20 and 7/29. That works out to 2 out of 10 opportunities for showers.
Regional Nurse #1 was interviewed on 7/27/27/22 at 9:18 AM. She was informed of the findings and confirmed that the resident received two showers since July.
2. Resident #31 was interviewed on 7/25/22 at 12:48 AM. The resident stated that he/she has not received a shower for awhile and bed baths are provided twice a week in the room. A review of the shower documentation in the clinical records revealed that the resident has not had a shower in two months. There were documented refusals on 6/12, 6/14, and 7/29.
Regional Nurse #1 was interviewed on 8/1/22 at 12:13 PM. She said that the resident did not receive a shower in the past 30 days according to the shower task sheet but did produce two times the resident refused.
3. An interview with Resident #102's son on 7/26/22 at 12:32 PM revealed the resident has had only two showers since admission.
Regional Nurse #1 and the Assistant Director of Nursing/Staff #20 were interviewed on 7/29/22 at 8:19 AM. Informed them that the resident's son stated the resident has not had more than 2 showers since admission.
Regional Nurse #1 was interviewed on 7/29/22 at 11:37 AM. She confirmed that the resident has had only showers during the past year.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0567
(Tag F0567)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to properly manage the funds of a resident (Resident #109). This was e...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to properly manage the funds of a resident (Resident #109). This was evident for 1 out of 3 residents reviewed during an annual survey.
The findings include:
During interview with Resident #109 on 7/26/22 at 11:51 AM the Resident stated the facility has failed to pay his/her AARP (The American Association of Retired Persons) insurance coverage from his/her pension funds. The Resident stated he/she had the AARP insurance prior to coming to the facility and the facility agreed to pay using his/her funds when he/she was admitted to the facility. Resident also stated had that time he/she has received 2 late notices from AARP.
Review of the Resident's medical record revealed the Resident was admitted to the facility on [DATE].
On 7/26/22 the facility provided the surveyor a copy of the Resident's RFMS (Resident Fund Management Service) Resident statement that showed payments monthly for insurance premiums in the amount of $441.00.
The Resident provided the surveyor the 2 notices of nonpayment he/she had received from AARP Supplemental and Personal Health from United Healthcare. The first notice was dated 5/7/22 and stated Our records show that we have not received a needed premium payment for your account. Premium payments for your health insurance coverage are due on the first of the month The second notice was dated 7/9/22 and stated Our records show that we have not received a needed premium payment for your account.
Review of the Resident's RFMS Statement revealed the facility failed to pay the Resident's AARP Insurance premium for April 2022 by the first of the month and the facility documented not withdrawn from the Resident's account until 4/25/22. Further review of the Resident's RFMS Statement revealed there was no payment made in June 2022.
Interview with the Business Office Manager and Regional Nurse #1 on 7/29/22 at 9:13 AM confirmed the Surveyor's findings.
CONCERN
(D)
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 review of facility documents and staff interview it was determined the facility failed to timely report an allegation o...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility documents and staff interview it was determined the facility failed to timely report an allegation of abuse to the State Survey Agency which is the Office of Health Care Quality (OHCQ). This was evident for 2 (#218 and #317) of 12 residents reviewed for abuse.
The findings include:
On 7/29/22 at 9:15 a.m. closed medical record review was conducted of the facility reported incident MD00168244 related to an allegation of verbal abuse involving resident #218 on 6/2/21. The facility documentation indicated the alleged incident was reported to the state agency on 6/4/21 which was two days after the alleged incident. Law enforcement agency documented reporting to facility on 6/4/21 arrival 9:24 p.m. The facility failed to report the abuse incident immediately not later than 2 hours of the event that caused the allegation.
On 7/29/22 at 1:00 p.m. conduct staff interview with Corporate Regional Nurse verified these allegations had not been reported to the Office of Healthcare Quality in required reporting time frame.
All concerns were discussed in detail with Administrator, Director of Nursing and Corporate Regional Nurse in detail during and prior to annual survey exit.
2. The facility staff failed to report an allegation of misappropriation of property in a timely manner.
Review of Resident #317's medical record on 8/2/22 revealed the Resident was admitted to the facility on [DATE] from the hospital and was later discharged from the facility.
Review of a facility reported incident reported to the Office of Health Care Quality (OHCQ) on 9/23/19 revealed the Resident's family member reported to facility staff on 9/21/19 the Resident was missing a ring the family brought in and placed on the Resident's finger on 9/17/19.
Further review of the facility reported incident revealed although the facility staff were aware the ring was missing on 9/21/19 it was not reported to police and OHCQ until 9/23/19, 2 days after the incident.
Interview with Regional Nurse #1 on 8/5/22 at 9:02 AM confirmed the facility failed to report an allegation of misappropriation of property to OHCQ and the police in a timely manner.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Quality of Care
(Tag F0684)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview, it was determined the facility staff failed to provide wound treatments as ordered...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview, it was determined the facility staff failed to provide wound treatments as ordered by the physician for residents (Resident #37 and #315). This was evident for 2 out of 7 residents reviewed for skin conditions during the annual survey.
The findings include:
1. The facility staff failed to provide wound care for Resident #37.
Review of Resident #37's medical record on 7/29/22 revealed the Resident was admitted to the facility on [DATE] and had a physician order on 6/15/22 for wound care on left second finger daily. Further review of the Resident's medical record revealed the wound to be an arterial ulcer related to vascular insufficiency. Arterial wounds, also known as arterial ulcers, are painful injuries in your skin caused by poor circulation.
During interview with Resident #37 on 8/3/22 at 11:28 AM, the Resident stated the facility staff are not changing his/her wound dressings daily.
Review of Resident #37's Treatment Administration Records (TAR) on 8/3/22 for June, July and August 2022 revealed the facility staff did not administer wound treatment as ordered for the Resident's left 2nd finger on 6/20, 6/21, 6/25, 6/28, 6/30, 7/5, 7/7, 7/9, 7/11, 7/13, 7/19, 7/23, 8/1 and 8/2/2022.
Interview with Regional nurse #1 on 8/4/22 at 7:30 AM confirmed the surveyor's findings of facility staff not administering wound treatment daily as ordered for Resident #37.
2. The facility staff failed to provide wound care for Resident #315.
During interview with Resident #315 on 7/26/22 at 10:19 AM, the Resident stated the facility doesn't always do his/her foot wound dressing because they don't have enough supplies. Observation of the Resident at the time revealed a wound dressing and wound vac in place to the Resident's left foot.
Review of Resident #315's medical record on 7/28/22 revealed the Resident was admitted to the facility on [DATE] from the hospital following surgical amputation of the left foot. Review of the Resident's hospital discharge summary revealed the Resident was discharged with physician orders for a wound vac and dressing to the left foot.
Further review of the Resident's medical record revealed the facility staff obtained the wound vac on 7/13/22 and began treatment on 7/13/22 as ordered three days a week: Mondays, Wednesdays and Fridays.
On 7/20/22 at 3:31 PM the facility staff documented, Wet to dry dressing apply. Wound vac dressing supply not available at this time. Further review of the Resident's medical record revealed the wound vac was not reapplied until 7/22/22.
The facility staff did not document if the wound vac dressing was changed on 7/25/22 but only that the dressing was in place.
Interview with Regional nurse #1 on 8/4/22 at 7:30 AM confirmed the facility staff failed to have wound vac dressing supplies in place to change the Resident's dressings as ordered from 7/20/22 until 7/22/22 and did not document if the wound vac dressing was changed on 7/25/22.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Pressure Ulcer Prevention
(Tag F0686)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview, the facility staff failed to provide treatment/services to prevent/heal pressures ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview, the facility staff failed to provide treatment/services to prevent/heal pressures ulcers for a resident (Resident #37). This is evident for 1 of 7 residents reviewed for pressure ulcers during an annual survey.
A pressure ulcer also known as pressure sore, or decubitus ulcer is any lesion caused by unrelieved pressure that results in damage to the underlying tissue. Pressure ulcers are staged according the their severity from Stage I (area of persistent redness), Stage II ( superficial loss of skin such as an abrasion, blister or shallow crater), Stage III ( full thickness skin loss involving damage to subcutaneous tissue presenting as a deep crater), Stage IV (full thickness skin loss with extensive damage to muscle, bone or tendon) or Unstageable Pressure Ulcer (full thickness tissue loss in which the base of the ulcer is covered by slough and / or eschar in the wound bed).
The findings include:
Review of Resident #37's medical record on 7/29/22 revealed the Resident was admitted to the facility on [DATE] with a diagnosis to include an unstageable pressure ulcer to the right buttock and an unstageable pressure ulcer to the left buttock.
During interview with Resident #37 on 8/3/22 at 11:28 AM, the Resident stated the facility staff are not changing his/her wound dressings daily.
Review of Resident #37's Treatment Administration Records on 8/3/22 for June, July and August 2022 revealed:
A. The Resident's right buttock wound dressing was not administered on 6/7, 6/14 and 6/20/22. The pressure ulcer to the right buttock is documented as healed on 6/21/22.
B. The Resident's left buttock wound dressing was not administered on 6/7, 6/14, 6/20, 6/21, 6/28, 630, 7/5, 7/7, 7/11, 7/19, 7/23, 8/1 and 8/2/22.
Interview with Regional nurse #1 on 8/4/22 at 7:30 AM confirmed the facility staff did not provide daily dressings as ordered to Resident #37's right and left buttock wounds.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Incontinence Care
(Tag F0690)
Could have caused harm · This affected 1 resident
Based on medical record review, observation, and interviews with facility staff it was determined the facility staff failed to provide evidence of adequate care to residents with indwelling urinary ca...
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Based on medical record review, observation, and interviews with facility staff it was determined the facility staff failed to provide evidence of adequate care to residents with indwelling urinary catheters (Residents #103). This was evident for 1 of 5 residents reviewed for indwelling urinary catheters during the annual survey.
The Findings:
A review of Resident #103's clinical record revealed that the resident's primary physician wrote an order on 6/30/2022, Patient has Foley catheter 16Fr; Balloon size 10ml, for stage 4 sacral ulcer. Provide catheter care every shift.
On 07/26/22 at 10:22 AM an observation of resident #103's revealed the foley catheter tubing resting by the resident's left hip. At that time the Unit Manger was made aware of the findings and confirm that the resident did not have a foley catheter leg strap.
On 8/5/22 at 1 pm interview with Regional Nurse revealed that catheter care does not include leg straps and a physician order will be obtained.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0692
(Tag F0692)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On 8/3/22 at 9 AM a medical record review for Resident #64 revealed on 12/4/21 the physician ordered: weight every week. The Nut...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On 8/3/22 at 9 AM a medical record review for Resident #64 revealed on 12/4/21 the physician ordered: weight every week. The Nutrition Assessment on 12/7/21 also stated to monitor weights for trends. The Nutrition Assessment recommendations were approved by the Certified Registered Nurse Practitioner (CRNP # 16)
A review of medical records revealed the facility staff obtained weekly weights from 12/4/21 -3/7/22, after that no weights were obtained as ordered by the physician.
On 8/03/22 1:19 PM interview with the Unit manager (#17) revealed that Resident #64 refuses weights, turning, and mouth care, and that the refusal of care is not documented in Resident's #64 medical record.
On 8/5/22 at 8 am an interview with RN#19 stated that Resident #64 refuses care such as turning and repositioning, wound care, weights, and personal hygiene care due to pain. The refusal of care is not documented in the resident's medical record by facility staff nor was a care plan initiated for refusal of care.
An interview with the Director of Nursing on 8/8/22 at 12 PM confirmed the facility staff failed to obtain weights as ordered by the physician for Resident #64.
2. The facility staff failed to recognize a resident's weight loss, reweigh and provide a dietary consult in a timely manner.
Observation of Resident #5 on 7/25/22 at 9:18 AM revealed the Resident to be thin.
Review of Resident #5's medical record on 7/27/22 revealed the Resident was admitted to the facility on [DATE] and had a diagnosis of malnutrition. Malnutrition occurs when the body doesn't get enough nutrients, causes include a poor diet, digestive conditions, or another disease.
Further review of Resident #5's medical record revealed on 4/13/22 the Resident weighed 128.2 pounds and on 5/24/22 the Resident weighed 113 pounds, for a loss of 15.2 pounds. The Resident was weighed again on 6/2/22 and again weighed 113 pounds.
On 6/7/22 the Resident was seen and assessed by the Nurse Practitioner (NP), 2 weeks after the weight loss. At that time the NP documented: Patient has had an abnormal weight loss of about 15 pounds in 2 months. We will ask for a re-weigh. Patient eats about 50% of meals and refuses assistance with meals and care. Unspecified protein-calorie malnutrition. Patient with abnormal weight loss. To follow-up with dietitian.
Further review of the Resident's weights revealed the Resident was not weighed again until 7/4/22 with a weight of 114 pounds.
Further review of the Resident's medical record revealed the Resident was not seen and assessed by the dietitian until 7/19/22.
Interview with Regional nurse #1 on 7/29/22 at 11:45 AM confirmed the facility staff failed to recognize, reweigh and obtain a dietary consult for Resident #5 in a timely manner.
Based on resident interview, staff interview, and clinical record review it was determined that the facility staff failed to ensure a resident's physician was notified about weight loss (#102), failed to recognize a resident's weight loss, reweigh and provide a dietary consult in a timely manner (#5), and failed to obtain ordered weights (#61). This was evident for 3 residents out of the 66 sampled as part of the survey.
The evidence is:
1. A review of Resident #102's clinical record revealed that the resident has had a 22% weight loss since admission a year ago. There was no mention in the clinical record of the physician being contacted regarding this weight loss.
A review of the resident's clinical record revealed that on 8/2/21 the dietician wrote a note Resident readmitted after short stay hospital . Received IVF [Intravenous fluids] and IVABT [IV antibiotics] during hospital course. Wt [weight] 7/29 168.3#. Magic cup (nutritional supplement) was ordered to continue, and dietician added Med Pass 120 ml three times a day for additional calories and protein.
The dietician wrote another note on 9/16/21. The resident's weight was noted to be 168 lb on 8/2/21, 130 lb on 9/6/21, and 130 lb on 9/13/21. The dietician wrote Resident with significant weight loss of 22% x 1 month s/p [status post] hospitalization, weight has been stable x 3 weeks. Resident with variable PO [by mouth] intake. The primary physician is then notified.
A review of the clinical record revealed that the physician was not contacted on 9/6/21 when it was found that the resident had a weight loss of 22% in one month.
Regional Nurse #1 was interviewed on 7/29/22 at 11:37 AM. She said she could not find evidence that the primary physician was immediately notified of the weight loss or that there was an immediate intervention.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Respiratory Care
(Tag F0695)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medical record review and interview, it was determined the facility staff failed to provide oxygen therapy...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medical record review and interview, it was determined the facility staff failed to provide oxygen therapy consistent with professional standards of practice for a resident (Resident #37). This was evident for 1 out of 3 residents reviewed for oxygen therapy during an annual survey.
The findings include:
Observation of Resident #37 on 7/25/22 at 9:34 AM revealed the Resident was wearing humidified oxygen at 2 liters nasal cannula.
Review of Resident #37's medical record on 7/29/22 revealed the Resident was admitted to the facility on [DATE] and did not have a physician order for oxygen. Further review of the Resident's medical record revealed the facility staff began documenting the Resident was wearing oxygen on 8/27/21.
During interview with Resident #37 on 8/3/22 at 11:28 AM, the Resident stated he/she couldn't remember the exact date he/she began wearing oxygen but stated it has been a long time. Observation of the Resident's humidified oxygen revealed it was dated 7/28/22.
Review of the Resident's July 2022 Treatment Administration Record revealed there was no documentation of when to change and date the Resident's oxygen equipment.
Interview with Regional nurse #1 on 8/4/22 at 7:30 AM confirmed the facility staff failed to obtain a physician order for oxygen and document care of the oxygen equipment on the Resident #37's Treatment Administration Records.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Transfer Notice
(Tag F0623)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
6). On 8/4/22 at approximately 9:00 a.m. during closed medical record review of facility reported incident intake MD00177364 in...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
6). On 8/4/22 at approximately 9:00 a.m. during closed medical record review of facility reported incident intake MD00177364 involving Resident #225 for hospitalization transfer revealed on 5/19/22 resident #225 had experienced a change in condition. Resident #225 was sent out to the hospital for further medical evaluation.
On 8/5/22 at 7:30 a.m. during interview with Corporate Regional Nurse verified no written notice in writing for reason for nursing home transfer to hospital was given to resident or their family members.
The Administrator with Director of Nursing and Corporate Regional Nurse was provided in detailed discussion of concerns prior and during survey exit on 8/8/2022.
Based on medical record review and interview with staff it was determined the facility staff failed to provide written notice for emergency transfers to the residents, and residents' representative. This was found to be evident for 6 out of 7 (#3, #97 #103, #104, #225, and #37) residents reviewed for a facility-initiated transfer during the investigative of the survey.
The findings include:
1. A review of Resident # 3's clinical record revealed that on 6/16/22 and 7/2/22, the resident was sent to the hospital for treatment and evaluation. The review also revealed that the facility staff failed to provide written notice for emergency transfers to the residents and/or the residents' representative.
2. A review of Resident # 97's clinical record revealed that on 6/23/22, the resident was sent to the hospital for treatment and evaluation. The review also revealed that the facility staff failed to provide written notice for emergency transfers to the residents and/or the residents' representative.
3. A review of Resident # 103's clinical record revealed that on 6/18/22, the resident was sent to the hospital for treatment and evaluation. The review also revealed that the facility staff failed to provide written notice for emergency transfers to the residents and/or the residents' representative.
4. A review of Resident # 104's clinical record revealed that on 7/28/22, the resident was sent to the hospital for treatment and evaluation. The review also revealed that the facility staff failed to provide written notice for emergency transfers to the residents and/or the residents' representative.
On 08/01/22 at 07:40 AM, the Regional Nurse stated that they did not provide written notice for emergency transfers to the residents or the residents' representative.
5. Review of Resident #37's medical record on 7/28/22 revealed the Resident was admitted to the facility on [DATE]. The Resident was discharged from the facility to the hospital on 3/31/22. Further review of the Resident's medical record failed to reveal any documentation that a notice regarding the transfer had been provided to the Resident or the Resident's responsible party.
Interview with Regional Nurse #1 on 7/29/22 at 7:45 AM confirmed the facility had no evidence Resident #37 and the Resident's responsible party had been given written notification of the transfer to the hospital and the reason for the transfer.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Comprehensive Care Plan
(Tag F0656)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
4. On 7/26/22 at 12 PM a review of Resident # 64's clinical record revealed that the resident's weekly weight was last recorded...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
4. On 7/26/22 at 12 PM a review of Resident # 64's clinical record revealed that the resident's weekly weight was last recorded on 3/7/2022 and no other documentation was noted until 7/13, 7/15, and 7/19 which stated that the resident refused weights.
On 8/03/22 1:19 PM interview with the Unit manager (#17) revealed that Resident #64 refuses weights, turning and reposition, and mouth care, and that the refusal of care is not documented in Resident's #64 medical record.
On 8/5/22 at 8 am an interview with RN#19 stated that Resident #64 refuses care such as turning and repositioning, wound care, weights, and personal hygiene care due to pain. The refusal of care is not documented in the resident's medical record by facility staff nor was a care plan initiated for refusal of care.
Further record review revealed the facility staff documented care plan meetings on 12/6/2021, and 3/30/2022 and failed to initiate care plans to address the refusal of multiple areas of care such as weights, mouth care, and turning from side to side.
On 8/5/22 at 11:37 AM The Regional Nurse confirmed the surveyor's findings.
Based on medical record review and interview, it was determined the facility staff failed to develop comprehensive care plans for residents (Resident #37, #64, #89, #113). This was evident for 4 out of 66 residents reviewed during an annual survey.
The findings include:
A care plan is an outline of nursing care showing all the resident's needs and the ways of meeting the needs. Care plans provide direction for individualized care of the resident. A care plan flows from each resident's unique list of diagnoses and should be organized by the individual's specific needs. It is a dynamic document initiated at admission and subject to continuous reassessment and change by the nursing staff caring for the resident. The care plan typically includes nursing and medical diagnoses, nursing interventions, and outcomes to ensure consistency of care.
1. The facility staff failed to develop a care plan addressing Resident #37's need for oxygen therapy.
Observation of Resident #37 on 7/25/22 at 9:34 AM revealed the Resident was wearing humidified oxygen at 2 liters nasal cannula.
Review of Resident #37's medical record on 7/29/22 revealed the Resident was admitted to the facility on [DATE] and did not have a physician order for oxygen. Further review of the Resident's medical record revealed the facility staff began documenting the Resident was wearing oxygen on 8/27/21.
Review of Resident #37's care plans revealed the Resident did not have a care plan to manage the Resident's oxygen therapy that would include goals and interventions.
Interview with Regional nurse #1 on 8/4/22 at 7:30 AM confirmed the facility staff failed to develop a care plan to manage Resident #37's oxygen therapy.
2. The facility staff failed to develop a care plan addressing Resident #89's urinary catheter.
Observation of Resident #89 on 7/25/22 at 11:49 AM revealed the Resident had a urinary catheter. A urinary catheter is a flexible tube used to empty the bladder and collect urine in a drainage bag.
Review of Resident #89's medical record on 8/2/22 revealed the Resident was admitted to the facility on [DATE]. Review of the Resident's physician orders revealed the Resident had a catheter change order dated on 12/13/21.
Review of Resident #89's care plans revealed the Resident did not have a care plan to manage the Resident's urinary catheter that would include goals and interventions.
Interview with Regional nurse #1 on 8/2/22 at 10:20 AM confirmed the facility staff failed to develop a care plan to manage Resident #89's urinary catheter.
3. The facility staff failed to develop a dialysis care plan for Resident #113.
Review of Resident #113's medical record on 8/2/22 revealed the Resident was admitted to the facility on [DATE] with a diagnosis to include dependence on renal dialysis. Dialysis is a treatment for people whose kidneys are failing.
Review of the Resident's physician orders on 8/2/22 revealed the Resident is ordered to receive dialysis 3 times a week.
Review of Resident #113's care plans revealed the Resident did not have a care plan to manage the Resident's dialysis that would include goals and interventions.
Interview with Regional nurse #1 on 8/3/22 at 7:45 AM confirmed the facility staff failed to develop a dialysis care plan for the Resident.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0725
(Tag F0725)
Could have caused harm · This affected multiple residents
Based on resident council members meeting and interviews It was determined that the facility failed to provide residents with enough nurse staffing.
The finding includes:
On 08/02/22 at 1:00 p.m. dur...
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Based on resident council members meeting and interviews It was determined that the facility failed to provide residents with enough nurse staffing.
The finding includes:
On 08/02/22 at 1:00 p.m. during resident council meeting with attending resident's #8, #33, #51, #82, and #110 who asked the Activity Director to be present during council meeting. Five members were interviewed when asked the question do you get the help and care you need without waiting a long time and does answer your call lights in a timely manner all five resident council members answered no, we must sit in our wheelchairs or in lay in bed for over a 1 hour in soiled incontinent briefs only for staff who don't change us this happens on weekend and night shifts. The staff comes turn off the call light and tell you I will be right back and don't return to help you until hours later.
On 8/03/22 at 9:00 a.m. during interview with Corporate Regional Nurse was made aware of resident council concerns.
The Administrator, Director of Nursing and Corporate Regional Nurse was aware of this concern prior and during survey exit on 08/08/2022.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Staffing Information
(Tag F0732)
Could have caused harm · This affected multiple residents
Based on observations during the survey it was determined that the facility staff failed to post staffing information at the entrance to the facility. This was evident from the start of the survey unt...
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Based on observations during the survey it was determined that the facility staff failed to post staffing information at the entrance to the facility. This was evident from the start of the survey until 8/5/22.
The evidence is:
During tours of the facility and observation when the surveyors entered and left the facility it was noted that there was no posting of the current nurse staffing information at the entrance for visitors and residents to see.
Regional Nurse #1 was interviewed on 8/5/22 at 1:50 PM and informed of the findings.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0757
(Tag F0757)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview, it was determined the facility staff failed to ensure that medication regimens wer...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview, it was determined the facility staff failed to ensure that medication regimens were free from unnecessary medications (Residents #103, #315, #31 and #110). This is evident for 4 of 66 residents selected for review during the survey process.
The findings include:
1. The facility staff failed to hold a medication when the heart rate and systolic blood pressure was (top number) below the set parameter.
Medical record review on 8/5/22 at 8 AM for Resident #103 revealed on 7/1/11 the physician ordered: Amlodipine besylate tablet 5 mg give one tablet via Peg tube one time a day for hypertension hold for SBP less than 110 mmhg or heart rate less than 55bpm. Amlodipine is in a class of medications called calcium channel blockers. It lowers blood pressure by relaxing the blood vessels, so the heart does not have to pump as hard. A review of the Medication Administration Record revealed on 7/2 at 9 AM the facility staff documented the resident's SBP as 104 and on 7/19 at 9 AM the resident's SBP as 100, however, documented the administration of the Amlodipine Besylate.
On 6/30/22 the physician ordered: Hydralazine HCL 25 mg give 1 tablet via Peg tube three times a day for hypertension hold for SBP less than 110mmhg or heart rate less than 55bpm. Hydralazine is used to treat high blood pressure. A review of the Medication Administration Record revealed on 7/4, 7/17, and 7/19 the SBP was less than 100, and facility staff documented the administration of the Hydralazine HCL.
An interview with the Regional Nurse on 8/5/22 at 9 AM confirmed the facility staff failed to hold a medication when the SBP was documented below the set parameter.
4. The facility staff failed to clarify a Resident's insulin orders on admission and during stay in a timely manner.
Review of Resident #315's medical record revealed the Resident was admitted to the facility on [DATE] from the hospital with a diagnosis to include diabetes mellitus. Diabetes mellitus refers to a group of diseases that affect how the body uses blood sugar (glucose). Insulin is a medication that lowers the level of glucose in the blood by helping glucose enter the body's cells. On admission the facility staff obtained insulin orders for the Resident including: 1. Humalog 5 units at bedtime, 2. Lantus 10 units at bedtime, and 3. Humalog sliding scale coverage before meals and at bedtime.
During interview with Physician #1 on 7/29/22 at 10:00 AM, Physician #1 was asked why the Resident was receiving standing Humalog and Lantus insulin at the same time in addition to Humalog sliding scale insulin coverage. At that time Physician #1 stated the Resident shouldn't have had an order for both standing Humalog and sliding scale Humalog at the same time along with Lantus insulin. Physician #1 stated on 7/13/22 she reconciled the insulin orders and discontinued the standing Humalog 5 units at bedtime.
Further review of the Resident' medical record revealed on 7/13/22 the Resident was ordered Novolog insulin sliding scale coverage as a pharmacy therapeutic substitute for the Humalog insulin sliding scale coverage. Review of Resident #315's July 2022 Medication Administration Record revealed on 7/13/22 the facility staff failed to discontinue the Humalog insulin sliding scale coverage until 7/14/22. The facility staff documented on 7/13/22 at 4:00 PM the Resident received 2 units of Novolog insulin and at 4:30 PM the Resident received 2 units of Humalog insulin.
Interview with Regional nurse #1 on 8/4/22 at 7:30 AM confirmed Resident #315 received duplicate doses of insulin.
2. A review of Resident #31's clinical record on 8/1/22 revealed that nursing staff are administering cardiac medications outside of the physician's order parameters.
The resident's primary physician ordered Losartan 25 mg to be given once day, hold for SBP (systolic blood pressure - top number) less than 110 or HR (heart rate) less than 60. A review of the July Medication Administration Record revealed that the resident had a HR of 56 on 7/11 but was given the medication and on 7/17 the resident had a blood pressure of 104/60 but was given the medication.
The resident's primary physician ordered Metoprolol Tartrate 25 mg twice a day hold for SBP (systolic blood pressure - top number) less than 110 or HR (heart rate) less than 60. A review of the July Medication Administration Record revealed that the resident had a HR of 56 on 7/11 but was given the medication. On 7/17 the resident had a blood pressure of 104/60 at 9 AM and 108/64 at 9 PM but was given the medication both times that day.
Regional Nurse #1 was interviewed on 8/2/22 at 10:15 AM. She confirmed that the behavioral monitoring was not consistently documented. She also confirmed that there are times the B/P medication was administered outside of the ordered parameters.
3. A review of Resident #110's clinical record on 8/3 at 9:30 AM revealed that the resident was administered doses of insulin unnecessarily.
The resident's primary physician ordered Novolog 100 units/ml 4 units with meals. Hold for finger sticks less than 120. On 7/22 at 12 Noon the resident's blood sugar was 117 and on 7/31 at 12 Noon the resident's blood sugar was 106 but the resident was administered the insulin on both occasions.
The management staff was informed of findings prior to exit.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Food Safety
(Tag F0812)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and staff interviews it was determined that the facility staff failed to ensure that food was served and ha...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and staff interviews it was determined that the facility staff failed to ensure that food was served and handled in sanitary manner during lunch meal service and failed to ensure that food was stored in accordance with professional standards for food service safety. This practice has a potential of effecting all residents in facility.
Finding includes:
On 7/29/22 at 12:00 p.m. during observation of lunch meal service in main dining room. Surveyor observed staff member #8 was plating up hot resident lunch plates from hot meal cart without wearing required hair net to cover braid hair while handling food. During the same date and time this same staff member #8 was observed bare hand touching and handling hamburger buns serving in this meal observation.
On 7/29/22 at 12:25 p.m. conducted interview with staff member #8 replied I forgot to put on a hair net. I was in a hurry to serve lunch. Staff member asked surveyor if he/she was required to plastic gloves while touching food.
On 7/29/22 at 12:30 p.m. conducted interview with administrator in training who verified staff member #8 was not wearing hair net or plastic gloves was serving and handling food during lunch meal service.
The Administrator, Director of Nursing with Corporate members were made aware of surveyor's finding prior and during survey exit on 8/8/2022.
On 7/25/22 at 9:20 AM, during the initial tour and observation of the facility kitchen with the Dietary Manager staff #14, it was found that:
1.
The dry storage room had a large container of Kitchen Bouquet that had an expiration date of 7/20/21 and a container of Italian season open on 1/22/22.
2.
The pipes over the stove and oven had an accumulation of dust and webs hanging from them.
3.
The freezer temperature was found to be 40 degrees. Food was found in various stages of defrosting.
4.
Condensation was dripping from the ceiling in the freezer with an accumulation of water on the floor and on the boxes of stored food.
On 7/25/22 at 9:30 AM During an interview with Dietary Manager #14, it was revealed that the freezer was noted on 7/22/22 with a broken fan blade and that maintenance was notified and ordered the part to fix the freezer.
On 7/23/22 at 4:35 AM the freezer temperature was 0 degrees. On 7/24/22 at 5 AM the temperature was noted to be 40 degrees. On 7/25/22 the freezer temperature was 40 degrees.
Dietary Manager #14 stated that no food has been used from the freezer and the dietary menu was changed to use the food products from the refrigerator.
On 7/25/22 at 9:45 AM the Administrator, Regional Nurse #1, and Regional Nurse #2 were made aware of the findings and the following foods were disposed of:
9 cases of various vegetables ([NAME] blend, Scandinavian blend, San Francisco, lima bean, Italian blend, and collard greens)
9 cases of various seafood (shrimp, cod, batter fish, fish squares, shrimp, and potato crunch fish)
6 cases of various chicken (chicken tenders, chicken parts, and chicken pot pies)
1.5 cases of various shakes (strawberry, vanilla, and chocolate)
4 cases of magic cups
6 cases of various pork products (bacon, sausage, pork chops, ground pork, pork riblets, and ham)
4 cases of various beef products (hamburger, ground beef, Salisbury steak, and hot dogs)
1 case of veggie burger
½ case of lasagna
4 cases of various egg products (egg whites, egg patties, and cheese omelets)
On 7/25/22 food was ordered from [NAME] and was left in the freezer truck until the new freezer truck temperature was 0 degrees.
On 07/26/22 9:09 am - A follow-up visit to the kitchen was conducted with the Administrator, a check on the freezer room indicates that the freezer is now working at its optimal level and the frozen food from the freezer truck was transferred to the kitchen freezer.
These deficiencies were confirmed with the Administrator, Dietary Manager, Regional Nurse #1, and Regional Nurse #2.
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**
2. Medication and Treatment Record Administration and Q-Shift is a computer-generated schedule for administering medications, t...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
2. Medication and Treatment Record Administration and Q-Shift is a computer-generated schedule for administering medications, treatments and medical interventions and task to a patient for a defined period of time, including dosing timing of administration and details about physician's orders for the patient.
On 8/3/22 at 9:00 a.m. conducted a closed medical record review for intake MD00175795 revealed resident #226 was admitted to the facility for rehabilitation services with other chronic health condition which requires ongoing medical supervision and treatment.
Intake MD00175795 was reviewed on 8/3/22 at 9:00 a.m. with concerns of neglect in care. On this same date and time, the medical record review revealed (R#226) had written nursing intervention task orders in month of March 2022 for ADL's (assistance in daily living) which includes but not limited to bathing, oral care, bed mobility, dressing, movement on unit, personal hygiene, toileting, transferring, walking in room, hearing aids/glasses, behavioral monitoring and offering night-time snacks to the resident.
During this review of medical record Q-Shift revealed the facility staff failed to document or initial the resident received ADL medical nursing intervention or task orders in the month of March 2022.
On 8/3/22 at 11:00 a.m. during interview with Corporate Regional Nurse verified the facility staff failed to initial on nursing Q-shift report that ordered inventions/task was provided to resident #226.
The Administrator with Director of Nursing and Corporate Regional Nurse was provided in detailed discussion of concerns prior and during survey exit on 8/8/2022.
Based on medical record review and interview, it was determined the facility staff failed to maintain medical records in the most accurate form for residents (Resident #31, #89, #110 and #226). This was evident for 4 of 66 residents reviewed during the annual survey.
The findings include:
A medical record is the official documentation for a healthcare organization. As such, it must be maintained in a manner that follows applicable regulations, accreditation standards, professional practice standards, and legal standards. All entries to the record should be legible and accurate.
1. Review of Resident #89's medical record on 7/29/22 revealed the Resident was admitted to the facility on [DATE] with a diagnosis to include depression. Review of the Resident's physician orders revealed the Resident was ordered Mirtazapine 30 mg one time a day for appetite stimulant.
Review of the Resident's psychiatric progress note on 3/30/22 revealed the Resident was receiving Mirtazapine 30 mg for depression.
Interview with Regional nurse #1 on 8/4/22 at 7:30 AM confirmed the Resident #89's diagnosis for Mirtazapine should be depression and not appetite stimulant and the medical record was incorrect.
3. A review of Resident #31's clinical record on 8/1/22 revealed the resident's primary physician ordered to have the resident's behavior monitored for agitation, jittery, or nervousness. Staff are to document each shift how often it is witnessed. One or more shifts had blanks on 7/4, 7/5, 7/8, 7/11, 7/12, 7/13, 7/14, 7/16, 7/17, 7/18, 7/20, 7/21, 7/22, 7/23, 7/25, and 7/26.
Regional Nurse #1 was interviewed on 8/2/22 at 10:15 AM. She confirmed that the behavioral monitoring was not consistently documented. She also confirmed that there are times the cardiac medication was administered outside of parameters.
4. A review of Resident #110's clinical record revealed the resident's primary physician ordered to have the resident's behavior monitored for calling staff names. Staff are to document how often it is witnessed each shift. One or more shifts had blanks on 7/4, 7/5, 7/8, 7/11, 7/12, 7/13, 7/14, 7/16, 7/17, 7/18, 7/20, 7/21, 7/22, 7/23, 7/25, and 7/26.
Regional Nurse #1 was interviewed on 8/8/22 at 11:06 AM. She confirmed that the behavioral monitoring has gaps.
Oct 2018
30 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Resident Rights
(Tag F0550)
Could have caused harm · This affected 1 resident
Based on observation, it was determined that the facility staff failed to treat each resident in a dignified manner by 1) failing to knock on a resident's door to request permission before entering an...
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Based on observation, it was determined that the facility staff failed to treat each resident in a dignified manner by 1) failing to knock on a resident's door to request permission before entering and 2) failing to provide resident privacy while a treatment was performed. This was evident for 1 (#48) of 4 residents interviewed on the 4th floor.
The findings include:
1) On 9/27/18, an interview was conducted with Resident #48 in the resident's room and Resident #48's door was closed. At 11:11 AM, Staff #4 was observed entering Resident #48's room without knocking on the door. At 11:20 AM, the Surveyor observed Staff #13 enter Resident #48's room without knocking on the door.
2) At 11:27 AM, Staff #4 was observed entering Resident #48's room without knocking on the door. The Surveyor observed Staff #4 provide care and apply a dressing to Resident #48's gastrostomy (GT) (feeding tube) site. At that time, Staff #4 failed to provide privacy to the resident by failing to pull the resident's privacy curtain prior to giving the resident care and failed to obtain Resident #48's permission to perform GT site care in front of the surveyor.
Each resident has the right to be treated with dignity and respect.
Staff #10 was advised of these on 10/5/18 at 12:00 PM.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0655
(Tag F0655)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the medical record, it was determined that the facility failed to develop a baseline care plan which included...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the medical record, it was determined that the facility failed to develop a baseline care plan which included instructions needed to provide effective and person-centered care that met professional standards of quality care. This was evident for 1(#324) of 5 residents reviewed for respiratory care and 1 (#90) of 6 residents reviewed for unnecessary drugs.
A care plan is a guide that addresses the unique needs of each resident. It is used to plan, assess and evaluate the effectiveness of the resident's care.
The findings include:
Resident #324's medical record was reviewed on 10/4/18 at 11:27 AM. The resident was admitted to the facility on [DATE]. His/Her diagnoses included, but were not limited to, Difficulty walking, Chronic obstructive pulmonary disease, Sleep apnea, Cellulitis (infection) of left lower limb, Arthritis due to bacteria unspecified knee, presence of artificial knee joint bilateral (both knees) and muscle weakness. A baseline care plan was created on 9/26/18. The section :Active Diagnoses Contributing to Admission, had no entries. The section 2.C. Mobility devices, was not completed to indicate if the resident normally used any of the listed devices, another device or none of the above. The section 3. A. Health Conditions/Special Treatments did not identify that the resident utilized a CPAP machine, required IV medications or oxygen. Section 3.D. Medications, did not reflect that the resident was taking an anticoagulant, opioid, insulin, psychotropic, diuretic and antibiotic medications. The section 3.G. Physicians orders did not include the physicians' orders but indicated See current orders. The section 4.C. Social Services had no entries.
Resident #90's record was reviewed on 10/5/18 at 8:11 AM. The resident was admitted on [DATE] a Baseline Care Plan was initiated 5/17/18. The section 4.C. Social Service had no entries. The Administrator was made aware of the above findings on 10/5/18 at approximately 3:30 PM.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Quality of Care
(Tag F0684)
Could have caused harm · This affected 1 resident
Based on record review and interview with the resident and staff, it was determined that the facility failed to identify and provide resident centered care and services in accordance with professional...
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Based on record review and interview with the resident and staff, it was determined that the facility failed to identify and provide resident centered care and services in accordance with professional standards of practice by failing to ensure a resident's individual diabetic care and dialysis needs were evaluated and consistently met. This was evident for 1 (#90) of 4 residents reviewed for dialysis.
The findings include:
Resident #90 was interviewed on 9/28/18 at 8:46 AM. Upon surveyor inquiry, the resident indicated that there was often a delay in staff coming to the on-site dialysis center to transport him/her back to his/her room after dialysis. The resident also indicated that he/she was diabetic, and the delay resulted in his/her blood sugar monitoring, insulin administration, and dinner being delayed, as well.
An interview was conducted with Staff #35, a dialysis center nurse on 10/4/18 at 2:50 PM. He/She confirmed that Resident #90 had dialysis from 2:15 PM - 6:15 PM on Monday, Wednesday and Friday and that it was the responsibility of the facility staff to transport the residents to and from dialysis. He/She also indicated that at times it took 1 to 2 hours for staff to pick Resident #90 and others up after dialysis.
Resident #90's record was reviewed on 10/4/18 at 12:10 PM. A care plan is a guide that addresses the unique needs of each resident. It is used to plan, assess, and evaluate the effectiveness of the resident's care. A plan of care was developed for increased nutrient needs related to ESRD (end stage renal disease) on HD (hemodialysis) the plan of care did not specify the residents ordered diet or if he/she was on a therapeutic renal diet, ora need for dietary or fluid restrictions, it did not specify the residents' supplement/snacks nor when the resident should be weighed.
The resident also had a plan of care for Diabetes Mellitus, risk for hyperglycemia (high blood sugar) and risk for hypoglycemia (low blood sugar) the approaches did not identify the residents prescribed diet nor measures to prevent or treat hyper or hypo glycemia, if it occurred.
A plan of care had been developed for Dialysis. The goal - will have no s/sx (signs/symptoms) of complications from dialysis. The interventions included but were not limited to Monitor intake and output (I&O) (monitoring the residents' intake and output of fluid). Further review of the residents' record failed to reveal that the staff were monitoring Resident #90's I & O.
The plans of care did not address Resident #90's Dialysis schedule nor guide the staff in meeting his/her diabetic needs on dialysis days. Dialysis communication sheets revealed that, on 9/13/18, post dialysis instructions indicated to continue watching fluid intake. On 9/17/18, the specific follow up for the facility staff from dialysis indicated needs to limit fluid intake, patient verbalizes understanding on fluid intake after education was provided. On 9/19/18, the follow up indicated continue to watch fluid intake. During an interview, on 10/5/18 at 10:44 AM, Staff #11 confirmed that Resident #90 was not on I&O monitoring.
Further review of the record reveald that the facility failed to implement measures for the provision of Resident #90's unique care needs related to his/her dialysis and diabetes, including interventions related to timely provision of transportation from dialysis and consistent accommodation of blood sugar monitoring and meals on dialysis days and the dialysis center's fluid concerns.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Tube Feeding
(Tag F0693)
Could have caused harm · This affected 1 resident
4) During an initial tour of the 1st floor nursing unit conducted on 10/2/2018 at 10:41 AM, Resident #74 was noted to have a container of glucerna hung and spiked at the bedside with only about 25% of...
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4) During an initial tour of the 1st floor nursing unit conducted on 10/2/2018 at 10:41 AM, Resident #74 was noted to have a container of glucerna hung and spiked at the bedside with only about 25% of the formula remaining. No label or date was noted on either the glucerna package nor on the tube feeding tubing. Unit Manager #9 was present for this observation and confirmed that no name or date was written on the container.
Based on resident and staff interview and medical record review, it was determined that the facility 1) failed to ensure that a resident with an enteral feeding tube received appropriate care and services to prevent complications, 2) failed to ensure that an enteral feeding tube was clinically indicated, and 3) failed to develop and implement comprehensive person-centered care plans with measurable goals and interventions to address a resident's enteral feeding tube. This was evident for 1 (#48) of 5 residents reviewed for tube feedings; And 4) failed to ensure that containers of tube feeding formula were labeled and dated for each resident receiving the feeding. This was true for 1 (Resident #74) of 7 residents observed on the 1st floor unit with tube feeding formula at the bedside.
The findings include:
1) On 9/27/18 at 10:28 AM, observation was made of Resident #48 sitting in a wheel chair in the 4th floor hallway. The surveyor introduced self and asked the resident how he/she was doing. At that time, the Resident #48 lifted his/her shirt above the abdomen, exposing a gastrostomy tube (GT) ((a tube inserted through the abdomen that delivers nutrition directly to the stomach) which was surrounded by bright red blood around the GT insertion site. When asked if the resident was okay, Resident #48 stated yes, that sometimes there was bleeding around the GT and indicated that at one time, the bleeding was worse.
On 9/27/18, at 11:20 AM, an observation was made of Staff #4 administering medication to Resident #48 via his/her gastrostomy tube. At that time, dried blood was observed around the GT site. Staff #4 then left the room and returned, cleaned around the GT site and applied a dry gauze dressing.
On 10/5/18, a review of Resident #48's medical record failed to reveal documentation related to the resident's recent bleeding around the GT or evidence that the physician had been notified of the bleeding.
On 10/5/18 at 2:48 PM, during an interview, Staff #11 was advised of the above finding and stated that if a resident had drainage or bleeding around a GT site, he/she would expect the nurse to notify the physician and document the resident's condition and the physician's response in the medical record.
2) On 9/27/18 at 11:10 AM, during an interview, Resident #48 stated that he/she was able to eat and did not get nutrition through his/her GT. When asked why the resident had a GT, Resident #48 stated he/she didn't know and thought it was for medication.
Review of the medical record revealed on 6/28/18, in a progress note, the physician documented that Resident #48 had dysphagia (difficulty swallowing) and was on puree and nectar thick liquids. The physician documented that Resident #48 was sore around the GT insertion site and had coffee ground secretions around the site likely caused from local irritation
Review of Resident #48's physician orders reveal a 5/31/8 diet order that indicated Resident #48 received nutrition orally. The diet order was pureed texture, nectar thick liquids consistency and allowed the resident to have thin liquid in between meals and mechanical soft snacks with 100% supervision. Continued review of Resident #48's physician orders revealed that the resident received medications and water flushes through his/her GT. On 10/2/18, in a Plan of Care Note, the Dietician documented that Resident #48 was able to feed self with set up help and eating mostly 75-100%, had no significant weight changes in past 6 months and received water flushes through the GT.
Continued review of the medical record failed to reveal documentation of why Resident #48's GT was currently clinically indicated and consented to by the resident. During an interview, when asked why Resident #48 had a GT, Staff #39 stated that the resident had the GT when he/she was admitted to the facility.
3) A care plan is a guide that addresses the unique needs of each resident. It is used to plan, assess and evaluate the effectiveness of the resident's care. Review of Resident #48's care plans revealed a care plan At risk for tube feeding dislodgment and aspiration with the Goal Feeding tube patent and correct placement had the interventions: 1) Auscultate lung before feeding is started, 2) check placement of tube before each feeding by two means and 3) Vital signs every shift. The care plan goal was not measurable or specific. The care plan interventions were not resident specific, were not measurable and failed to address the reason for the GT, and care of the GT site. Review of Plan of Care Notes revealed a 10/2/18 dietary note. Further review of the medical record failed to reveal evidence that Resident #48's feeding tube care plan had been evaluated.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Respiratory Care
(Tag F0695)
Could have caused harm · This affected 1 resident
Based on observation, medical record review and staff interview, it was determined that the facility staff failed to provide respiratory care that was consistent with professional standards as evidenc...
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Based on observation, medical record review and staff interview, it was determined that the facility staff failed to provide respiratory care that was consistent with professional standards as evidenced by 1) failing to administer oxygen per physician's orders and then documenting that it was administered per orders, 2) failing to administer respiratory medications per manufacturer's instructions and 3) failing to create a comprehensive person-centered care plan related to the respiratory status of the resident. This was evident for 1 (#78) of 5 residents reviewed for respiratory care.
The findings include:
Observation was made of Resident #78 on 9/27/18 at 9:17 AM. Resident #78 was sitting in a wheelchair next to the bed. The resident was wearing a nasal cannula (a lightweight tube that is hooked onto an oxygen concentrator that delivers oxygen to a resident who needs respiratory help). The nasal cannula was hooked onto the oxygen concentrator and was delivering between 2.0 and 2.5 liters (L) of oxygen. The nasal cannula was not dated with the date that the tubing was attached to the oxygen concentrator.
Resident #78 was observed again on 10/2/18 at 12:14 PM and was receiving between 2.0 and 2.5 L of oxygen. A second surveyor observed the resident at 2:09 PM and confirmed the oxygen level reading on the concentrator.
Review of Resident #78's medical record on 10/02/18 at 10:58 AM revealed the resident had the diagnosis of Chronic Obstructive Pulmonary Disease (COPD) which is a group of lung diseases that block airflow and make it difficult to breathe. The discharge summary from the hospital dated 9/6/18 documented COPD on 3.5 L home oxygen. In addition, Resident #78 had bronchitis and received the antibiotic Levaquin 750 mg. every day for 5 days which began on 9/27/18 to 10/1/18 and Robitussin Chest Congestion Syrup 10 cc. every day from 9/27/18 to 10/3/18.
Review of Resident #78's September 2018 and October 2018 physician's orders revealed the order oxygen via nasal cannula at 3.5 LPM every shift for COPD. Review of the September 2018 and October 2018 Treatment Administration Record (TAR) revealed nurse's initials that the resident received oxygen 3.5 Liters Per Minute (LPM) each shift. The documentation was not accurate as the surveyor observed the oxygen set on between 2 and 2.5 liters.
Observation was made on 10/2/18 at 8:33 AM of Staff #28 administering inhalers to Resident #78. Staff #28 handed Resident #78 the Ventolin inhaler and the resident said, I can't do that myself. Staff #28 took the inhaler and squirted a puff into the resident's mouth and the resident said, I didn't get anything. Staff #28 proceeded to squirt 2 more puffs into Resident #78's mouth. Staff #28 did not wait after the first puff. There was no evidence that anything came out of the inhaler. Staff #28 then got the Advair inhaler and gave 2 puffs to the resident. There was no time between inhalers and the resident did not rinse his/her mouth out after the second inhaler.
Review of the manufacturer's website for Ventolin gave the instructions shake the inhaler well before each spray. Staff #28 did not shake the inhaler. The instructions stated Push the top of the canister all the way down while you breathe in deeply and slowly through your mouth. After the spray comes out, take your finger off the canister. After you have breathed in all the way, take the inhaler out of your mouth and close your mouth. Hold your breath for about 10 seconds, or for as long as is comfortable. Breathe out slowly as long as you can. The resident did not breathe all the way in and the resident did not hold his/her breath or breathe out slowly. Staff #28 did not encourage or advise the resident the correct method for use of the inhaler. The directions continued, if your provider has told you to use more sprays, wait 1 minute and shake the inhaler again. Repeat. This direction was not followed and there was no time between inhalations and the inhaler was not shaken by Staff #28. The manufacturer's website stated, For correct use of your VENTOLIN HFA inhaler, remember: Breathe in deeply and slowly to make sure you get all the medicine. Hold your breath for about 10 seconds after breathing in the medicine. Then breathe out fully.
Review of the manufacturer's website for the Advair inhaler revealed the following, Shake inhaler for 5-10 seconds, (Staff #28 did not shake the inhaler) breathe out fully (in preparation to breathe in medication), (the resident did not do this), push the top of the canister all the way down one time while breathing in deeply and slowly through your mouth, hold your breath for 5-10 seconds, and then breathe out. (the resident did not do this). If your doctor has prescribed more than one dose (puff), wait 30 seconds and repeat above. (Staff #28 did not wait 30 seconds). Rinse mouth thoroughly with water after taking medication to decrease the risk of a mouth infection. Spit out the water. Do not swallow it. (Staff #28 did not have the resident rinse his/her mouth out). Staff #28 failed to follow the directions for adequate administration of 2 inhalers.
Resident #28's care plans were reviewed and there was no plan for respiratory care. The first diagnosis on the bottom of the care plans was Chronic Obstructive Pulmonary Disease. The resident received oxygen, had oxygen saturation levels monitored and received 2 inhalers.
Discussed with the Director of Nursing and the Corporate Nurse on 10/3/18 at 11:50 AM.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Drug Regimen Review
(Tag F0756)
Could have caused harm · This affected 1 resident
Based on medical record review and staff interview, it was determined that the pharmacist failed to report irregularities related to systolic blood pressure to the facility administration. This was ev...
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Based on medical record review and staff interview, it was determined that the pharmacist failed to report irregularities related to systolic blood pressure to the facility administration. This was evident for 1 (#78) of 5 residents reviewed for unnecessary medications. The findings include:
Resident #78's medical record was reviewed on 10/2/18. Review of the September 2018 Medication Administration Record (MAR) revealed an order for Metoprolol Tartrate Tablet 25 mg., Give 1 tablet by mouth two times a day for HTN (Hypertension) hold if SBP (Systolic Blood Pressure) is less than 110 and heart rate (HR) less than 60. The systolic blood pressure is the top number of a blood pressure reading.
Review of the September 2018 MAR documented that, on 9/8/18 at 9:00 AM, the BP was 107/71 with HR 64. On 9/20/18 at 9 AM, the BP was 107/73 with HR 81. On both days, the medication was given as the systolic b/p was not within parameters, but the heart rate was within parameters.
On 9/9/18 at 9:00 AM, the BP was 106/63 with HR 51 and the medication was given even though both BP and HR were not within parameters.
On 9/13/18 at 5 PM,,, the BP was 105/68 and HR 92, on 9/16/18 at 5 PM the BP was 93/63 and HR was 89, on 9/22/18 at 5 PM the BP was 100/62 and HR was 88, 9/26/18 at 5 PM BP was 101/65 and HR 87, 9/27/18 at 9 AM BP was 109/74 and HR 93. On these dates, the medication was held even though the heart rate was within parameters, but the BP was not within parameters. There were inconsistencies regarding the times that staff gave the medication or held the medication.
Staff #17 was interviewed on 10/4/18 at 10:08 AM, and stated that he/she read the order as SBP below 110 or HR below 60. He/she said one or the other I would hold the medication. Staff #18 stated if the SBP was below parameters and the HR was within parameters I would personally call the doctor; however, I will change the order. The surveyor stated, is that what the physician's intent was? Staff #18 stated I will call the doctor because it should say or. At that time Staff #18 called the physician who clarified the order should have said or and not and.
A pharmacy review on 9/20/18 did not identify any issues with the Metoprolol order with parameters, and did not identify inconsistencies in the MAR when the medication was given and held even though the systolic blood pressure was below 110.
Discussed with the Corporate Nurse on 10/3/18 at 11:10 AM.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Medication Errors
(Tag F0758)
Could have caused harm · This affected 1 resident
Based on record review and interview with facility staff, it was determined that the facility failed to ensure that residents' medication regimens were free of unnecessary psychotropic medications. Th...
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Based on record review and interview with facility staff, it was determined that the facility failed to ensure that residents' medication regimens were free of unnecessary psychotropic medications. This was evidenced by an unresponsive resident receiving antidepressant medication without evidence of monitoring. This was evident for 1 (Resident #68) of 6 residents reviewed for unnecessary medications.
The evidence includes:
The facility failed to ensure that Resident #68's antidepressant medication was necessary.
Review of Resident #68's medications that took place on 10/2/2018 at 10:15 AM, revealed the following order: Zoloft, 25mg. Take one tablet daily via Gastrostomy tube for depression. There was no other current medication for the resident with a psychiatric indication.
During an attempted interview with Resident #68 that took place on 10/2/2018 at 10:39 AM, the resident was found to be nonverbal. The resident did not demonstrate any meaningful response to the surveyor's presence or words.
Review of the resident's most recent Minimum Data Set (MDS) assessment (Assessment Reference Date of 6/26/2018) took place on 10/2/2018 at 12:05 AM. On the assessment, Item C0100 was coded as Resident is rarely/never understood.
Review of the most recent skilled nursing charting assessment, dated 9/26/2018, stated that the resident was unarousable.
A brief interview was conducted with Geriatric Nursing Assistant #22 on 10/2/2018 at 1:55 PM. During the interview, GNA #22 stated that the resident may occasionally smile, but displayed no emotions or facial expressions, other than occasionally coughing when turned.
Resident #68's most recent medication management assessment from psychiatric services, dated 8/20/2018, was reviewed on 10/2/2018 at 1:40 PM. In the additional pertinent information section of the social history, the assessment documented, has history of depression since [stroke] . sustained anoxic brain injury, has tracheostomy and gastrostomy tube; patient is vented, nonresponsive. The General Observations section of the Review of Systems states, Responsive to name. Nonverbal. Trached and vent dependent. Rely on staff to report on behaviors. The Psychiatric Exam section stated that resident behavior was within normal limits. All other topics in the psychiatric exam and abnormal or psychotic thoughts sections stated unable to assess. The Assessment stated, Anxiety: in remission, Depression: controlled; no behavioral dyscontrol; no signs or symptoms of anxiety or depression. The psychoactive medication justification was, Psych Dx requires medication; high risk of relapse.
During an interview on 10/2/2018 at 1:56 PM, Unit Manager #9 stated that grimacing, showing his/her teeth, and twisting his/her face was the best indication for Resident #68 of depressed mood. Zoloft had been ordered to mitigate these symptoms.
During an interview with the Director of Nursing (DON) on 10/2/2018 at 2:27 PM, the DON stated that the resident used to bite his/her lip and clench his/her jaw, and that Ativan and Zoloft had been ordered to mitigate these symptoms. The DON confirmed that Ativan had been discontinued by the psychiatric provider, but denied that Zoloft had ever been trialed as discontinued, referring to Zoloft as the reason the resident was not biting his/her lips.
A second review of nursing notes that took place on 10/3/2018 at 10:00 AM revealed no note that demonstrated either grimacing or lip biting for Resident #68.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0760
(Tag F0760)
Could have caused harm · This affected 1 resident
Based on observation, medical record review and staff interview, it was determined the facility failed to keep residents free from significant medication errors. This was evident for 3 (#78, #21, #75)...
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Based on observation, medical record review and staff interview, it was determined the facility failed to keep residents free from significant medication errors. This was evident for 3 (#78, #21, #75) of 8 residents observed during medication administration.
The findings include:
1) Staff #28 handed Resident #78 a Ventolin inhaler and the resident said, I can't do that myself. Staff #28 took the Ventolin inhaler and squirted a puff into the resident's mouth and the resident said, I didn't get anything. There was no evidence that anything came out of the inhaler. Staff #28 proceeded to squirt 2 more puffs quickly in the resident's mouth. Staff #28 did not shake the inhaler, did not instruct the resident to breathe in and hold, and did not wait between puffs. Staff #28 then proceeded to take the Advair inhaler and administer 2 puffs into the resident's mouth. Again, Staff #28 did not shake the inhaler and there was no time in between the 2 different inhalers. The resident did not hold his/her breath after the first inhalation. The resident did not rinse his/her mouth after use of the inhaler. When Staff #28 administered the second inhaler the spray was visible in the air. Staff #28 failed to follow manufacturer's directions in administering the inhalers and Staff #28 failed to make sure the resident understood how to take the inhalers effectively. Cross Reference F759.
Review of Resident #78's medical record revealed that Resident #78 had a diagnosis of COPD (Chronic Obstructive Pulmonary Disease) and was on 3.5 liters of oxygen continuously.
2) Further Review of Resident #78's medical record revealed the September 2018 Medication Administration Record (MAR) which had an order for Metoprolol Tartrate Tablet 25 mg., Give 1 tablet by mouth two times a day for HTN (Hypertension) hold if SBP (Systolic Blood Pressure) is less than 110 and heart rate (HR) less than 60. The systolic blood pressure is the top number of a blood pressure reading.
It was documented that, on 9/8/18 at 9:00 AM, the BP was 107/71 with HR 64. On 9/20/18 at 9 AM the BP was 107/73 with HR 81. On both days the medication was given, as the systolic b/p was not within parameters, but the heart rate was within parameters.
On 9/9/18 at 9:00 AM, the BP was 106/63 with HR 51 and the medication was given, even though both BP and HR were not within parameters.
On 9/13/18 at 5 PM, the BP was 105/68 and HR 92, on 9/16/18 at 5 PM the BP was 93/63 and HR was 89, on 9/22/18 at 5 PM the BP was 100/62 and HR was 88, 9/26/18 at 5 PM BP was 101/65 and HR 87 and on 9/27/18 at 9 AM the BP was 109/74 and HR 93. On these dates, the medication was held even though the heart rate was within parameters, but the BP was not within parameters.
Review of the October 2018 MAR revealed on 10/1/18 at 5 PM the BP was 95/61 and the HR was 87 and the medication was given. On 10/2/18 at 5 PM the BP was 100/67 and the HR was 77 and the medication was held. There were inconsistencies regarding when staff gave the medication and when staff held the medication.
Staff #17 was interviewed on 10/4/18 at 10:08 AM and stated that he/she read the order as SBP below 110 or HR below 60. He/she said one or the other I would hold the medication. Staff #18 stated if the SBP was below parameters and the HR was within parameters I would personally call the doctor; however, I will change the order. The surveyor stated, is that what the physician's intent was? Staff #18 stated I will call the doctor because it should say or. At that time Staff #18 called the physician who clarified the order should have said or and not and.
The facility staff failed to hold the blood pressure medication when it was outside of parameters and the facility staff failed to clarify the order or call the physician to question if the resident should have received the blood pressure medication or if it should have been held.
3) On 10/2/18 at 9:03 AM, the surveyor observed Staff #28 prepare medications for Resident #21. Resident #21 was to receive all medication through a gastrostomy tube (g-tube). A g-tube is a tube that is surgically placed in the stomach due to inability to swallow food/liquids.
Staff #28 poured Vimpat Sol. 10mg/ml., (15 ml.) into a medication cup. The liquid was clear. Staff #28 held the 30 ml. medication cup at a slant when pouring. Staff #28 then proceeded to put the bottle of Vimpat in the bottom drawer of the medication cart and he/she then signed the medication out in the controlled substance log book. Staff #28 signed out that 10 ml. was poured. Staff #28 was preparing to lock the medication cart and walk to the resident's room when the surveyor asked him/her to look at the Vimpat again to confirm that 15 ml. had been poured. Staff #28 looked and got another plastic cup. He/She poured 5 ml. into the cup and then looked at the remaining amount. He/She then proceeded to pour 2.5 ml. more into the medication cup for a total of 12.5 ml. The surveyor looked at the cup and stated, so the order is for 12.5 ml. and Staff #28 said, No, it is 10 ml. The surveyor looked at the medication cup again and advised that it was not 10 ml. It was noted that, on the bottom of the medication cup, there was a small piece of plastic which prevented the cup from sitting flat. Staff #28 then took the medication cup and poured out 2.5ml to reach a total of 10 ml. After surveyor intervention, the correct amount was poured into the medication cup. Vimpat is a federally controlled substance with side effects of dizziness, spinning sensation, drowsiness, double vision, nausea, vomiting and tiredness.
The surveyor observed Staff #28 enter Resident #21's room. The surveyor observed 3 ports to the feeding tube. There was a red cap to the far right, a purple cap in the middle, and a white cap on the left side. At the time, the resident was not hooked up to the tube feeding. The surveyor observed the white cap was off and not placed in the port. Staff #28 took the red cap off and flushed the tube with 30 ml. of water. Staff #28 did not listen for placement or check residual prior to flushing the tube. Staff #28 then poured the 10 ml. of Vimpat (the clear liquid) in the syringe with 5 ml. of water that was left over from the flush. Staff #28 then pushed the Vimpat into the white port and the surveyor observed clear liquid come out of the opened port when the white cap was off and spill onto the bedspread. Staff #28 then flushed the tube with 40 ml. of water after which the surveyor observed more clear liquid come out of the white port. Staff #28 then gave the Ferrous Sulfate (yellow liquid) with a 20 ml. water flush. During the observation, the surveyor observed the fluid coming out of the uncapped port. The surveyor advised Staff #28. He/she put the white cap back on. Staff #28 then administered the Senna and then a 20 ml. water flush. The surveyor asked Staff #28 about the amount of fluid coming out of the white port which would have been the anticonvulsant (Vimpat) and Staff #28 insisted it was not the medication, that the fluid on the bedspread was clear. It was unknown if the resident received the first 2 medications.
Review of Resident #21's October 2018 physician's orders revealed , every shift check tube for proper placement prior to each feeding, flush, or medication administration. This was not done. A second order stated, flush tube with at least 30 ml. of water before and after each medication pass. Flush tube with 5 ml. of water between each medication. This was not done as Staff #28 flushed with 40 ml. of water and 20 ml. of water twice as stated above, which was 80 ml. of water instead of 15 ml.
4) On 10/3/18 at 9:00 AM, observation was made of Staff #12 dispensing pills into a medication cup for Resident #75 which included Lasix 20 mg., Aspirin 81 mg., Senna 8.6-50 mg. (2), Januvia 50 mg., Glipizide 10 mg., Oxybutynin ER 10 mg. and Digoxin 0.125 mg. The surveyor asked Staff #12 to confirm the number of pills in the medication cup and the result was 8 pills.
Review of Resident 75's October 2018 physician's orders stated that, at 9 AM, the medications Lisinopril 2.5 mg. (2) tablets, Amlodipine Besylate 10 mg. and Macrobid 100 mg. should have been given. The medications were signed off as given on the MAR, however, the surveyor confirmed with Staff #12 that 8 pills were in the medication cup. The surveyor went back to Staff #12 after reviewing the physician's orders and Staff #12 told the surveyor that the medications were given. Staff #12 went through the trash can on the side of the medication cart to find the packet that the medications came in. Staff #12 was unable to find the packet in the trash. The surveyor advised if the medications had been given it would have been a total of 12 pills, and not 8 pills. Therefore, 2 blood pressure medications were not given. The blood pressure taken on 10/2/18 was 142/67 and on 10/3/18 was 155/69.
Discussed with the Director of Nursing and the Corporate Nurse on 10/3/18 at 11:50 AM.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Notification of Changes
(Tag F0580)
Could have caused harm · This affected multiple residents
Based on medical record review and staff interview, it was determined the facility staff failed to notify the physician of medications that were unavailable from the pharmacy for multiple days. This w...
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Based on medical record review and staff interview, it was determined the facility staff failed to notify the physician of medications that were unavailable from the pharmacy for multiple days. This was evident for 1 (#278) of 1 residents reviewed for constipation.
The findings include:
1) Review of the medical record for Resident #278 on 10/4/18 revealed physician's orders for September 2018 which stated, Ergocalciferol tablet 400 unit; give 1 tablet by mouth one time a day for supplement. The order was written to start on 9/15/18. Review of Resident #278's Medication Administration Record (MAR) documented that, on 9/15/18, 9/19, 9/20, 9/24, 9/25, 9/26, 9/28, 9/29 and 9/30/18, the medication was not available. Review of nursing progress notes documented that the medication was not available. There was no documentation as to staff notifying the physician that the medication was not available for 9 out of 16 opportunities for administration in September 2018.
Further review of the medical record for Resident #278 revealed the physician's order for the medication MgO tablet 400 mg. for 10 days to start on 9/19/18. Review of the September 2018 MAR documented that the medication was not available from the pharmacy on 9/23/18 and 9/26/18. The resident only received 7 doses of the medication as the resident refused the dose on 9/28/18. There was no documentation that the physician was notified that the resident only received 7 out of 10 doses of the medication.
Staff #26 was asked on 10/4/18 at 2:10 PM what he/she would do if a medication wasn't available and the response was after 3 days I would let the physician know. The unit manager was advised of the unavailability of the medication and that the physician was not notified, and the unit manager just shook his/her head.
The Nursing Home Administrator was advised of the findings on 10/5/18 at 2:02 PM.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Safe Environment
(Tag F0584)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 13) During an initial facility tour that took place on 9/27/2018 at 10:30 AM, it was found that the handrails in the hallways of...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 13) During an initial facility tour that took place on 9/27/2018 at 10:30 AM, it was found that the handrails in the hallways of the first floor unit were all damaged. Rectangular pieces of plastic in the center of the fixtures, measuring about 10 high and running the length of the handrails were found to be uneven with the rest of the fixture, and in some places broken, creating sharp edges in some sections of the handrails.
14) On 9/27/18 at 10:01 AM, observation of room [ROOM NUMBER] revealed the corner base board next to the bathroom was peeled and had a piece missing and there were cracked floor tiles. There was a large area of missing wall paper on the wall behind bed 2. The window vertical blinds had pieces of blind missing.
Observation of room [ROOM NUMBER]'s shared bathroom revealed a layer of paint missing 1 above the sink and extending across the back of the sink exposing a pink color, which was different than the cream color bathroom paint. On the left side of the hand soap dispenser, the wall had paint missing with exposed dry wall and exposed pink color; to the right of the soap dispenser, the wall had paint missing with exposed dry wall.
15) On 9/27/18 at 12:18 PM, observation of room [ROOM NUMBER] revealed the corner of the wall near the bathroom had paint missing with approximately 2 inches of metal corner bead exposed. The wall above the bed 1 had a large square of wall paper missing around the oxygen, outlets and above part of the light fixture.
16) On 9/27/18 at 12:57 AM, observation of room [ROOM NUMBER] revealed the floor next to the door was sticky and soiled with hair and small debris. On the wall behind bed 2, there were 2 areas, approximately 1-inch x 12 inches that were scraped and had paint missing,
17) On 9/28/18 at 9:18 AM, observation of room [ROOM NUMBER]'s room revealed the vertical blinds had sections of blind missing. room [ROOM NUMBER]'s bathroom floor was soiled along the bottom of the base board. The lower left bathroom wall had a discolored area with peeling paint, approximately 18 inches x 2-3 inches high, and there was a depressed, cracked area on the wall.
18) On 9/28/18 at 9:45 AM, observation of room [ROOM NUMBER] revealed the drawer pull was broken on the first drawer of bed 1's bedside table. The edge of the bedside table was scraped with finish missing and the left front foot base had a outer piece of laminate missing. On the right side of bed 1, the privacy curtain was not attached to the ceiling glide in two areas. Next to bed 2, the bedside table's bottom drawer did not close and the lower edge of the bottom drawer was scraped with finish missing.
19) On 10/2/18 at 2:00 PM, observation was made by 2 surveyors of the 4th floor, 400 hall shower room and revealed the corner bead was exposed 2 inches in 2 area. In the back 4th floor hallway, across from room [ROOM NUMBER] and 411, the ceiling tile was stained brown and there was a Geri-chair that was ripped on the side of the left upper arm approximately 4 inches and the right foot had a rip approximately 1 inch x 1 inch rip with padding exposed.
Staff # 31 was advised of these findings on 10/5/18 at 3:54 PM
Based on surveyor observation, it was determined the facility staff failed to provide housekeeping and maintenance services necessary to maintain a safe, clean, comfortable and homelike environment. This was evident throughout the survey on 4 of 4 nursing units.
The findings include:
1) On 9/27/18 at 12:25 PM, room [ROOM NUMBER] was observed. The covering of the call bell cord for the second bed was torn near the button end with internal wiring exposed. A loop of red wire was extending approximately ½ inch out of the torn area.
The walls within the bathroom were dirty, with brown splatters and streaks. The wall to the left and right behind the sink had cracked and peeling paint. The wall to the right side of the sink had an area, measuring approximately 3 inches by 5 inches, in which the paint was separated from the underlying wall. The paint below the soap dispenser was also separated from the wall, and had a 3-inch-long tear.
2) room [ROOM NUMBER] was observed on 9/27/18 at 12:47 PM. The exterior side of the bedroom door had several black marks, scuffs, and brown spots over its surface, faint black letters each approximately 12 inches tall by 6 inches wide spelled ADD across the top of the door. The wall across from the foot of the first bed had several black scuff marks and numerous patches of missing paint, each measuring approximately 1 by 2+ inches along the top of the base trim.
3) The bathroom in room [ROOM NUMBER] was observed on 9/28/18 10:56 AM. The wall behind and to the right of the sink had peeling paint over an area, measuring approximately 4 inches by 6 inches. The wall beside the right side of the sink had paint peeling over an area approximately 4 inches by 2 feet, as well as paint peeling under the paper towel and hand soap dispensers.
4) On 9/28/18 at 11:53 AM, the surveyor observed room [ROOM NUMBER]. The exterior side of the door had plastic veneer over the lower half of the door. The plastic was chipped and cracked with pieces sticking out along the edge located below the door knob. The Administrator was made aware of the above findings on 10/5/18 at approximately 3:30 PM.
5) In room [ROOM NUMBER]'s bathroom on 9/27/18 at 9:05 AM, there was a spackled area to the right of the toilet paper holder, approximately 8 inches by 8 inches that was not painted. There was a brown stain, approximately 10 inches by 4 inches on the second ceiling tile above the sink.
6) In room [ROOM NUMBER]-2 on 9/27/18 at 9:26 AM, there was a mauve tray that breakfast was served on. The bottom right corner had 3 inches that were chipped, and the left top corner was chipped and sharp. The molding strip, where the bureau drawers were located, was pulled away from the unit several feet long.
7) In room [ROOM NUMBER] on 9/27/18 at 9:41 AM, the resident's right wheelchair armrest had torn vinyl on the right side, with the underneath padding exposed.
8) In room [ROOM NUMBER]-1 on 9/27/18 at 9:54 AM, the over the bed tray table had the right front 2 inches caved in, missing the laminate covering.
9) Observation was made, on 9/27/18 at 1:05 PM, of Resident #281 sitting in a wheelchair. There was no armrest on the right side of the wheelchair. The resident was resting his/her arm on the metal frame.
10) Observations made on the 5th floor on 9/27/18 at 1:15 PM included the shower Room, which had chipped 2-inch by 2-inch tiles; a wet, soiled washcloth hanging on the grip bar; yellow slipper socks on the floor and body wash on the hand bar. The caulking in the corner, midway up the wall, was pulled away from the tile/grout.
The handrail between room [ROOM NUMBER] and #507 was missing.
The shower room by the locker room was missing drywall at the corner junction.
11) In room [ROOM NUMBER]-2 on 9/28/18 at 10:19 AM, the silver tube feeding pole had tan spills down the pole and the base had dried, caked on tube feeding residual.
12) Observation was made, on 10/5/18 at 11:25 AM, of Resident #8 sitting in a wheelchair in the dining room. The vinyl on the left armrest was torn on left side, exposing the underneath padding.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0604
(Tag F0604)
Could have caused harm · This affected multiple residents
Based on medical record review and interview with facility staff, it was determined that the facility failed to perform assessments on a resident who had been physically restrained by facility staff. ...
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Based on medical record review and interview with facility staff, it was determined that the facility failed to perform assessments on a resident who had been physically restrained by facility staff. This was true for 1 (#10) of 1 resident reviewed for physical restraints.
The evidence includes:
During a review of Resident #10's medical record, on 9/28/2018 at 9:50 AM, a psychiatric evaluation note was found which stated that staff occasionally use mittens on the resident due to their risky behavior of pulling on the trach during episodes of agitation.
Mittens are restraint devices that cover a resident's hands and prevent the use of their fingers. Application of mittens requires a physician's order, with a time limitation of 24 hours. Prior to implementing the restraint, the facility must demonstrate that other, less restrictive interventions were attempted to mitigate resident risk of the concerning behavior. During the use of the restraint, the facility must be able to demonstrate regular monitoring of the resident in the restraint and on any skin that is in contact with the device.
During an interview that was conducted on 10/4/2018 at 11:08 AM, the Corporate Nurse #19 stated that nursing staff are expected to complete an assessment whenever restraints are applied to a resident. Additionally, the Corporate Nurse stated that a unique order is required for each application of restraints and that the order must have a 24-hour limit.
Further review of Resident #10's medical record revealed the following orders for mitten restraints:
- 5/30/2018 at 2:46 PM, Apply bilateral hand mittens to prevent self decannulation. Check skin integrity every 2 hours. 24 hour order.
- 6/2/2018 at 5:46 PM, Apply bilateral hand mittens to prevent self decannulation. Check skin integrity every 2 hours. 24 hour order.
- 6/9/2018 at 11:02 PM, Apply bilateral hand mittens to prevent self decannulation. Check skin integrity every 2 hours. 24 hour order.
- 6/27/2018 at 3:25 PM, Place left hand in mitt to prevent patient from disconnecting from the ventilator x 24 hours.
- 8/9/2018 at 2:27 PM, Both sides hand mitts x 24 hours. Check skin every 2 hours.
- 8/15/2018 at 1:17 PM, Mitts as needed x 24 hours for safety.
- 8/28/2018 at 6:46 PM, Apply mitten on left hand for safety for 24 hours.
Decannulation is the removal of a tracheostomy annular which would put this respirator-dependent resident at risk for respiratory distress and asphyxiation.
Review of the facility's policy on the use of physical restraints revealed that the facility expects that a restraint assessment must be completed within a week of the initiation of a restraint. This surveyor reviewed the medical record for evidence of the resident's behaviors that warranted each of these restraint orders, of the interventions that were attempted prior to initiating the mitten restraints, and of the nursing assessment that was completed after each restraint use. This surveyor could not find any of these pieces of documentation.
During a follow up interview on 10/4/2018 at 12:16 PM, the Corporate Nurse indicated that none of the above documentation was available in the medical record for any of 7 restraint orders noted in the chart.
Cross Reference F 842.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0624
(Tag F0624)
Could have caused harm · This affected multiple residents
3) On 10/3/18, a review of Resident #19's medical record documented that Resident #19 was sent to the hospital emergency room (ER) on 8/16/18 for severe symptomatic anemia and returned to the facility...
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3) On 10/3/18, a review of Resident #19's medical record documented that Resident #19 was sent to the hospital emergency room (ER) on 8/16/18 for severe symptomatic anemia and returned to the facility on 8/19/18. The medical record failed to reveal any documentation that the resident received an explanation as to why he/she was going to the emergency room and the potential response of the resident's understanding. Continued review of Resident #19's medical record documented that Resident #19 was sent to the hospital emergency room on 8/16/18 for severe anemia. The medical record failed to reveal documentation that the resident received an explanation as to why he/she was going to the emergency room and the potential response of the resident's understanding. On 9/2/18, in a change of condition note, the nurse wrote that the resident was transferred to the emergency room for respiratory distress. The medical record failed reveal documentation that Resident #19 received an explanation as to why he/she was transferred to the emergency room and the potential response of the resident's understanding.
Based on medical record review and staff interview, it was determined that the facility failed to orient, prepare and document a resident's preparation for a transfer to the hospital. This is identified but not limited to 3 (#107, #108 and #19) of 7 residents reviewed for hospitalization.
The findings include.
1) Review of the medical record for Resident #108 on 10/2/18 revealed that, on 9/30/18, Resident #108 was transferred to an acute care facility due to a fall with noted injury. Review of the documented note in the chart does not reveal any information that the resident received an explanation of why he/she was going to the hospital or documentation of the resident's understanding.
2) Review of the medical record for resident #10,7 on 10/5/2018, revealed that the resident has had multiple admissions to the hospital in the past year. Review of the medical record for an admission to the hospital on 1/15/18 did not reveal any information that the resident had received an explanation of why he/she was going to the hospital and the potential response of the resident's understanding.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Assessment Accuracy
(Tag F0641)
Could have caused harm · This affected multiple residents
2) A. On 9/27/18 at 11:51 AM, observation of Resident #48 revealed that the resident did not have any teeth. When asked if the resident had dentures, Resident #48 stated he/she did not.
Review of Res...
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2) A. On 9/27/18 at 11:51 AM, observation of Resident #48 revealed that the resident did not have any teeth. When asked if the resident had dentures, Resident #48 stated he/she did not.
Review of Resident #48's annual MDS, with an assessment reference date (ARD) of 7/16/18, revealed Section L. Oral/Dental Status, L0200. Dental, B. No natural teeth or tooth fragment(s) (edentulous) was blank, indicating the resident had teeth, which was inaccurate.
B. On 9/27/18, during an interview, Resident #48 indicated that he/she had a gastrostomy tube (GT) (a tube inserted through the abdomen that delivers nutrition directly to the stomach) and did not receive nutrition through the tube.
Review of Resident #48's annual MDS, with an assessment reference date (ARD) of 7/16/18, revealed Section K. Swallowing/Nutritional Status, K0710 Percent Intake by Artificial Route, A. Proportion of total calories the resident received through parenteral or tube feeding, was coded 2. 26-50%. This was inaccurate. Further review of Resident #48's medical record failed to reveal that the resident had received nutrition via the GT in the MDS look back period.
3) On 9/28/18 at 9:10 AM, an interview was attempted with Resident #19. At that time, the resident indicated to the surveyor that he/she was hard of hearing.
On 10/3/18, a review of Resident #19's medical record was conducted. On 8/3/18 at 10:51 AM, the social worker documented in a progress note that the resident was hard of hearing (HOH) on the right side. On 8/15/18 at 5:36 PM, in an activity note, the facility staff documented that the resident was HOH and hears best in the left ear. On 8/28/18 at 3:13 PM, in a skilled charting note, the nurse documented the resident's right ear had hearing difficulties and on 9/1/18 at 3:01 PM, in a Skilled Charting note, the nurse documented the resident was hard of hearing, right ear.
Review of Resident #19's 9/2/18 5 day MDS with an ARD of 9/2/18, Section B, B0200.Hearing, Avblity to hear was coded 0, Adequate, indicating the resident had no difficulty in hearing in normal conversation, social interaction listening to TV. This was inaccurate.
On 10/5/18, during an interview with the MDS coordinator, Staff # 37 confirmed the above MDS inaccuracies.
Based on medical record review and staff interview, it was determined the facility staff failed to ensure that Minimum Data Set (MDS) assessments were accurately coded. This was evident for 4 (#78, #48, #19 and #11) of 33 residents in the initial resident pool. The MDS is part of the Resident Assessment Instrument that was Federally mandated in legislation passed in 1986. The MDS is a set of assessment screening items employed as part of a standardized, reproducible, and comprehensive assessment process that ensures each resident's individual needs are identified, that care is planned based on those individualized needs, and that the care is provided as planned to meet the needs of each resident. The findings include:
1) Observation was made, on 9/27/18 at 9:17 AM, of Resident #78 receiving oxygen through a nasal cannula. Review of the medical record revealed that the resident had a diagnosis of COPD (Chronic Obstructive Pulmonary Disease) and September 2018 physician orders stated, oxygen via nasal cannula at 3.5 L (liters). Further review of the medical record revealed documentation from a 9/6/18 discharge summary from the hospital that the resident used oxygen at home every day.
Review of the 14-day MDS assessment, with an assessment reference date (ARD) of 9/20/18, Section O0100C, was coded no for oxygen use. The MDS was completed on 9/20/18, locked and export ready.
The MDS Coordinator was interviewed on 10/5/18 at 9:18 AM and stated, once export ready, the MDS will not be touched or re-opened. The MDS Coordinator confirmed the error of the oxygen omission.
4) Review of an MDS assessment, with an assessment reference date (ARD) of 8/27/2018, indicated that resident #11 was receiving dialysis treatments. Interview of resident #11 on 9/28/2018 at 10:09 AM revealed that resident #11 was not receiving Dialysis treatment. Interview of the assessment coordinator (staff #37) on 10/5/2018 confirmed the inaccurate assessment.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0697
(Tag F0697)
Could have caused harm · This affected multiple residents
Based on resident interview and review of the medical record, it was determined that the facility staff failed to have an effective system in place for pain management as evidenced by failure to have ...
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Based on resident interview and review of the medical record, it was determined that the facility staff failed to have an effective system in place for pain management as evidenced by failure to have complete pain assessments when the resident experienced pain and failure to implement the resident's plan of care for pain. This was evident for 2 (#119, #16) of 4 residents reviewed for pain management. The findings include:
1) An interview was conducted with Resident #119 on 9/27/18 at 11:02 AM. The resident was asked if he/she had any pain, and the resident stated, where the cyst is.
Review of Resident #119's medical record revealed a physician's progress note dated 9/5/18, which documented still with min. to moderate abdominal pain. A 9/10/18 physician's progress note stated, without new complaints except for pain with touches on his/her left side. A 9/24/18 physician's note stated, pt. is complaining of abdominal pain. Since last week pt. had an abdominopelvic sonogram done with findings of positive cyst versus hematoma in the abdomen. Pending surgery for cystic mass.
A care plan is a guide that addresses the unique needs of each resident. It is used to plan, assess and evaluate the effectiveness of the resident's care.
A care plan was initiated on 8/10/18 and updated on 9/6/18 which documented at risk for pain r/t hx of CVA/chest pain/deconditioning/abdomen discomfort. Interventions listed included; identify, record and treat existing conditions which may increase pain and or discomfort, monitor/record pain characteristics: quality (e.g. sharp, burning); Severity (1 to 10 scale); anatomical location; onset; duration (e.g., continuous, intermittent); aggravating factors; relieving factors.
A plan of care note, dated 9/11/18 at 12:46 PM, stated appraise and observe daily for changes in physical and/or mental status every shift, oxycodone 5 mg q 6 hrs. prn. This was not a thorough assessment, as it did not evaluate the measures on the care plan to determine if the interventions were working or required alteration.
Review of the medical record on 10/5/18 found a physician's order, dated 8/18/18, for Oxycodone (an Opioid pain medication) give 5 mg. tablet every 6 hours as needed for pain.
The September 2018 MAR (Medication Administration Record) revealed documentation indicating that the resident was medicated with the prn Oxycodone on 9/1/18, 9/4, 9/5, 9/7 at 14:54 and 20:57, 9/10 at 09:14 and 14:57, 9/11, 9/12 at 00:58 and 21:00, 9/14 at 14:41 and 22:00, 9/16 at 08:00 and 20:48, 9/17, 9/18 (3) times at 08:07, 13:32 and 21:30, 9/19 at 13:34 and 22:00, 9/20, 9/21, 9/22 at 00:23 and 21:00, 9/23 at 07:30 and 22:00, 9/24, 9/26 at 12:00 and 22:00, 9/27, 9/28 at 14:34 and 22:00, 9/29 at 12:29 and 21:03 and 9/30/18. The October 2018 MAR documented that the resident received the Oxycodone on 10/1/18 at 14:25 and 22:30, 10/2 at 09:52 and 20:16, 10/3 at 10:30 and 22:00 and 10/4/18 at 09:00 and 21:00. The pain levels ranged from 5 to 8 on a scale from 1-10.
Further review of the September 2018 MAR revealed pain level records each shift. On 9/7/18, 9/10, 9/14 and 9/29 the resident received Oxycodone twice in a 24-hour period, however, the pain level record was marked off as no pain for the 24-time period. On 9/18/18, the resident received Oxycodone 3 times at 08:07, 13:32 and 21:30, however the pain level record only documented pain on 1 shift.
Review of nursing progress notes, dated 9/1/18 to 9/7/18, documented that Oxycodone was given for complaints of pain but did not describe where the pain was located or any characteristics or description of the pain. There was no documentation of non-pharmacological interventions. On 9/8/18 at 19:47 a skilled nursing note documented resident verbalizes presence of pain, scale of 8/10. Took oxycodone po x 1 for pain. Pain relieved. There was no documentation on the September 2018 MAR for Oxycodone being given on 9/8/18. Further review revealed documentation that the Oxycodone was given for pain and was effective for all the dates above, except for 9/18/18 at 9:30 PM, where there was documentation that the resident had generalized pain. Non-pharmaceutical interventions were not attempted prior to the administration of pain medication and probable cause of each pain episode, per the resident plan of care, was not documented in the medical record.
2) Review of Resident #16's medical record on 10/5/18 revealed a pain care plan related to a sacral ulcer. The approaches included; monitor/document for probable cause of each pain episode; Remove/limit causes where possible; monitor/record pain characteristics: quality (e.g. sharp, burning) Severity (1 to 10 scale). anatomical location; onset; duration (e.g. continuous, intermittent) aggravating factors, relieving factors); non-pharmacological interventions (like relaxation, guided imagery, music, distraction and massage) before, after and if possible during painful activities or before pain occurs.
The care plan evaluation note dated 9/4/18 at 15:33 stated, appraise and observe daily for changes in physical and/or mental status every shift. Gabapentin 100 mg tid (3x/day), tramadol 50 mg q 12 hrs. prn, acetaminophen 325 mg 2 tabs q 6 hrs prn. This was not an evaluation as it did not evaluate the measures on the care plan to determine if the interventions were working or if they needed to be altered.
Review of Resident #16's September 2018 MAR documented that the resident had 2 medications that could be administered for pain which included Tramadol 50 mg. and Tylenol 325 mg (2) tablets. Documentation on the MAR revealed the resident received the Tylenol on 9/1, 9/4, 9/6, 9/9, 9/12, 9/13, 9/15 and 9/16/18. The resident received PRN Tramadol 50 mg. on 9/1, 9/3, 9/7, 9/8, 9/9, 9/10, 9/11, 9/13, 9/14, 9/15, 9/16, 9/17, 9/19, 9/20/18 and Tramadol 50 mg. ½ tablet two times per day as scheduled 9/24/18 through 10/4/18.
Further review of nursing progress notes failed to identify if non-pharmaceutical interventions were attempted prior to the administration of pain medication. There was no description of the pain, characteristics or relieving factors of each pain episode, per the resident plan of care.
Discussed with the Nursing Home Administrator on 10/5/18 at 2:02 PM.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0698
(Tag F0698)
Could have caused harm · This affected multiple residents
2.) On 9/27/18 at 12:52 PM, during an interview, Resident #56 stated he/she went to dialysis three times a week and that his/her dialysis access site was in the upper left arm. Above the resident's be...
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2.) On 9/27/18 at 12:52 PM, during an interview, Resident #56 stated he/she went to dialysis three times a week and that his/her dialysis access site was in the upper left arm. Above the resident's bed, the surveyor observed a sign that stated, no left arm procedures and next to the sign was a plastic bag containing a clamp.
On 10/2/18, a review of Resident #56's medical record revealed that the resident received hemodialysis (kidney dialysis) (process of cleaning a person's blood whose kidneys are not working properly. Review of Resident #56's physician orders revealed an 8/5/18 order for hemodialysis 3 times a week on Monday, Wednesday and Friday. Continued review of the Resident #56's physician orders failed to reveal physician orders for dialysis access care and failed to reveal ongoing assessment of the resident's condition and monitoring for complications before and after dialysis treatments received at a certified dialysis facility.
On 10/2/18, at 2:43 PM, during an interview, Staff #11 confirmed the above findings. On 10/2/18 at 3:00 PM, Staff #10 was advised of these findings.
3.) Resident #90 was interviewed on 9/28/18 at 8:46 AM. Upon surveyor inquiry, the resident indicated that there was often a delay in staff coming to the on-site dialysis center to transport him/her back to his/her room after dialysis. The resident also indicated that he/she was diabetic, and the delay resulted in his/her blood sugar monitoring, insulin administration and dinner being delayed as well.
An interview was conducted with Staff #35, a dialysis center nurse, on 10/4/18 at 2:50 PM. He/She confirmed that Resident #90 had dialysis from 2:15 PM - 6:15 PM on Monday, Wednesday and Friday and that it was the responsibility of the facility staff to transport the residents to and from dialysis. He/She also indicated that, at times, it took 1 to 2 hours for staff to pick Resident #90 and others up after dialysis.
Resident #90's record was reviewed on 10/4/18 at 12:10 PM. A care plan is a guide that addresses the unique needs of each resident. It is used to plan, assess, and evaluate the effectiveness of the resident's care. A plan of care was developed for increased nutrient needs related to ESRD (end stage renal disease) on HD (hemodialysis) the goal - will meet estimated nutritional needs via po intake thru review date. it did not indicate what the residents estimated nutritional needs were. Approaches - diet as ordered, supplements/snacks as ordered, Vitamin/Minerals as ordered, Weigh resident per facility protocol and Monitor labs as needed. The plan of care did not specify the residents ordered diet or if he/she was on a therapeutic renal diet, it did not address the resident's nutritional needs related to his/her dialysis and renal failure.
A plan of care had been developed for Dialysis. The goal - will have no s/sx (signs/symptoms) of complications from dialysis. The interventions - do not draw blood or take B/P (blood pressure) in arm with graft. Encourage resident to go for the scheduled dialysis appointments. Monitor intake an output (I&O) (monitoring the residents' intake and output of fluid). Monitor labs and report to doctor as needed. Monitor vital signs every shift and notify MD of significant abnormalities. Monitor/document report to MD s/sx of depression. Obtain order for mental health consult if needed. Monitor/document/report as needed any s/sx of infection to access site: Redness, Swelling, warmth or drainage. Monitor/document/report as needed for s/sx of the following; Bleeding, Hemorrhage, Bacteremia, septic shock.
The plan did not specify the resident's dialysis days or times, it did not address dietary approaches, fluid overload risk, transportation needs, assessment of access site.
The resident also had a plan of care for Diabetes Mellitus, risk for hyperglycemia (high blood sugar) and risk for hypoglycemia (low blood sugar) the approaches did not identify the residents prescribed diet nor measures to prevent or treat hyper or hypo glycemia if it occurred.
Dialysis communication sheets revealed that, on 9/13/18, post dialysis instructions indicated to continue watching fluid intake. On 9/17/18, the specific follow up for the facility staff from dialysis indicated needs to limit fluid intake, patient verbalizes understanding on fluid intake after education was provided. On 9/19/18 the follow up needed indicated continue to watch fluid intake.
During an interview on 10/5/18 at 10:44 AM Staff #11 confirmed that Resident #90 was not on I&O monitoring.
The record revealed that the facility failed to coordinate measures with the dialysis center for the provision of Resident #90's unique care needs related to dialysis and diabetes. The facility failed to implement interventions related to diet and potential for fluid overload nor timely provision of transportation from dialysis, consistent accommodation of blood sugar monitoring and meals on dialysis days and the dialysis center's fluid concerns. The plans did not identify nor address how staff were to simultaneously manage Resident #90's specific diabetes and dialysis needs. Cross reference F 684.
Based on record review and interviews with the resident and staff it was determined that the facility staff failed to ensure that residents who require dialysis receive such services consistent with professional standards of practice, the comprehensive person-centered care plan and the residents' goals and preferences. This was evident for 3 (#119, #56 and #90) of 4 residents reviewed for dialysis.
The findings include:
1.) Resident #119 was interviewed on 9/27/18 at 11:03 AM and stated that he/she went to dialysis 3 times per week on the first floor of the facility. The resident was asked if there were any issues related to his/her dialysis treatment and the resident stated, depends on the staff. They have problems communicating.
Dialysis is a procedure that performs many of the normal duties of the kidneys, such as filtering waste products from the blood, when the kidneys no longer work adequately. The problems that a patient on hemodialysis may experience are fluid overload (hypervolemia), electrolyte imbalance, and alterations in blood components, leading to anemia or platelet abnormalities resulting in a tendency to bleed excessively.
Resident #119's medical record was reviewed on 10/4/18. Resident #119 had a diagnosis of end stage renal disease with dependence on renal dialysis. The resident had physician's orders which included hemodialysis 3 times a week on Monday, Wednesday and Friday. The resident was ordered a NAS (no added salt), LCS (low concentrated sweets) diet, no bananas, no OJ/oranges. There were no orders for fluid restriction.
Review of the care plan hemodialysis r/t renal failure had the goal will have no s/sx of complications from dialysis through the review date. Approaches on the care plan included do not draw blood or take b/p in LUE (left upper extremity) with graft, Document vital signs every shift and prn (when necessary). Notify MD of significant abnormalities, monitor for dry skin and apply lotion as needed and staff to provide assistance for transport to and from dialysis center. There were no interventions related to monitoring the resident upon return from dialysis, or if the facility should weigh the resident or be on a fluid restriction.
The care plan increased nutrient needs r/t wounds, renal disease/hemodialysis had the goal will meet estimated nutritional needs via po (by mouth) intake thru review date. The goal was not measurable as it did not state what the estimated nutritional needs were. The approaches diet as ordered, protein supplement as ordered, vitamin/minerals as ordered, liberalize diet prn, monitor labs prn, SLP evaluation as ordered, feeding/assist/supervision by staff, review nutritional needs with resident and family as needed and honor advanced directives. The approaches failed to address weights, fluid restriction, food restrictions such as high potassium foods and monitoring of the resident's compliance with the restrictions.
There was no care plan for potential of fluid volume overload and it was not addressed in either the dialysis care plan or the nutrition care plan.
On 10/4/18 at 1:47 PM Staff #26, a registered nurse assigned to the resident, was asked if the resident had any dietary restrictions. Staff #26 stated, she is diabetic so no sweets. The surveyor asked if there was anything else and Staff #26 said no. The surveyor asked if Staff #26 was aware the resident should not have bananas, oranges and orange juice. Staff #26 said I knew about the orange juice. Staff #26 was asked if the resident was on a fluid restriction as the surveyor saw a water cup at the bedside of Resident #119. Staff #26 had to look in the computer to determine if the resident was on fluid restriction. Staff #26 stated, no, he/she is not on fluid restriction.
Review of the communication book that was at the nurse's station for Resident #119 had 3 communication papers in the book. The most recent communication form was dated 10/3/18 and the Important Information for Facility Charge Nurse that was at the lower one third of the page documented specific follow up needed: pt. to continue watching fluid intake. Staff #26 was asked if he/she was aware of the recommendation from dialysis and if the physician was notified. The response was I did not work yesterday. When asked would you expect to see documentation in nursing progress notes about the recommendation the response was yes, that would have been the proper thing to do. The surveyor asked Staff #26 how often the resident was weighed, and Staff #26 looked in the computer and stated, every Friday. The surveyor questioned the frequency and Staff #26 stated, it makes sense she should be on weights 3 times a week. Staff #26 continued to look in the computer and stated, he/she is not on a fluid restriction. Probably the order got missed when he/she came in.
Continued review of the communication book revealed that the only communications in the book were dated 10/3/18, 10/1/18 and 9/10/18. Staff #26 stated they sometimes lose the book, so I don't know where the other communication forms are. He/she is third shift dialysis and I am not here when he/she gets back. At that time the unit manager stated he/she thought the communication forms had been thinned and brought to the surveyor the September communication logs. Communication forms dated 9/17/18 and 9/24/18 documented continue to watch fluid intake.
On 10/4/18 at 2:12 PM, Staff #27, the physician's assistant, was at the nursing station and was asked as a dialysis patient would you expect Resident #119 to be on a fluid restriction and to be weighed more than once a week? Staff #27 replied, I would have expected the resident to be on a 1,000 to 1,200 per day fluid restriction and I just ordered that. I would expect the resident to be weighed 3 times per week. Staff #27 stated, I have only been in this building for 2 days. This is not my normal building.
It was noted on 10/4/18 that an order was written for no water cup at bedside.
Discussed with the Dietician on 10/5/18 at 11:37 AM. Discussed all care plan concerns with the Nursing Home Administrator on 10/5/18 at 2:02 PM.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0726
(Tag F0726)
Could have caused harm · This affected multiple residents
Based on observation and interview with facility staff, it was determined that the facility failed to ensure that residents received care from nursing staff with adequate competencies and skill sets t...
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Based on observation and interview with facility staff, it was determined that the facility failed to ensure that residents received care from nursing staff with adequate competencies and skill sets to provide care based on resident needs, as evidenced by a nurse failing to check feeding tube placement by auscultation and failing to unclamp a feeding tube prior to starting the feeding infusion on the pump. This was true for 1 (Resident #72) of 1 Resident observed during routine initiation of the resident's tube feeding.
A feeding tube is a device that allows a resident to receive nutrition through a tube tunneled through their abdomen into their stomach. It is used to bypass the mouth and throat when a resident is unable to eat or at high risk of having swallowed food go down their trachea instead of their esophagus.
Auscultation is the process of using the sense of hearing to assess a resident's status and often involves the use of a stethoscope. Feeding tubes require checking to assure that they end in the correct part of the body. This can be done by aspirating (withdrawing air or fluid into a syringe) the contents of wherever the tube is placed and by auscultating the abdomen while the aspirant is returned to the resident through the tube.
The evidence includes:
Facility nursing staff failed to check feeding tube placement by auscultation and failed to unclamp a resident's feeding tube prior to starting the feeding infusion on the pump.
During an observation that took place on 10/3/2018 at 12:11 PM, this surveyor observed Licensed Practical Nurse (LPN) #16 initiate the resident's 12:00 PM daily tube feeding infusion. LPN #16 was noted to perform hand hygiene and don gloves. Then, using the syringe assigned to the resident, LPN #16 withdrew about 40 mL of fluid into the syringe, checked its contents, and then returned it to the resident. LPN #16 did not utilize a stethoscope while returning the fluid to the resident. LPN #16 then spiked and primed the new container of feeding formula.
No concerns were identified during the process of preparing and priming the container of feeding formula and tubing, nor when LPN #16 attached the primed tubing to the resident's g-tube. However, after attaching the tubing but before unclamping the small white plastic clamp on the g-tube, LPN #16 started the infusion on the feeding pump, then began collecting his/her supplies, disposing of trash, and performing hand hygiene. Within about 10 seconds, the pressure from the infusion pushed the cap off of another port at the end of the g-tube and formula began flowing out onto the resident's bedding.
The surveyor indicated the engaged clamp on the g-tube and LPN #16 unclamped it. But because the other port was open on the end of the g-tube, gastric contents then began flowing out quickly onto the bed. LPN #16 did not appear to notice that the g-tube port was uncapped, but capped it after surveyor notification.
These concerns were shared with Unit Manager #9 on 10/5/2018 at 10:40 AM.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0730
(Tag F0730)
Could have caused harm · This affected multiple residents
4) Review of Staff #36's employee file on 10/3/18 at 12:58 PM revealed that the employee's DOH was 10/6/14. A single annual performance evaluation, dated 3/17/17, was found in the file. Annual perform...
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4) Review of Staff #36's employee file on 10/3/18 at 12:58 PM revealed that the employee's DOH was 10/6/14. A single annual performance evaluation, dated 3/17/17, was found in the file. Annual performance evaluations were not present for 2015 nor 2016.
Based on review of Geriatric Nursing Assistant (GNA) personnel files and staff interview, it was determined the facility failed to conduct yearly performance reviews at least every 12 months for 4 out of 7 personnel files reviewed.
The findings include:
1) Review of Staff #29's employee file revealed a date of hire (DOH) of 7/16/13. The last yearly review found in the personnel file was dated 2/24/17.
2) Review of Staff #30's employee file documented a DOH of 11/18/13. The last yearly review found in the personnel file was dated 1/19/17.
3) Review of Staff #31's employee file documented a DOH of 5/11/10. The last yearly review found in the personnel file was dated 5/27/15 and 6/17/14.
The Corporate nurse was advised on 10/3/18 at 1:19 PM. The Corporate nurse confirmed and stated they should be done annually and I noticed they weren't in there when I went through them.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Pharmacy Services
(Tag F0755)
Could have caused harm · This affected multiple residents
Based on review of the medical record and staff interview, it was determined that the facility failed to provide resident medications in a timely manner. This was evident for 1 (#21) of 8 residents ob...
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Based on review of the medical record and staff interview, it was determined that the facility failed to provide resident medications in a timely manner. This was evident for 1 (#21) of 8 residents observed during medication administration and 1 (#278) of 1 residents reviewed for constipation.
The findings include:
1) Observation was made, on 10/2/18 at 9:03 AM, of the medication administration for Resident #21. While preparing the medications, Staff #28 looked through the medication cart and was unable to find the medication Colace (a stool softener) and Lansoprazole (a proton-pump inhibitor which treats stomach ulcers, gastroesophageal reflux disease and high levels of stomach acid. The Colace was to be administered twice a day and the Lansoprazole once a day. Both medications were initially ordered on 8/24/18, therefore, should have been in-house for administration. Staff #28 stated, they are on re-order. I will call pharmacy and give it when it comes in.
Review of Resident #21's Medication Administration Record (MAR) on 10/3/18 revealed that the Colace was administered at the schedule time of 9:00 PM and the Lansoprazole was not administered at all on 10/2/18.
2) Review of the medical record for Resident #278 on 10/4/18 revealed physician's orders for September 2018 which stated Ergocalciferol tablet 400 unit; give 1 tablet by mouth one time a day for supplement. The order was written to start on 9/15/18. Review of Resident #278's Medication Administration Record (MAR) documented that, on 9/15/18, 9/19, 9/20, 9/24, 9/25, 9/26, 9/28, 9/29 and 9/30/18, the medication was not available. Review of nursing progress notes revealed that the medication was not available. There was no documentation as to staff notifying pharmacy about the medication unavailability and what the response was from pharmacy.
Further review of the medical record for Resident #278 revealed the physician's order for the medication MgO tablet 400 mg. for 10 days to start on 9/19/18. Review of the September 2018 MAR revealed that the medication was not available from the pharmacy on 9/23/18 and 9/26/18. The resident only received 7 doses of the medication, as the resident refused the dose on 9/28/18.
Staff #26 was asked on 10/4/18 at 2:10 PM what he/she would do if a medication wasn't available and the response was after 3 days I would let the physician know. The unit manager was advised of the unavailability of the medication and the unit manager just shook his/her head.
The Nursing Home Administrator was advised on 10/5/18 at 2:02 PM.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0757
(Tag F0757)
Could have caused harm · This affected multiple residents
2) A review was conducted of Resident #90's medical record on 10/5/18 at 8:11 AM. The resident's diagnoses included, but were not limited to, Diabetes. Physicians orders included but were not limited ...
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2) A review was conducted of Resident #90's medical record on 10/5/18 at 8:11 AM. The resident's diagnoses included, but were not limited to, Diabetes. Physicians orders included but were not limited to, insulin and Glucagon Emergency Kit 1 mg (milligram) inject subcutaneously (under the skin) every 4 hours as needed for low blood sugar. Glucagon is an emergency medicine used to treat severe hypoglycemia (low blood sugar) in diabetes patients treated with insulin who are unable to swallow. The physicians order was not clear as to how low the blood sugar level must be for staff to administer the Glucagon.
Based on medical record review and staff interview, it was determined that the facility staff 1) failed to clarify an order that was not clear as to when to hold a medication and 2) failed to ensure that a physician's order for Glucagon included adequate indication for its use. This was evident for 2 (#78 and #90) of 5 residents reviewed for unnecessary medications.
The findings include:
1) Resident #78's medical record was reviewed on 10/2/18. Review of the September 2018 Medication Administration Record (MAR) revealed an order for Metoprolol Tartrate Tablet 25 mg., Give 1 tablet by mouth two times a day for HTN (Hypertension) hold if SBP (Systolic Blood Pressure) is less than 110 and heart rate (HR) less than 60. The systolic blood pressure is the top number of a blood pressure reading.
Review of the September 2018 MAR documented that, on 9/8/18 at 9:00 AM, the BP was 107/71 with HR 64. On 9/20/18 at 9 AM, the BP was 107/73 with HR 81. On both days, the medication was given as the systolic b/p was not within parameters, but the heart rate was within parameters.
On 9/9/18 at 9:00 AM, the BP was 106/63 with HR 51, and the medication was given even though both BP and HR were not within parameters.
On 9/13/18 at 5 PM, the BP was 105/68 and HR 92, on 9/16/18 at 5 PM the BP was 93/63 and HR was 89, on 9/22/18 at 5 PM the BP was 100/62 and HR was 88, 9/26/18 at 5 PM BP was 101/65 and HR 87, 9/27/18 at 9 AM BP was 109/74 and HR 93. On these dates, the medication was held even though the heart rate was within parameters, but the BP was not within parameters.
Review of the October 2018 MAR revealed that, on 10/1/18 at 5 PM, the BP was 95/61 and the HR was 87 and the medication was given. On 10/2/18 at 5 PM, the BP was 100/67 and the HR was 77 and the medication was held. There were inconsistencies regarding when staff gave the medication and when staff held the medication.
Staff #17 was interviewed on 10/4/18 at 10:08 AM and stated that he/she read the order as SBP below 110 or HR below 60. He/she said one or the other I would hold the medication. Staff #18 stated if the SBP was below parameters and the HR was within parameters I would personally call the doctor; however, I will change the order. The surveyor stated, is that what the physician's intent was? Staff #18 stated I will call the doctor because it should say or. At that time Staff #18 called the physician who clarified the order should have said or and not and.
The facility staff failed to hold the blood pressure medication when it was outside of parameters and the facility staff failed to clarify the order or call the physician to question if the resident should have received the blood pressure medication or if it should have been held.
Discussed with the Corporate Nurse on 10/3/18 at 11:10 AM.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Unnecessary Medications
(Tag F0759)
Could have caused harm · This affected multiple residents
Based on medication administration observation, staff interview and medical record review, it was determined that the facility staff failed to ensure a medication error rate of less than 5 percent for...
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Based on medication administration observation, staff interview and medical record review, it was determined that the facility staff failed to ensure a medication error rate of less than 5 percent for 4 (#78, #21, #75, #71) of 8 residents observed with 55 medication administration opportunities, which resulted in an error rate of 29.09% by 1 of 3 registered nurses and 1 of 1 licensed practical nurse observed. The findings include:
1) Observation was made on 10/2/18 at 8:33 AM of Staff #28, a registered nurse, preparing medications for Resident #78. Staff #28 had already poured 5 pills in a cup and cough syrup, so the surveyor watched a Lidoderm patch being placed on the resident and the administration of 2 inhalers.
Staff #28 handed Resident #78 a Ventolin inhaler and the resident said, I can't do that myself. Staff #28 took the Ventolin inhaler and squirted a puff into the resident's mouth and the resident said, I didn't get anything. There was no evidence that anything came out of the inhaler. Staff #28 proceeded to squirt 2 more puffs quickly in the resident's mouth. Staff #28 did not shake the inhaler, did not instruct the resident to breathe in and hold, and did not wait between puffs. Staff #28 then proceeded to take the Advair inhaler and administer 2 puffs into the resident's mouth. Again, Staff #28 did not shake the inhaler and there was no time in between the 2 different inhalers. The resident did not hold his/her breath after the first inhalation. The resident did not rinse his/her mouth after use of the inhaler. When Staff #28 administered the second inhaler, the spray was visible in the air.
Review of the manufacturer's website for the Ventolin inhaler gave the instructions shake the inhaler well before each spray. Staff #28 did not shake the inhaler.
The instructions stated Push the top of the canister all the way down while you breathe in deeply and slowly through your mouth. After the spray comes out, take your finger off the canister. After you have breathed in all the way, take the inhaler out of your mouth and close your mouth. Hold your breath for about 10 seconds, or for as long as is comfortable. Breathe out slowly as long as you can. The resident did not breathe all the way in and the resident did not hold his/her breath or breathe out slowly. Staff #28 did not encourage or advise the resident the correct method for use of the inhaler.
The directions continued, if your provider has told you to use more sprays, wait 1 minute and shake the inhaler again. Repeat. This direction was not followed and there was no time between inhalations and the inhaler was not shaken by Staff #28.
The manufacturer's website stated, For correct use of your VENTOLIN HFA inhaler, remember: Breathe in deeply and slowly to make sure you get all the medicine. Hold your breath for about 10 seconds after breathing in the medicine. Then breathe out fully. This was not done, and Staff #28 said nothing to the resident during the administration of the inhaler.
Review of the manufacturer's website for the Advair inhaler revealed, Shake inhaler for 5-10 seconds, (Staff #28 did not shake the inhaler) breathe out fully (in preparation to breathe in medication), (the resident did not do this), push the top of the canister all the way down one time while breathing in deeply and slowly through your mouth, hold your breath for 5-10 seconds, and then breathe out. (the resident did not do this). If your doctor has prescribed more than one dose (puff), wait 30 seconds and repeat above. (Staff #28 did not wait 30 seconds). Rinse mouth thoroughly with water after taking medication to decrease the risk of a mouth infection. Spit out the water. Do not swallow it. (Staff #28 did not have the resident rinse his/her mouth out). Staff #28 failed to follow the directions for adequate administration of 2 inhalers.
2) On 10/2/18 at 9:03 AM, the surveyor observed Staff #28 prepare medications for Resident #21. Resident #21 was to receive all medications through a gastrostomy tube (g-tube). A g-tube is a tube that is surgically placed in the stomach due to an inability to swallow food/liquids.
Staff #28 poured Vimpat Sol. 10mg/ml. Staff #28 poured 15 ml. into a medication cup. The liquid was clear. Staff #28 held the 30 ml. medication cup at a slant when pouring. Staff #28 then proceeded to put the bottle of Vimpat in the bottom drawer of the medication cart and he/she then signed the medication out in the controlled substance log book. Staff #28 signed out that 10 ml. was poured.
Staff #28 then poured Senna syrup concentrate 5 ml. which was a dark brown liquid, and 5 ml. of Ferrous Sulfate, which was a yellow color. Staff #28 then told the surveyor that the Colace and Lansoprazole was not in the medication cart, that it was on re-order and would not be administered at that time.
Staff #28 advised the surveyor that the Lisinopril was being held due to the blood pressure not being within parameters.
Staff #28 was preparing to lock the medication cart and walk to the resident's room when the surveyor asked him/her to look at the Vimpat again to confirm that 15 ml. had been poured. Staff #28 looked and got another plastic cup. He/She poured 5 ml. into the cup and then looked at the remaining amount. He/She then proceeded to pour 2.5 ml. more into the medication cup for a total of 12.5 ml. The surveyor looked at the cup and stated, so the order is for 12.5 ml. and Staff #28 said, No, it is 10 ml. The surveyor looked at the medication cup again and advised that it was not 10 ml. It was noted that on the bottom of the medication cup there was a small piece of plastic which prevented the cup from sitting flat. Staff #28 then took the medication cup and poured out 2.5ml to reach a total of 10 ml. Staff #28 then locked the medication cart to walk to the resident's room. Staff #28 left the remaining Vimpat on the top of the medication cart. Vimpat is a federally controlled substance (C-V) because it can be abused or lead to drug dependence. Vimpat should be kept in a safe place to protect it from theft.
The surveyor observed Staff #28 enter Resident #21's room and raise the bed. Staff #28 did not shut the privacy curtain or the door. The surveyor observed 3 ports to the feeding tube. There was a red cap to the far right, a purple cap in the middle and a white cap on the left side. At the time, the resident was not hooked up to the tube feeding. The surveyor observed that the white cap was off and not placed in the port. Staff #28 took the red cap off and flushed the tube with 30 ml. of water. Staff #28 did not listen for placement or check residual prior to flushing the tube. Staff #28 then poured the 10 ml. of Vimpat (the clear liquid) in the syringe with 5 ml. of water that was left over from the flush. Staff #28 then pushed the Vimpat into the white port and the surveyor observed clear liquid come out of the opened port where the white cap was off and spill onto the bedspread. Staff #28 then flushed the tube with 40 ml. of water after which the surveyor observed more clear liquid come out of the white port. Staff #28 then gave the Ferrous Sulfate (yellow liquid) with a 20 ml. water flush. During the observation the surveyor observed the fluid coming out of the uncapped port. The surveyor advised Staff #28. He/she put the white cap back on. Staff #28 then administered the Senna and then a 20 ml. water flush. The surveyor asked Staff #28 about the amount of fluid coming out of the white port which would have been the anticonvulsant (Vimpat) and Staff #28 insisted it was not the medication, that the fluid on the bedspread was clear.
Review of Resident #21's October 2018 physician's orders stated, every shift check tube for proper placement prior to each feeding, flush, or medication administration. This was not done. A second order stated, flush tube with at least 30 ml. of water before and after each medication pass. Flush tube with 5 ml. of water between each medication. This was not done as Staff #28 flushed with 40 ml. of water and 20 ml. of water twice as stated above.
The physician's order for Vimpat (Lacosamide) stated, give 10 ml via g-tube 2 times a day for seizure. Staff #28 poured 15 ml. and was prepared to administer until the surveyor intervened. The physician's orders stated give Lansoprazole 15 mg via g-tube every day which was written on 8/24/18. The drug was not available, but should have been, as it was not a new prescription. A physician's order, Docusate Sodium (Colace), give 10 ml. via g-tube every day, which was written on 8/24/18, was not available and was not given that day. In addition, upon medication reconciliation review, the resident was to receive Lopressor Solution, 1.25 ml. for hypertension. Staff #28 told the surveyor about the Lisinopril being held due to blood pressure readings of 103/54 which were outside of parameters. The resident did not receive the Lopressor, however, Staff #28 signed off that the resident received the Lopressor. Physician's order for Chlorhexidine Gluconate solution that was to be given at 9 AM was not given when the surveyor observed medication administration, however, Staff #28 signed off that it was given.
3) On 10/3/18 at 9:00 AM, observation was made of Staff #12 dispensing pills into a medication cup for Resident #75 which included Lasix 20 mg., Aspirin 81 mg. Senna 8.6-50 mg. (2), Januvia 50 mg., Glipizide 10 mg., Oxybutynin ER 10 mg. and Digoxin 0.125 mg. The surveyor asked Staff #12 to confirm the number of pills in the medication cup and the result was 8 pills. Staff #12 crushed all the pills and placed in pudding.
The Oxybutynin ER should not have been crushed. The (ER) initials that follow the name of the medication stand for extended release, which means the medication releases in the blood stream over an extended period of time. Breaking or crushing the pill form of the medication may cause too much of the medication to be released at one time and could cause serious side effects.
Review of Resident 75's October 2018 physician's orders revealed that, at 9 AM, the medications Lisinopril 2.5 mg. (2) tablets, Amlodipine Besylate 10 mg. and Macrobid 100 mg. should have been given. The medications were signed off as given on the MAR, however, the surveyor confirmed with Staff #12 that 8 pills were in the medication cup. The surveyor went back to Staff #12 after reviewing the physician's orders and Staff #12 told the surveyor that the medications were given. Staff #12 went through the trash can on the side of the medication cart to find the packet that the medications came in. Staff #12 was unable to find the packet in the trash. The surveyor advised if the medications had been given, it would have been a total of 12 pills and not 8 pills.
4) On 10/3/18 at 9:10 AM, the surveyor observed Staff #12 preparing medications for Resident #71. Staff #12 dispensed an 81 mg. Aspirin EC (enteric coated). Staff #12 crushed the Aspirin. Enteric coated medications should not be crushed as they have a protective covering on the medication to hold the medication together in the stomach, to protect the stomach and to protect the medicine from the acid in the stomach or to release the medicine after the stomach e.g. in the intestine.
Staff #12 poured Lactulose 10g/15 ml. which was 25 ml. in the plastic medication cup. As Staff #12 locked the medication cart to go into the resident's room, the surveyor asked Staff #12 to confirm the amount of medicine in the medication cup. Staff #12 looked at the cup and stated, it would be too full. Staff #12 looked at the surveyor and then proceeded to get the bottle of Lactulose back out of the cart and pour up to the 30 ml. line. Staff #12 went into Resident #71's room and administered the medications and then proceeded to prepare to put eye drops in Resident #71's eyes. Staff #12 took the Azopt 1% and administered 2 drops in the left eye and 1 drop in the right eye.
Review of Resident #71's physician's orders for October 2018 stated, Azopt 1% drops; instill 1 drop in both eyes 2 times a day for glaucoma.
The surveyor sat with the Director of Nursing and the Corporate Nurse on 10/3/18 at 11:50 AM to discuss the concerns with the medication observation and the number of errors.
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 observation, staff interview, and facility documentation review, it was determined the facility staff failed to 1) labe...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, and facility documentation review, it was determined the facility staff failed to 1) label medications when opened, 2) failed to discard medications when expired and 3) failed to lock a controlled substance when the medication cart was unattended. This was evident for 5 of 5 medication carts observed and for 1 of 4 nurses observed during medication administration.
The findings include:
1) Observation was made on [DATE] at 1:30 PM of medication cart #3, unit 5.
Resident #111's Breo Ellipta 100/25 Inhaler, Lot 8ZP0346 was opened, but not dated when opened. According to the manufacturer's website, the inhaler should be discarded 6 weeks after being opened.
There was an opened vial of Bacteriostatic 0.9% sodium chloride, Lot 86-054-d/c that was date opened on [DATE]. According to the Joint Commission website, multi-dose vials are to be discarded 28 days after first use.
There was a vial of Novolog Insulin10 ml. 100 Units (u) with a date opened of [DATE], a vial of Humalog 10 ml 100/U with a date opened of [DATE], and a 3 ml. vial of Humalog insulin with no date opened. Humalog Insulin is good for 28 days after being opened.
Staff #2 was with the surveyor and advised on [DATE] at 1:30 PM.
2) Observation was made, on [DATE] at 1:40 PM, of medication cart #2, unit 5.
Resident #125's Humalog 100U insulin was not dated when opened.
Resident #98's Humalog 100U insulin was not dated when opened.
Resident #16's Humalog 100U insulin was not dated when opened.
Resident #281's Lantus 100U/ml was not dated opened.
Resident #124's Novolog injection was dispensed on [DATE] with a written expiration date of [DATE].
A random opened Humalog insulin 3 ml. vial NDC 0002-7510-17 did not have a date opened.
Resident #121's Lantus Solo Star 3 ml. prefilled pen was opened on [DATE]. The writing on the pen from the manufacturer indicated 'expires 28 days after opening.
Resident #98's Lantus SoloStar 3 ml. prefilled pen did not have a date opened.
A Lantus Solo Star 3 ml. prefilled pen that did not have a name had a sticker which documented date opened 8/4, exp 9/6.
Lantus should be discarded after being opened for 28 days.
Staff #3 was with the surveyor and advised on [DATE] at 1:40 PM.
3) Observation was made, on [DATE] at 2:12 PM, of medication cart #B, unit 4.
Resident #90's Humalog 100 U insulin had a date opened on the container of [DATE] but on the bottle the date [DATE] was written.
Resident #66's Lantus 100 U/ml insulin had a date opened of [DATE].
Staff #4 was with the surveyor and advised on [DATE] at 2:12 PM.
4) Observation was made, on [DATE] at 2:12 PM, of medication cart #A, unit 4.
Resident #87's opened Prednisolone Ac opth. Susp 1% eye drops were dispensed on [DATE]. The drops were not dated when opened. The drops should be discarded 4 weeks after being opened.
Advised Staff #5 on [DATE] at 2:21 PM
5) Observation was made, on [DATE] at 2:25 PM, of medication cart #1, unit 6.
Resident #30's Lantus 100U insulin was opened on 8/14.
Resident #81's Novolog 100U insulin was opened on 8/23.
Staff #6 was advised on [DATE] at 2:25 PM.
6) Observation was made, on [DATE] at 2:30 PM, of medication cart 2, Unit 6.
Resident #59's Lantus 100u/ml insulin was opened on [DATE].
Resident #60's Lantus 100u/ml insulin was opened [DATE].
Resident #14's Patanol eye drops were opened on [DATE]. According to the manufacturer's website, the drops should be discarded 4 weeks after being opened.
Patanol Eye Drops contain a preservative which helps prevent germs from growing in the solution for the first four weeks after opening the bottle. After this time, there is a greater risk that the drops may become contaminated and cause an eye infection. A new bottle should then be used.
Resident #14's Latanoprost eye drops were dated opened on [DATE]. According to the manufacturer's website the drops are good for 6 weeks once opened which would have been expired on [DATE].
Staff #6 was advised at that time.
7) Observation was made, on [DATE] at 9:03 AM, of Staff #28 preparing medications for Resident #21. Staff #28 poured the medication Vimpat 15 ml (milliliters) into a medication cup. The order was for 10 ml., so Staff #28 poured the remaining 5 ml. in a medication cup. Vimpat is a federally controlled substance because it can be abused or lead to drug dependence. Vimpat should be stored in a safe place and protected from theft. Staff #28 left the remaining 5 ml. cup of Vimpat on top of the medication cart in the hallway, unattended while he/she went into the resident's room for over 10 minutes dispensing medications.
Review of the Medication Administration Policy that was given to the surveyor by nursing administration, documented procedure #8 which stated, medications are not to be left on top of an unattended medication cart.
The Corporate Nurse and the Director of Nursing were advised of all observations on [DATE] at 11:50 AM.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Medical Records
(Tag F0842)
Could have caused harm · This affected multiple residents
10) During an interview on 10/4/2018 at 11:08 AM with Corporate Nurse #19, the Corporate Nurse stated that nursing is expected to complete an assessment whenever restraints are applied to a resident. ...
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10) During an interview on 10/4/2018 at 11:08 AM with Corporate Nurse #19, the Corporate Nurse stated that nursing is expected to complete an assessment whenever restraints are applied to a resident. Additionally, the Corporate Nurse stated that a unique order is required for each application of restraints and that the order must have a 24-hour limit.
Review of Resident #10's medical record revealed the following orders for mitten restraints:
- 5/30/2018 at 2:46 PM, Apply bilateral hand mittens to prevent self decannulation. Check skin integrity every 2 hours. 24 hour order.
- 6/2/2018 at 5:46 PM, Apply bilateral hand mittens to prevent self decannulation. Check skin integrity every 2 hours. 24 hour order.
- 6/9/2018 at 11:02 PM, Apply bilateral hand mittens to prevent self decannulation. Check skin integrity every 2 hours. 24 hour order.
- 6/27/2018 at 3:25 PM, Place left hand in mitt to prevent patient from disconnecting from the ventilator x 24 hours.
- 8/9/2018 at 2:27 PM, Both sides hand mitts x 24 hours. Check skin every 2 hours.
- 8/15/2018 at 1:17 PM, Mitts as needed x 24 hours for safety.
- 8/28/2018 at 6:46 PM, Apply mitten on left hand for safety for 24 hours.
Decannulation is the removal of a tracheostomy annular which would put this respirator-dependent resident at risk for respiratory distress and asphyxiation.
Review of the facility's policy on the use of physical restraints revealed that the facility expects that a restraint assessment must be completed within a week of the initiation of a restraint. This surveyor reviewed the medical record for evidence of the resident's behaviors that warranted each of these restraint orders, of the interventions that were attempted prior to initiating the mitten restraints, and of the nursing assessment that was completed after each restraint use. This surveyor could not find any of these pieces of documentation.
During with a follow up interview on 10/4/2018 at 12:16 PM, the Corporate Nurse indicated that none of the above documentation was available in the medical record for any of 7 restraint orders noted in the chart.
Cross Reference F 604.
5) Resident #24's medical record was reviewed on 9/27/18 at 10:37 AM for Advance Directives. The record revealed an Advanced Directive, signed 3/26/18, selecting his/her niece as health care agent when he/she was no longer capable of making health care decisions. A prior advanced directive signed by the resident and dated 4/29/08, named a different person as Resident #24's health care agent and went into effect when signed. No documentation was found in the residents record to explain why another person was designated to be the resident's health care agent when one was already in place. An interview was conducted with Staff #38 on 10/2/18 at 3:06 PM. He/She indicated that the resident's niece had been more involved with the resident, and the facility was unable to get in touch with the resident's designated health care agent. He/She indicated that the resident's niece wanted to make preplanned funeral arrangements for the resident but was unable because she was not his/her agent. He/She indicated that a discussion was held with Resident #24 who decided he/she wanted his/her niece as surrogate and agent. Resident #24 then signed new power of attorney papers designating his/her niece as his/her health care agent. Staff #38 confirmed that this information was not documented in the resident's medical record.
6) On 10/2/18 at 11:25 AM, the surveyor reviewed the facility's documentation of an incident involving Resident #331 which occurred on 6/25/17. The facility's documentation, which included statements from staff, indicated that the resident became hostile and agitated toward staff, was cursing at staff and behaving in an irrational manor. During an interview at that time, Staff #1 indicated that the resident was very agitated. During another interview on 10/3/18 at 9:54 AM, Staff #1 indicated that the resident would get agitated and his/her family would be called to calm the resident down. Review of Resident #331's medical record failed to reveal that the resident's episode of increased agitation, verbal hostility toward staff and irrational behavior were documented in the resident's record, including any interventions implemented by the staff and the effectiveness.
7) Resident #90's medical record was reviewed on 10/4/18 at 12:10 PM. The resident's diagnoses included, but were not limited to, diabetes. He/she had a physician's order to check his/her blood sugar level before meals and at bedtime. Insulin was ordered to be given on a sliding scale (the dosage to be determined by the resident's blood sugar level reading). Blood sugar levels 60 mg/dL (milligrams per deciliter) or below are considered too low and require further intervention. Resident #90's blood sugar testing results on 7/2/18, 7/30/18 at 5:52 PM, 8/1/18 at 6:16 PM and 9/19/18 at 6:23 PM were recorded as 1.0 mg/dL. No further documentation was found in the record related to the recorded critically low blood sugar levels. On 10/4/18 at 1:02 PM, Staff #19 confirmed these findings. He/She indicated after contacting the nurse responsible for entering the results, that Resident #90 was not available for his/her blood sugar test due to dialysis, that the test was not actually done, however the responsible nurse entered 1.0 mg/dL in the resident's record. Staff #19 confirmed that he/she would expect to find documentation in the resident's record explaining that the resident was not available, not an inaccurate test result.
8) Resident #59's medical record was reviewed on 10/5/18 at 12:21 PM. The residents' diagnoses included, but were not limited to, vascular dementia with behavioral disturbance, depressive disorder and anxiety disorder. The physicians' orders included, but were not limited to, Seroquel (an antipsychotic medication) 100 mg (milligrams) by mouth at bedtime for psychosis. The physician also ordered behavior monitoring every shift for refusing care, medication, yelling and screaming at staff. The resident was receiving psychiatric services. A plan of care for Psychotropic Drug use (Seroquel for mood disorder) included the approach, Monitor for target behavior/symptoms and document per facility protocol. On 10/5/18 at 2:22 PM, Staff #6 was asked where staff document Resident #59's behavior monitoring. He/She indicated in the electronic medical record and printed the Resident #59's behavior records for September and October 2018. The record indicated Behavior monitoring for refusing care, medication, yelling and screaming at staff. Every shift. In the spaces labeled Day, Eveni, and Night were check marks with staff initials. The monitoring did not indicate what the check marks represented, nor did it indicate if the resident was demonstrating any or all the identified behaviors.
Based on observation, medical record review and staff interview, it was determined the facility staff failed to accurately document in the resident's medical record as evidenced by 1) failing to administer oxygen per physician's orders and then documenting that it was administered per orders, 2) failing to administer respiratory medications per physician's orders, but signing off that directions were followed and 3) failing to accurately document regarding tube feeding flushes and medication administration and 4) failing to give medication, but documenting the medication was given. This was evident for 3 (#78, #21, #75) of 8 residents observed during medication observation. 5) a change in health care agent for 1 (#24) of 1 residents reviewed for Advance Directives, 6) an episode of resident behavior and staff interventions for 1 (#331) of 4 residents reviewed for Abuse, 7) complete and accurate information related to blood sugar testing for 1 (#90) of 4 residents reviewed for Dialysis and 8) adequate monitoring every shift for identified behaviors for 1 (#59) of 2 residents reviewed for Dementia Care, 9) failing to document a resident's pulse oximetry readings for 1(#56) of 4 residents reviewed for dialysis and 10) failed to maintain accurate medical records for a resident who had been physically restrained by facility staff. This was true for 1 (#10) of 1 resident reviewed for physical restraints. The findings include:
1) Observation was made of Resident #78 on 9/27/18 at 9:17 AM sitting in a wheelchair next to the bed. The resident was receiving between 2.0 and 2.5 liters (L) of oxygen. Review of Resident #78's September 2018 and October 2018 physician's orders revealed the order oxygen via nasal cannula at 3.5 LPM every shift for COPD. Review of the September 2018 and October 2018 Treatment Administration Record (TAR) revealed nurse's initials that the resident received oxygen 3.5 LPM each shift. The documentation was not accurate as the surveyor observed the oxygen set on between 2 and 2.5 liters on multiple days. Cross Reference F695
2) Observation was made on 10/2/18 at 8:33 AM of Staff #28 administering inhalers to Resident #78. Staff #28 took the Ventolin inhaler and squirted a puff into the resident's mouth and the resident said, I didn't get anything. Staff #28 proceeded to squirt 2 more puffs into Resident #78's mouth. There was no evidence that anything came out of the inhaler. Staff #28 then got the Advair inhaler and gave 2 puffs to the resident. The resident did not rinse his/her mouth out after the second inhaler.
Review of Resident #78's October Medication Administration Record (MAR) documented that the resident received 2 puffs of the Ventolin inhaler and it was documented that the resident rinsed his/her mouth out after use of the inhaler.
3) On 10/2/18 at 9:03, observation was made of Staff #28 administering medications to Resident #21. The surveyor observed 3 ports to the feeding tube. There was a red cap to the far right, a purple cap in the middle and a white cap on the left side. At the time, the resident was not hooked up to the tube feeding. The surveyor observed the white cap was off and not placed in the port. Staff #28 took the red cap off and flushed the tube with 30 ml. of water. Staff #28 did not listen for placement or check residual prior to flushing the tube. Staff #28 then poured the 10 ml. of Vimpat (the clear liquid) in the syringe with 5 ml. of water that was left over from the flush. Staff #28 then pushed the Vimpat into the white port and the surveyor observed clear liquid come out of the opened port when the white cap was off and spill onto the bedspread. Staff #28 then flushed the tube with 40 ml. of water, after which the surveyor observed more clear liquid come out of the white port. Staff #28 then gave the Ferrous Sulfate (yellow liquid) with a 20 ml. water flush. During the observation, the surveyor observed the fluid coming out of the uncapped port. The surveyor advised Staff #28. He/she put the white cap back on. Staff #28 then administered the Senna and then a 20 ml. water flush. The surveyor asked Staff #28 about the amount of fluid coming out of the white port which would have been the anticonvulsant (Vimpat) and Staff #28 insisted it was not the medication, that the fluid on the bedspread was clear.
Review of Resident #21's October 2018 physician's orders revealed1, every shift check tube for proper placement prior to each feeding, flush, or medication administration. This was not done, however, Staff #28 signed off that it was done. A second order stated, flush tube with at least 30 ml. of water before and after each medication pass. Flush tube with 5 ml. of water between each medication. This was not done, as Staff #28 flushed with 40 ml. of water and 20 ml. of water twice as stated above., however, Staff #28 signed off that the correct amount of flush was delivered to the resident.
In addition, upon medication reconciliation review, the resident was to receive Lopressor Solution, 1.25 ml. for hypertension. The resident did not receive the Lopressor due to the blood pressure reading of 103/54, however Staff #28 signed off that the resident received the Lopressor. Physician's order for Chlorhexidine Gluconate solution that was to be given at 9 AM was not given when the surveyor observed medication administration, however, Staff #28 signed off that it was given.
4) On 10/3/18 at 9:00 AM, observation was made of Staff #12 dispensing pills into a medication cup for Resident #75, which included Lasix 20 mg., Aspirin 81 mg. Senna 8.6-50 mg. (2), Januvia 50 mg., Glipizide 10 mg., Oxybutynin ER 10 mg. and Digoxin 0.125 mg. The surveyor asked Staff #12 to confirm the number of pills in the medication cup, and the result was 8 pills.
Review of Resident 75's October 2018 physician's orders stated that, at 9 AM, the medications Lisinopril 2.5 mg. (2) tablets, Amlodipine Besylate 10 mg. and Macrobid 100 mg. should have been given. The medications were signed off as given on the MAR, however, the surveyor confirmed with Staff #12 that 8 pills were in the medication cup. The surveyor went back to Staff #12 after reviewing the physician's orders and Staff #12 told the surveyor that the medications were given. Staff #12 went through the trash can on the side of the medication cart to find the packet that the medications came in. Staff #12 was unable to find the packet in the trash. The surveyor advised if the medications had been given, it would have been a total of 12 pills and not 8 pills. Staff #12 signed off that medications were administered when they were not administered.
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** 5.) On 9/27/18 at 10:01 AM, observation of room [ROOM NUMBER]'s shared bathroom revealed a yellow, plastic bed pan on the bathro...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 5.) On 9/27/18 at 10:01 AM, observation of room [ROOM NUMBER]'s shared bathroom revealed a yellow, plastic bed pan on the bathroom floor. The bed pan was not labeled with a resident's name and was not covered in a manner to prevent infection.
On 9/27/18 at 2:45 PM, a second observation of room [ROOM NUMBER]'s shared bathroom revealed a yellow, plastic bed pan on the bathroom floor. The bed pan was not labeled with a resident's name and was not covered in a manner to prevent infection. On 9/27/18 at 12:18 PM, observation of room [ROOM NUMBER]'s shared bathroom revealed a yellow, plastic bed pan on the bathroom floor. The bed pan was labeled 415-2 and was not bagged.
On 9/28/18 at 9:09 AM, observation of room [ROOM NUMBER]'s shared bathroom revealed that 2 yellow, plastic bed pans, one on top of the other, were on the bathroom floor. The bed pans were not labeled with a resident's name and not bagged.
4) The bathroom in room [ROOM NUMBER] was observed on 9/28/18 10:56 AM. A yellow fracture bedpan (wedge shaped bedpan) labeled 612-2 was observed between the wall and the safety grab rail. The open side of the bedpan was against the grab rail. The bedpan was not covered, therefore exposing the grab rail and wall to potentially harmful organisms from the bedpans surface.
Based on observation and medical record review, it was determined that the facility staff failed to follow infection control practices and guidelines to prevent the development and transmission of disease by 1) failing to ensure that a resident's urinary catheter bag was properly kept off of the floor, 2) failing to remove soiled items from the shower after resident use, 3) failing to follow hand hygiene procedures during medication administration, 4) failing to properly store and label bed pans. This was evident during a tour of the facility and during observation of 2 of 4 nurses administering medications for 2 (#33, #99) of 8 residents.
The findings include:
1) Observation was made of Resident #16 lying in bed. There was a urinary catheter that was observed hanging from the frame of the right side of the bed on 9/27/18 at 9:57 AM. The bottom one third of the catheter was lying on the floor. A second observation was made on 10/2/18 at 2:14 PM along with another surveyor. The bottom of the catheter was touching the floor.
Review of Resident #16's medical record on 10/2/18 revealed the resident had a history of urinary tract infections. Results of a urine culture collected on 9/7/18 was noted as 50,000-100,000 no lactose fermenting gram negative rods. Identification and susceptibility to follow. On 9/9/18, the physician documented wait for cs (culture and sensitivity) and update provider tomorrow. On 9/10/18 a microbiology report noted, the source was the Foley and verified 50,000-100,000 cfu/ml proteus mirabilis with susceptibility result: proteus mirabilis. Proteus mirabilis is a bacteria. The antibiotic Augmentin 500/125mg three times a day for 5 days was ordered.
Review of the Urinary Indwelling Catheter Guidelines Policy that was given to the surveyor by the administrative team revealed documentation only staff knowledgeable in the correct technique of aseptic insertion and maintenane of catheter should handle catheter. There was nothing in the policy about keeping the catheter bag off the floor at all times. According to the CDC, (Centers for Disease Control) the urinary catheter bag should not touch the floor as microbes could be introduced into the urinary tract via the bag/tubing.
2) Observation was made on the 5th floor on 9/27/18 at 1:15 PM, which included the shower room. There was a wet, soiled washcloth hanging on the grip bar; yellow slipper socks on the floor and body wash on the hand bar.
3) Observation was made during medication administration on 10/3/18 at 8:40 AM of Staff #4 preparing and administering medication. While dispensing medications into a medication cup for Resident #33, Staff #4 had his/her hands rummaging through his/her pants pockets looking for keys. Staff #4 then proceeded to get other medications out of the drawer. After placing all medications in the medication cup, Staff #4 walked into Resident #33's room and gave the medications. Staff #4 then went to the medication cart and began to dispense medications for Resident #99 which included Saline Nasal Spray. Staff #4 walked into Resident #99's room and fed the resident the pills via a spoon. Staff #4 then proceeded to administer the Saline Nasal Spray and wiped the resident's nose. Staff #4 then touched the medication keys and medication cart and then sanitized his/her hands. Staff #4 failed to sanitize hands between residents and failed to sanitize his/her hands immediately after wiping the resident's nose.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Comprehensive Care Plan
(Tag F0656)
Could have caused harm · This affected most or all residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medical record review and staff interview, it was determined that the facility failed to develop and imple...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medical record review and staff interview, it was determined that the facility failed to develop and implement comprehensive person-centered care plans. This was evident for 2 (#68 and #11 ) of 4 residents reviewed for activities, 1 (#108) of 2 residents reviewed for dementia care, 1 (#78) of 5 residents reviewed for respiratory care, 2 (#119 and #56) of 4 residents reviewed for dialysis, 1 (#19) of 4 residents reviewed for communication and sensory problems, 1 (#59) of 6 residents reviewed for unnecessary medications and 2 (#90 and #324) of 4 residents reviewed for nutrition.
A care plan is a guide that addresses the unique needs of each resident. It is used to plan, assess and evaluate the effectiveness of the resident's care.
The findings include:
1) During a review of Resident #68's care plan that took place on 10/2/2018 at 10:39 AM, it was found that the resident's care plan included the problem statement, Needs a supportive environment which offers recreational and sensory experiences during the week in the comfort of his/her room as well as small groups when appropriate. Two of the associated approaches ofthe [NAME] plan were, incorporate into conversation and sensory stimulation topics or items which might be meaningful to resident's past life such as talking about family and sharing family related experiences, and Provide or offer activities such as talking to resident, reading to resident about previous interest or from favorite reading .
An interview was performed with Activities Professional #14, who was responsible for providing activities to Resident #68, and the Activities Director at 10/3/2018 at 10:07 AM. When asked what information from the resident's past was being incorporated into the activities provided to Resident #68, Activities Professional #14 stated that s/he did not have access to any of that information. The Activities Director stated that the resident was nonverbal and no information had been provided by any family members. The Activities Director also stated that the resident's daughter had visited the resident daily for a long time but recently started only coming once or twice a month.
The resident was noted to have been admitted more than five years ago.
Because facility activities staff did not incorporate topics or items twhich might be meaningful to the resident's past life or read to the resident about previous interests or from favorite reading, the facility failed to implement this portion of Resident #68's care plan.
10) On 9/28/18 at 9:10 AM, an interview was attempted with Resident #19. At that time the resident indicated to the surveyor that he/she was hard of hearing.
On 10/3/18, a review of Resident #19's medical record was conducted and revealed the resident was hard of hearing. On 8/3/18 at 10:51 AM, the social worker documented in a progress note that the resident was hard of hearing (HOH) on the right side. On 8/15/18 at 5:36 PM, in an activity note, the facility staff documented that the resident was HOH and hears best in the left ear. On 8/28/18 at 3:13 PM, in a skilled charting note, the nurse documented the resident's right ear had hearing difficulties and on 9/1/18 at 3:01 PM, in a Skilled Charting note, the nurse documented that the resident was hard of hearing, right ear.
Review of Resident #19's care plans failed to reveal a comprehensive care plan with resident centered, individualized approaches to care to address Resident #19's hearing deficit,
11) On 10/2/18, Continued review of the Resident #56's care plans revealed a care plan Dialysis HD (hemodialysis) r/t renal failure had the approach Monitor vital signs every shift. Notify MD of significant abnormalities. Continued review of the medical record failed to reveal evidence that the facility staff were monitoring Resident #56's vital signs every shift. The facility staff failed to follow Resident #56's care plan by failing to monitor the resident's vital signs every shift.
12) Resident #59 was observed, on 9/27/18 at 8:30 AM, and approximately 4 more times until12:56 PM; each time the resident was sleeping in bed and did not awaken when surveyor knocked on door. Staff indicated that resident had his/her days and nights mixed up and that he/she slept all day and was up all night. The resident's privacy curtain was closed at approximately 12:15 PM, staff were providing care and indicated that the resident was awake. The surveyor attempted to interview the resident again at approximately 12:25 PM, however, the resident fell asleep repeatedly and the surveyor was unable to complete an interview. Resident #59's record was reviewed on 10/5/18 at 12:21 PM. A physician's order was written for Trazodone 50 milligrams by mouth at bedtime for insomnia. Trazodone, a psychotropic medication, is an antidepressant that is sometimes prescribed for sleep disorders with major depression.
Further review of the record revealed a plan of care for Mood problem related to Diagnosis Major Depressive Disorder. The goals included, but were not limited to, - will have improved sleep pattern by fewer episodes of insomnia through the review date. The approaches however did not include monitoring sleep pattern or insomnia, nor did it identify that the resident was taking Trazodone for the insomnia.
13) A plan of care had been developed for Psychotropic Drug use (Seroquel for mood disorder) on 5/25/18. The resident's goal was - Will be free of any adverse side effects of psychotropic meds. The approaches 1) consult with pharmacy, MD to consider dosage reduction when clinically appropriate 2) consult with psych services when needed and/or PRN (as needed) 3) Medicate per MD orders 4) Monitor for target behavior/symptoms and document per facility protocol and 5) Observe, Document, report to MD prn s/sx (signs/symptoms) of drug related complications. The plan was not specific as to the residents' targeted behavior and/or symptoms, the facility protocol, how and when monitoring should be done, and where the results of the monitoring should be documented, nor was it clear as to how monitoring behaviors/symptoms supported the resident in reaching his/her goal of being free from adverse side effects from the medication. The plan of care failed to include person specific objectives to be measured to evaluate the residents progress toward his/her goal. This care plan also failed to include the Psychotropic medication Trazodone which the resident was receiving for sleep.
14) Another plan of care had been developed for resident #59 for Impaired cognitive function/dementia or impaired thought processes related to dementia. The goals included- Will be able to communicate basic needs daily through the review date; Will maintain current level of cognitive function through the review date; Will improve current level of cognitive function through the review date and Will develop skills to cope with cognitive decline and maintain safety by the review date. The plan was unclear if the resident's goal was to maintain or improve his/her current level of cognitive function nor what the residents' current level of cognitive function was. The plan also failed to identify how the resident was to develop skills to cope with his/her cognitive decline and failed to include the objectives that were to be measured when evaluating the residents progress toward reaching his/her goals.
15) During an interview, on 9/28/18 at 8:46 AM, Resident #90 indicated that he/she was diabetic and received dialysis in the afternoon after dinner time. During an interview, on 10/4/18 at 2:50 PM, Staff #35, a dialysis nurse confirmed that the resident's dialysis was scheduled for Monday, Wednesday and Friday 2:15 PM - 6:15 PM.
A review of Resident #90's medical record on 10/4/18 at 12:10 PM revealed that a plan of care was developed for Dialysis related to renal failure. The resident's goal was - Will have no s/sx of complications from dialysis through the review date. The approaches included but were not limited to: Do not draw blood or take blood pressure in arm with graft - it did not specify which arm; Encourage resident to go for the scheduled dialysis appointments. Resident receives dialysis (specify frequency) - the frequency was not specified. The resident also had plans of care for Diabetes, Risks for Hyperglycemia (high blood sugar) and Hypoglycemia (low blood sugar). The plans of care failed to address this residents' unique needs related to management of his/her diabetes and conflicting dialysis schedule.
16) Resident #90 also had a plan of care for Increased nutrient needs related to ESRD (end stage renal disease) on HD (hemodialysis). His/Her goal was: will meet estimated nutritional needs via po (oral) intake thru review date. The approaches included: Diet as ordered, Supplement/snacks as ordered, Vitamin/Minerals as ordered and Weigh resident per facility protocol - the plan was not specific as to what these were for Resident #90.
17) Resident #324's medical record was reviewed on 9/28/18 at 11:32 AM. A Nutritional assessment dated [DATE], identified that the resident was requesting a diabetic diet, and that food preferences were relayed to dietary. The assessment plan was Low Concentrated Sweets, Low fat/Low cholesterol diet with no added sweets snack at bedtime. A nutritional plan of care was developed 9/27/18 for Decreased nutrient needs related to Diabetes, Obesity. The residents' goal - will experience adequate nutrition via oral intake thru review date (12/24/18). The approaches - Weights per facility protocol, diet as ordered, snack as ordered. The plan failed to identify the residents' specific diet, snack and individual preferences. The plan also failed to include objective(s) to be measured when evaluating the residents progress toward meeting his/her dietary goal.
Administrator was made aware of the above findings on 10/5/18, at approximately 3:30 PM.
4) Review of Resident #78's medical record on 10/02/18 at 10:58 AM revealed that the resident had the diagnosis of Chronic Obstructive Pulmonary Disease (COPD) which is a group of lung diseases that block airflow and make it difficult to breathe. The discharge summary from the hospital, dated 9/6/18, documented COPD on 3.5 L home oxygen.
Review of Resident #78's September 2018 and October 2018 physician's orders revealed that the order oxygen via nasal cannula at 3.5 LPM every shift for COPD, Ventolin HFA Inhaler 2 inhalations, inhale orally four times a day r/t COPD, Rinse mouth after use and Fluticasone-Salmeterol Aerosol (Advair)115-2 puffs a day for COPD 21 mcg/act. The physician's orders also stated, pulse oximeter (maintain O2 sat above 94%) notify physician if below q shift; change humidifier bottler q (every)week and change oxygen tubing every week, every night shift, every Friday.
Review of Resident #78's care plans failed to produce a care plan for respiratory care. This was confirmed by the Corporate Nurse on 10/3/18.
5) Review of Resident #78's September 2018 and October 2018 physician's orders revealed the order Coumadin 12.5 mg. q (every) pm afib (atrial fibrillation). Coumadin (warfarin) is an anticoagulant (blood thinner). Warfarin reduces the formation of blood clots. Coumadin is used to treat or prevent blood clots in veins or arteries, which can reduce the risk of stroke, heart attack, or other serious conditions.
Review of the care plan Anticoagulant therapy (Coumadin) r/t Atrial Fibrillation which was created on 9/7/18, had the goal will be free from discomfort or adverse reactions related to anticoagulant use through the review date. The goal was not measurable. There was no range for INR levels. The approaches on the care plan were not resident specific. The approaches did not address monitoring for bleeding, specifically, as Coumadin is a blood thinner and lowers the chances of blood clots forming in the body, therefore increasing the serious risk of bleeding. The approaches on the care plan did not address the dietary restrictions such as large amounts of leafy green vegetables such as kale, spinach and Brussel sprouts which contain Vitamin K. Too much vitamin K can lower the effect of Coumadin. The approach, monitor skin during care, did not say what to monitor on the skin.
6) Resident #119 was interviewed on 9/27/18 at 10:55 AM about activities and the resident stated he/she did not go to activities but would like someone to stop in and offer him/her things to do. Staff #15, the Activities Director, was interviewed on 10/4/18 at 12:00 PM and was able to show the surveyor an activity log for Resident #119. The surveyor asked about an activities' care plan for Resident #199 and Staff #15 advised that a nurse on the unit developed the care plan for activities. The surveyor asked why nursing created the activities care plan and the response was because the IDT (interdisciplinary team) created it. The care plans that were pointed out to the surveyor as being activity related were: Needs some guidance to help maintain optimal social relationships and recreational opportunities, inappropriate behaviors with the goal will portray calm and socially acceptable behaviors while engaging in care center life by next evaluation date with approaches check to help make sure resident basic needs are met prior to each activity for resident's comfort, listen to resident and respond to need, provide an unhurried pace.
7) A second care plan Potential for adjustment issues r/t nursing facility admission and lifestyle changes had the goal will maintain the ability seek social contact and stimulation through the review date with the approaches orient to the facility layout and provide directions to activities, dining room, rehab, gym, etc., when approaching the resident, identify yourself and your role, introduce the resident to residents with similar background, interests and encourage/facilitate interaction, encourage the resident to participate in conversation with other residents, staff and visitors.
The care plans were not measurable, and the approaches were not resident centered as to the resident's wishes and likes. Staff #15 agreed that the care plans were not resident centered.
8) Review of Resident #119's medical record revealed the resident received hemodialysis 3 times per week. Dialysis is a procedure that performs many of the normal duties of the kidneys, such as filtering waste products from the blood, when the kidneys no longer work adequately. The problems that a patient on hemodialysis may experience are fluid overload (hypervolemia), electrolyte imbalance, and alterations in blood components, leading to anemia or platelet abnormalities resulting in a tendency to bleed excessively. Another problem was infection, either of the access site and the blood or in the urinary or respiratory tract, because of urinary or pulmonary stasis.
Review of Resident #119's medical record revealed a care plan Hemodialysis r/t renal failure with the goal will have no s/sx of complications from dialysis through the review date. The goal was not measurable. The approaches on the care plan stated, do not draw blood or take b/p in LUE (left upper extremity) with graft; document vital signs q (every) shift and prn (when necessary); monitor for dry skin and apply lotion as needed; monitor labs and report to doctor as needed and staff to provide assistance for transport to and from dialysis center.
The care plan did not address the main concern with dialysis patients which is fluid overload. The care plan did not address limiting the resident's fluid intake. The care plan did not address monitoring for infection as the resident had a recent infection per the 9/3/18 physician's progress note which documented recent sepsis left AV fistula abscess.
9) In addition, Resident #119's care plan increased nutrient needs r/t wounds, renal disease/hemodialysis with a goal will meet estimated nutritional needs via po (by mouth) intake thru review date was not measurable and the approaches diet as ordered, protein supplement as ordered, vitamin/minerals as ordered, liberalize diet PRN, monitor labs prn, SLP evaluation as ordered, feeding/assist/supervision by staff, review nutritional needs with resident and family as needed and honor advanced directives were not resident centered approaches. The care plan did not address that the resident should not have orange juice and oranges along with other potassium rich foods. September 2018 and October 2018 physician's orders stated, diet: other diet, regular texture, thin liquids consistency: NAS (no added salt) LCS (low concentrated sweets, no bananas, no OJ/oranges, No carb active liquid protein, snack at bedtime. The care plan did not address these physician's orders along with fluid restriction.
Discussed with the Dietician on 10/5/18 at 11:37 AM. Discussed all care plan concerns with the Nursing Home Administrator on 10/5/18 at 2:02 PM.
2) Resident #11 was admitted to the facility in August of 2014. Review of resident #11's care plans during the survey process revealed a plan that was initiated on 3/6/2018 written as Potential for adjustment issues related to nursing facility admission and lifestyle changes. The goal for this care plan was written as Will show evidence of adjustment to nursing facility by [SPECIFY] through the review date. The facility failed to specify what the evidence of adjustment to the nursing home would be. This care plan problem and goal was not resident centered as resident had lived in the facility for over 4 years.
3) Review of resident #108's care plans on 10/3 revealed a plan of care, written as artery thrombosis r/t disease process and immobility. One of the interventions was documented as: check the presence of pedal pulses and record findings every 8 hours. On 10/3/18 at 1:40 PM, the Unit manager (staff#6) was asked: Where does staff record resident #108's pedal pulses? The unit manger did not know where every 8-hour pedal pulse checks were recorded. The documentation was not found in the medical record. The staff had failed to implement the plan of care as written. Another care plan problem for resident #108 was written as Hyperlipidemia. (Hyperlipidemia is a medical term for abnormally high levels of fats (lipids) in the blood.) The goal was written as there will be no s/s (signs or symptoms) of hyperlipidemia through review date. This goal was not measurable as there were no signs or symptoms of hyperlipidemia. On 10/5/18 at 12:30 PM, a corporate nurse (staff #10) acknowledged that there were no signs and symptoms of hyperlipidemia.
Resident #108 was dependent on staff for care, comfort and safety as comprehensive assessments indicated resident's total dependence on staff for activities of daily living. The care plan goal for the written problem of ADL self-care performance deficit r/t vascular dementia stated Will maintain current level of function through the review date
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0657
(Tag F0657)
Could have caused harm · This affected most or all residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4) On 9/27/18 at 11:48 AM, during an interview, when asked if the resident was involved in care planning and if he/she went to c...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4) On 9/27/18 at 11:48 AM, during an interview, when asked if the resident was involved in care planning and if he/she went to care plan meetings, Resident #48 stated that he/she had never heard about care plan meetings.
On 10/5/18, review of Resident #48's medical record revealed an Interdisciplinary Care Plan signature sheet which documented that care plan meetings had been held on 9/26/17, 3/13/18, 4/10/18, 5/22/18 and 7/31/18. There was no documentation that Resident #48 attended those care plan meetings. Continued review of the medical record failed to reveal documentation that the resident had been invited to participate in the development and review of his/her care plan.
On 9/27/18 at 12:42 PM, during an interview, when asked if the resident was involved in care planning and if he/she went to care plan meetings, Resident #56 stated he/she did not know if he/she was invited and could not recall going to a care plan meeting.
On 10/5/18, review of Resident #56's medical record revealed an Interdisciplinary Care Plan signature sheet which documented that care plan meetings had been held on 12/14/17, 4/3/18, 8/5/18, 8/21/18 and 9/4/18. There was no documentation on the sheet that Resident #56 attended his/her care plan meeting. Continued review of the medical record failed to reveal documentation that the resident had been invited to participate in the development and review of his/her care plan.
On 9/27/18 at 10:28 AM, observation of Resident #48 revealed the resident had a gastrostomy tube (GT) (feeding tube) and had some bleeding around the GT site. On 9/27/18 at 11:10 AM, during an interview, the Resident #48 stated that he/she was able to eat and did not get nutrition through his/her GT.
Review of Resident #48's care plans revealed a care plan At risk for tube feeding dislodgment and aspiration with the Goal Feeding tube patent and correct placement had the interventions: 1) Auscultate lung before feeding is started, 2) check placement of tube before each feeding by tow means and 3) Vital signs every shift. The care plan goal was not measurable or specific. The care plan interventions were not resident specific, were not measurable and failed to address the reason for the GT, and care of the GT site. Review of Plan of Care Notes revealed a 10/2/18 dietary note. Further review of the medical record failed to reveal evidence of that the resident feeding tube care plan had been evaluated.
On 9/27/18 at 12:42 PM, Resident #56 was observed not wearing oxygen. On 10/2/18, at 2:08 PM, Resident #56 was observed wearing an oxygen nasal cannula (NC). When asked how often the resident utilized oxygen, Resident #56 stated the only time I use it is when I need it.
On 10/2/18, a review of Resident #56's September 2018 TAR (treatment administration record) revealed an 8/21/18 physician order for oxygen via nasal cannula (NC) at 2 LPM (liters per minute) as needed for SOB (shortness of breath). There was no documentation in the TAR to indicate the resident utilized oxygen during the month of September. Review of the resident's October 2018 TAR revealed an order for oxygen via nasal cannula at 2 LPM as needed for SOB. There was no documentation in the TAR to indicate Resident #56 utilized oxygen during the month of October.
Review of Resident #56's progress notes revealed on 8/31/18, at 5:39 PM, in a Plan of Care Note, with the focus, COPD r/t HX Smoking, the nurse documented Oxygen at 2 LPM PRN (as needed) for SOB. Cont. with current POC (plan of care).
Review of Resident #56's care plans revealed a care plan COPD (chronic obstructive pulmonary disease) r/t (related to) HX (history of smoking) had the approach Oxygen settings: 02 via NC @ 2 LPM every shift, indicating the resident was to have oxygen continuously at 2 LPM. This was in contradiction to the resident's current order for the resident to use oxygen only when needed. The facility failed to follow the care plan related to the Resident #56 utilizing oxygen continuously and failed to update the care plan to reflect the resident's current oxygen order and use of oxygen as needed.
A review of Resident #19's medical record revealed on 9/12/18, in a progress note, the physician documented that Resident #19 was sent to the emergency room for severe symptomatic anemia, admitted on [DATE] until 8/19/18, and given blood transfusions. Resident #19 was again transferred to the hospital on 8/23/18 until 8/27/18, for severe symptomatic anemia and received blood transfusions. The resident was again transferred to the hospital emergency room and admitted on [DATE] until 9/10/18 with shortness of breath and found to have antral gastritis (inflammation in the lower portion of the stomach) with anemia and received blood transfusions.
Review of Resident #19's care plans revealed a care plan Anemia, Abnormal hct (hematocrit) and hgb (hemoglobin) 8/23/18 hgb 6.5 / hct 21.4) (lab values) had the interventions 1) encourage intake of foods high in iron, vitamin C, 2) Give medications as ordered. Monitor for side effects, effectiveness; 3) Hospital transport to ER for evaluation 8/23/19, 4) Obtain and monitor lab/diagnostic work as ordered. Report results to MD and follow up as indicated and Repeat HGB & HCT 8/21/18.
Review of Resident #19's care plan evaluations revealed on 9/11/18 at 5:12 PM, in a Plan of Care Note, the nurse wrote that the resident was re-admitted after a hospital stay and was on Iron for anemia and a multivitamin for a supplement and to continue with the plan of care. Further review of the medical record failed to reveal that Resident #19's anemia care plan had been evaluated and updated following each hospitalization and readmission to the facility.
3) Review of Resident #59's medical record, on 10/5/18 at 12:47 PM, revealed a plan of care for Major depressive disorder. The resident's goals included: will have improved mood state happier, calmer appearance, no s/sx (signs/symptoms) of depression, anxiety or sadness through the next review date. Will have improved sleep pattern by fewer documented episodes of insomnia through the review date. An evaluation, dated 8/14/18, indicated: last saw psych on 8/13 and included prescribed medications. The review did not measure and evaluate the resident's progress or lack of progress toward reaching his/her goals, including the status of the resident's mood state, evidence of depression, anxiety, or sadness and the number of episodes of insomnia.
Resident #90's plans of care were reviewed on 10/4/18 at 12:10 PM. The resident had a care plan for diabetes mellitus, with the goal - will have no complications related to diabetes through the review date, and plans for at risk for hyperglycemia (high blood sugar) and at risk for hypoglycemia (low blood sugar) both with the goal - will be free from any s/sx (signs/symptoms) of hyperglycemia and hypoglycemia through the review date. Care plan review progress notes revealed that the diabetes care plans were reviewed on 8/31/18 at 4:33 PM. All 3 evaluations indicated CP (care plan) updated. Patient is currently on finger stick monitoring Q AC and HS (daily before meals and at bedtime) with SSI (sliding scale insulin) Lantus 22 units with meals. Glucagon emergency kit for low sugar. Continue to monitor. Continue with POC (plan of care). The note did not reflect an evaluation of the residents measured progress or lack of progress toward reaching his/her care plan goals.
Resident #90 had a plan of care for Dialysis(hemo) r/t related to renal failure. The resident's goal was -will have no s/sx of complications from dialysis through the review date. The care plan evaluation note 8/31/18 at 4:54 PM indicated CP updated. Patient is currently on HD (hemodialysis) Mon/Wed/Fri weekly. Rena Vite B-complex folic acid, give 1 tab daily for supplement. Cont. with current POC. The note did not reflect an evaluation of the residents measured progress or lack of progress toward reaching his/her care plan goal.
A plan of care for Insomnia was also developed for Resident #90. The resident's goal - will have no difficulty falling asleep at least 4 nights per week. The evaluation progress note of 8/31/18 at 9:39 AM indicated CP updated. Patient is currently on Trazodone 50 mg po (by mouth) daily at HS for insomnia. Cont. with current POC. It failed to measure the residents progress toward reaching his/her goal by failing to reflect if the resident fell asleep at least 4 nights per week with no difficulty.
2) Review of the activities' care plans for Resident #119 on 10/4/18 revealed the following: Needs some guidance to help maintain optimal social relationships and recreational opportunities, inappropriate behaviors and the care plan Potential for adjustment issues r/t nursing facility admission and lifestyle changes. Further review of the medical record revealed that a care plan meeting was held on 9/13/18. There was no evaluation found in the medical record that the care plans were evaluated. The Activity Director confirmed on 10/4/18 at 12:00 PM that there was no evaluation.
A care plan was initiated on 8/10/18 and updated on 9/6/18, for Resident #119 which notedat risk for pain r/t hx of CVA/chest pain/deconditioning/abdomen discomfort. Interventions listed included; identify, record and treat existing conditions which may increase pain and or discomfort, monitor/record pain characteristics: quality (e.g. sharp, burning); Severity (1 to 10 scale); anatomical location; onset; duration (e.g., continuous, intermittent); aggravating factors; relieving factors.
A plan of care note, dated 9/11/18 at 12:46 PM, stated appraise and observe daily for changes in physical and/or mental status every shift, oxycodone 5 mg q 6 hrs. prn. This was not an evaluation as it did not evaluate the measures on the care plan to determine if the interventions were working or not.
Review of Resident #16's medical record on 10/5/18 revealed a pain care plan related to a sacral ulcer. The approaches included; monitor/document for probable cause of each pain episode; Remove/limit causes where possible; monitor/record pain characteristics: quality (e.g. sharp, burning) Severity (1 to 10 scale). anatomical location; onset; duration (e.g. continuous, intermittent) aggravating factors, relieving factors); non-pharmacological interventions (like relaxation, guided imagery, music, distraction and massage) before, after and if possible during painful activities or before pain occurs.
The care plan evaluation note, dated 9/4/18 at 15:33, stated, appraise and observe daily for changes in physical and/or mental status every shift. Gabapentin 100 mg tid (3x/day), tramadol 50 mg q 12 hrs. prn, acetaminophen 325 mg 2 tabs q 6 hrs prn. This was not sufficient as it did not evaluate the measures on the care plan to determine if the interventions were working or if they needed to be altered.
Discussed with the Nursing Home Administrator on 10/5/18 at 2:02 PM.
Based on observation, record review and interview with facility staff, it was determined that facility staff: 1) failed to revise a resident's plan of care to specify the evidence of adjustment to the nursing home. This was evident for 1 (#11) of 4 residents reviewed for activities; 2) failed to evaluate care plans to determine if the problem remained the same, the goals were being accomplished and if the interventions were appropriate or needed to be revised to meet the needs of the resident This was evident for 1 (#119) of 4 residents reviewed for activities and 2 (#119, #16) of 4 residents reviewed for pain management. 3) failed to evaluate the effectiveness of the care plan and measure the residents progress or lack of progress toward reaching his/her goal(s) for 1 (#59) of 2 residents reviewed for dementia care and for 1 (#90) of 4 residents reviewed for Dialysis; and 4) failed to include a resident in the development of the care plan and invite to the care plan meeting and to evaluate and update a care plans for 2 (#48 and #56) of 5 residents reviewed for Care Planning and 1 (#19) of 7 residents reviewed for hospitalizations.
The findings include.
1) Resident #11 was admitted to the facility in August of 2014. Review of resident #11's care plans during the survey process revealed a plan of care that was initiated on 3/6/2018 written as Potential for adjustment issues related to nursing facility admission and lifestyle changes. The goal for this problem was written as Will show evidence of adjustment to nursing facility by [SPECIFY] through the review date. The facility failed to specify how the evidence of adjustment to the nursing home was to be determined. The facility did show evidence of quarterly evaluations, dated 3/6/18, 6/11/18 and 9/7/18. Even though the facility failed to specify the evidence of adjustment to the nursing, they indicated that the resident was adjusted. The update plan of care note, dated 3/6/18 revealed; Resident has adjusted well to her placement . On 9/7/18, the evaluation reflected Resident continues to adjust well to facility. The resident may have met the goal of adjustment to the nursing home and the problem may be discontinued.
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 observation and interview with facility staff, it was determined that the facility failed to ensure that food was stored and prepared in a safe and sanitary way. This practice had the potenti...
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Based on observation and interview with facility staff, it was determined that the facility failed to ensure that food was stored and prepared in a safe and sanitary way. This practice had the potential to affect all residents that eat food prepared by the central kitchen.
The evidence includes:
During an initial kitchen tour on 9/27/2018 at 8:34 AM, in the presence of the Assistant Kitchen Manager (Staff #7), significant condensation was found at the back of the walk-in freezer. The lower part of the fans were covered in frost. The cooling unit's undercarriage had 2 icicles dangling from it. There was a 6-10 portion of the condenser piping where the insulation had come away from it. The condensation was present on parts of the freezer wall and ceiling closer to the cooling unit. Boxes below the cooling unit were covered in frost and ice and two boxes were leaning to the side because they had gotten wet. Additionally, the wall near the three compartment sink had significant buildup of a brown material that appeared to have drip patterns going down the wall. The drain near the three compartment sink was covered in a layer of grime and there was an odor of mildew. The drain grate beneath the tilt skillet was also dirty.
During a follow up tour that took place on 10/4/2018 at 12:45 PM, the above concerns had been corrected.
MINOR
(C)
Minor Issue - procedural, no safety impact
Deficiency F0559
(Tag F0559)
Minor procedural issue · This affected most or all residents
Based on medical record review and interview with staff, it was determined the facility failed to notify a resident/resident representative in writing of a room change. This was evident for 1 (#19) of...
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Based on medical record review and interview with staff, it was determined the facility failed to notify a resident/resident representative in writing of a room change. This was evident for 1 (#19) of 7 residents reviewed for hospitalizations.
The findings include:
On 10/4/18, a review of Resident #19's medical record indicated the resident had a room change on 8/20/18. Continued review of the medical record failed to reveal documentation of the reason for the room change, that the resident had been advised of the room change and there was no documentation in the medical record that written notification was made.
On 10/4/18 at 1:45 PM, during an interview, when asked who was responsible for notifying a resident about a room change, Staff #21 stated that the admission's department was responsible for notifying a resident of a room change and that the social worker would write the note in the electronic record. On 10/4/18 at 2:20 PM, during an interview, when asked about the facility's process for room change notification, Staff #20 stated that the facility staff speak to the resident and the roommate regarding the room change, a roommate change notification is sent to the department heads and the social worker would document the change in the electronic medical record. When asked if the resident or resident representative is given written notice when there is a room change, Staff #20 stated no.
MINOR
(C)
Minor Issue - procedural, no safety impact
Deficiency F0567
(Tag F0567)
Minor procedural issue · This affected most or all residents
Based on interview with staff, it was determined that the facility failed to have a system in place to ensure resident access to personal funds when the business office was closed. This was evident du...
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Based on interview with staff, it was determined that the facility failed to have a system in place to ensure resident access to personal funds when the business office was closed. This was evident during personal funds review.
The findings include:
During an interview on 10/5/18 at 10:59 AM regarding resident finances, Staff #29 indicated that the business office was not open during the evenings or weekends. He/She was asked how the facility ensures that the residents have access to their personal funds when the business office is closed. He/She indicated that residents can get their money anytime they want during the week when the business office is open but could not get it when the business office was closed. The Administrator was made aware of the above findings on 10/5/18 at approximately 3:30 PM.
MINOR
(C)
Minor Issue - procedural, no safety impact
Transfer Notice
(Tag F0623)
Minor procedural issue · This affected most or all residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4) On 10/2/18, a review of Resident #56's medical record revealed that, on 7/27/18, the resident was transferred to an acute car...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4) On 10/2/18, a review of Resident #56's medical record revealed that, on 7/27/18, the resident was transferred to an acute care hospital for surgery. There was no documentation in the medical record that the resident was notified in writing of the reason for the transfer.
On 10/02/18 at 11:28 AM, during an interview with the Director of Nurses (DON), when asked if the facility staff notified the resident/resident representative is notified in writing regarding transfer to hospital, DON stated yes, and documentation would be in paper chart.
Continued review of Resident #56's medical record failed to produce documentation that the resident was notified in writing of the resident's transfer to the acute care facility.
5) On 10/3/18, a review of Resident #19's medical record was conducted. On 9/11/18, in a History and Physical note, the physician documented that Resident #19 was sent to the hospital emergency room (ER) on 8/16/18 and returned to the facility on 8/19/18; the resident was again sent to the ER on [DATE] and returned on 8/27/18 and transferred to the ER again on 9/2/18 and returned to the facility on 9/10/18. There was no documentation in the medical record that the resident was notified in writing of the reason that the resident was transferred to the hospital.
3) Resident #59's medical record was reviewed on 9/28/18 at 1:55 PM for hospitalization. The record revealed that the resident was sent to the hospital on 7/15/18 for further evaluation and that the resident's family was called and made aware of the residents' condition and transfer to the hospital. No documentation was found in the record to indicate that a written notification of the transfer had been completed. The Administrator was made aware on 10/5/18 at approximately 3:30 PM.
Based on medical record review and staff interview, it was determined the facility failed to notify the resident/resident representative in writing of a transfer/discharge of a resident along with the reason for the transfer. This was evident for 5 (#107, #108, #59, #19 and #56) of 7 residents reviewed for hospitalization.
The findings include:
1) Review of the medical record for Resident #108 on 10/2/18 revealed that, on 9/30/18, Resident #108 was transferred to an acute care facility due to a fall with noted injury. There was no evidence found in the medical record that written notification was made to the responsible party regarding the reason for the transfer and or location of the transfer. Interview of the Director of nursing (staff #1) and a corporate nurse (staff #10) on 10/02/18 at12:34 PM revealed that a three-page form entitled Notice of Facility Initiated Transfer is sent to the hospital with the resident. Resident #108 is deemed incapable of decision making. But staff #1 and #10 indicated that no forms are sent to resident representatives.
2) Review of the medical record for resident #107 on 10/15/2018 revealed that the resident has had multiple admissions to the hospital in the past year. Review of the medical record for an admission to the hospital on 1/10/2018 did not reveal any evidence of written notification was made to the resident/responsible party regarding the reason for the transfer and location of the transfer.
MINOR
(C)
Minor Issue - procedural, no safety impact
Deficiency F0625
(Tag F0625)
Minor procedural issue · This affected most or all residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2) On 10/2/18, a review of Resident #56's medical record revealed that, on 7/27/18, the resident was transferred to an acute car...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2) On 10/2/18, a review of Resident #56's medical record revealed that, on 7/27/18, the resident was transferred to an acute care hospital and readmitted to the facility on [DATE].
On 10/2/18 at 12:00 PM, during an interview, the Director of Nurses provided the Surveyor with a blank copy of the facility's bed hold policy and indicated that the resident would be given the bed hold policy upon transfer to the hospital and a copy would be filed in the resident's medical record.
On 10/2/18 at 2:08 PM, during an interview, when asked if the resident had received a copy of the bed hold policy when he/she had been hospitalized , Resident #56 stated not that I remember. Continued review of Resident #56's medical record failed to reveal documentation that the resident or the resident's responsible party was given a copy of the bed hold policy upon transfer to the hospital.
3) On 10/3/18, a review of Resident #19's medical record was conducted. On 9/11/18, in a History and Physical note, the physician documented that Resident #19 was sent to the hospital emergency room (ER) on 8/16/18 and returned to the facility on 8/19/18; the resident was again sent to the ER on [DATE] and returned on 8/27/18. The resident was transferred to the ER again on 9/2/18 and returned to the facility on 9/10/18. There was no documentation found in the medical record that the resident or the resident's responsible party was given a copy of the bed hold policy upon transfer to the hospital.
Based on medical record review, and resident and staff interview, it was determined the facility failed to provide the resident/representative with a written notice of the facility's bed hold policy upon transfer/discharge to an acute care facility. This was evident for 3 (#59, #56 and #19) of 7 residents reviewed for hospitalization.
The findings include:
1) Resident #59's medical record was reviewed on 9/28/18 at 1:55 PM for hospitalization. The record revealed that the resident was sent to the hospital on 7/15/18 for further evaluation and the resident's family was called and made aware of the residents' condition and transfer to the hospital. No documentation was found in the record to indicate that the resident/representative were provided with written notification of the facility's bed hold policy, at the time of the transfer. The Administrator was made aware of the above findings on 10/5/18 at approximately 3:30 PM.
Jun 2017
3 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0225
(Tag F0225)
Could have caused harm · This affected 1 resident
Based on staff interview and review of facility incident reports, it was determined that the facility staff failed to report an episode of elopement to Maryland's Office of Health Care Quality after a...
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Based on staff interview and review of facility incident reports, it was determined that the facility staff failed to report an episode of elopement to Maryland's Office of Health Care Quality after a resident (Resident #84) was found to have fallen off the facility's rear loading dock platform. This was true for 1 of 1 instance of elopement reviewed during the annual survey.
The findings include:
Based on a review that took place on 6/23/2017 of a faciltiy's internal investigation, Resident #84 was found to have eloped out of the facility's rear loading dock door and to have fallen 2 feet from the loading dock to the driveway. The resident was not found to have sustained any injuries. The resident's status of being outside the building was not known to any facility staff member until staff member #1 found the resident on the ground six minutes after the resident had exited.
During an interview with the Administrator and the Director of Nursing (DON) that took place on 6/23/2017 at 9:50 AM, the Administrator stated that the facility did not report the incident because the resident was not injured and the facility did not consider this event an elopement because the resident never left our property. However, when asked if the resident's behavior in this instance demonstrated exit-seeking behavior, the DON stated yes it did. Because the resident fell out of his/her wheelchair when s/he fell from the loading dock, it is uncertain if s/he would have gone further off the property if s/he had remained mobile.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0323
(Tag F0323)
Could have caused harm · This affected 1 resident
Based on review of medical record, observation, and interviews with facility staff and residents' families, it was determined that the facility: 1.) failed to prevent a resident with known unsafe wand...
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Based on review of medical record, observation, and interviews with facility staff and residents' families, it was determined that the facility: 1.) failed to prevent a resident with known unsafe wandering behaviors (Resident #84) from eloping from the facility and falling, and 2.) failed to ensure that there were adequate safeguards in place to protect residents with known unsafe wandering behaviors from placing themselves at risk of harming themselves or others. This was true for four of four residents with identified unsafe wandering behaviors.
The findings include:
1. Resident #84 has the diagnoses of Alzheimer's Dementia and confusion. A Brief Interview for Mental Status (BIMS) test was conducted on 2/17/2017 and generated a score of 2 out of 15, which indicates that the resident has poor attention, recall, and awareness. According to the Centers for Medicare and Medicaid, a BIMS score between 0-7 demonstrates severe impairment in these areas. On 1/6/2017, the facility identified the resident as being at risk for elopement and the resident's care plan was modified to reflect that. The interventions on the care plan include: wanderguard in place, check placement of wanderguard [every shift] and document on Treatment Administration Record, check functioning of wanderguard daily, and monitor resident for changes in behavior.
A wanderguard is a device attached to a resident's ankle that causes an alarm to sound when a resident passes one of the device's sensors stationed around the facility. The wanderguard does not restrict residents' movements but alerts facility staff when a confused resident may be leaving a safe area of the facility.
On 6/23/2017 at 10:50 AM, a review was conducted of an internal investigation performed by the facility relating to an elopement and fall sustained by Resident #84. On 6/18/2017, Resident #84 was found outside the facility beyond the rear loading dock. S/he was found by Staff Member #1 at 12:10 PM when the staff member exited at the rear loading dock to take a smoke break. The resident was found lying on the concrete driveway below a 2 foot drop from the loading dock's loading platform. The resident was lying sideways and his/her wheelchair was lying on its side further away. The loading dock is accessible to a Baltimore street about 100 feet away from the dock and the resident's prone position would have been visible to passerby.
According to assessments performed by registered nurse (RN) #2 on 6/18/2017 directly after the incident and by physician #3 on the following day, the resident sustained no injury from the fall. The resident had his/her wanderguard in place and it was found to be functioning correctly. The resident had last been seen on his/her unit at 11:30 AM.
The facility reviewed closed circuit camera footage, conducted interviews, and assessed mechanical and electrical devices to identify how the resident left the building. The resident, who lives on the 5th floor, had taken an elevator down to the 1st floor, entered the unsecured administrative area, and entered a rear corridor where the loading dock door is located. The loading dock door slides open automatically but is secured by a keypad. Camera footage reviewed by the survey team on 6/23/2017 at 9:54 AM shows that the resident did not enter a code to open the door but that the door slid open automatically. The camera footage also revealed that the resident had exited the facility about 6 minutes prior to being found by staff member #1.
According to review of the facility's investigation and interview with the Maintenance Director (Staff #4), it was determined by the facility that the door was most likely malfunctioning when the resident eloped. Specifically, a sensor that keeps the door from closing on someone walking through it while open seemed to have been triggered by the resident's wheelchair, causing the door to open without requiring the keypad's use.
During an interview with the Administrator and Director of Nursing (DON) that took place on 6/23/17 at 9:40 AM, the Administrator stated that there were no wander guard sensors installed between the resident's room on the 5th floor and the rear door that the resident exited through. Wanderguard sensors were only present in front of the dialysis unit and at the main entrance. In response to this incident, the Administrator stated that a keypad was now installed in the rear door of the administrative offices, that the sensor on the loading dock door had been replaced, that a new security camera was being installed to observe the loading dock door from the inside, and that wanderguard sensors were going to be installed at the loading dock door. When asked what was being put into place for the resident specifically, the DON stated that the resident would now be positioned in front of the nurse's station to maintain close observation. However, the DON also stated that the resident could still wander around and wanders up and down the unit a lot.
In an interview with Resident #84's family member that took place on 6/26/2017 at 10:30 AM, the family member stated that there had been two previous instances where the family member had come to visit Resident #84 and the resident was off the unit but the unit staff did not know where s/he was.
2. During an interview with the Administrator and DON that took place on 6/23/2017 at 9:40 AM, the DON provided a list of all residents who had a positive screen for wandering behaviors and have wanderguard devices. The care plans for these residents were reviewed and all four have appropriate interventions regarding the devices. These four residents live on three different units.
A tour of the facility conducted by the survey team on 6/26/2017 at 9:00 AM revealed that wandering residents could reach hazardous spaces without a wanderguard alarm triggering. Specifically, the ventilator unit, which contains delicate life support breathing equipment, and the activities room, which was found to have loose scissors out, were both accessible. Also, the rear kitchen door through the dining room was found to be propped open by a deadbolt and could have been accessed by a wandering resident.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0514
(Tag F0514)
Could have caused harm · This affected 1 resident
Based on medical record review and interview it was determined the facility staff failed to maintain the medical record in the most complete and accurate form for Resident (# 160). This was evident fo...
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Based on medical record review and interview it was determined the facility staff failed to maintain the medical record in the most complete and accurate form for Resident (# 160). This was evident for 1 of 3 residents observed during medication observation.
The findings include:
A medical record is the official documentation for a healthcare organization. As such, it must be maintained in a manner that follows applicable regulations, accreditation standards, professional practice standards and legal standards. All entries to the record should be legible and accurate.
During medication observation pass for resident #160 on 6/22/17 at 9am, revealed a physician order dated 5/5/17 on the June 2017 MAR (Medication Administration Record) to administer Renvela 800 mg (milligram) tablet. Give three tabs (1600 mg) by mouth with meals for Hyperphosphatemia.
During reconciliation of the medication observation pass it was revealed that three tablets of Renvela 800 mg total 2400 mg not the 1600 mg that was printed on the MAR.
During interview with the Director of Nursing on 6/22/17 at 10:00 AM, it was revealed that the Renvela 800 mg was increased from 2 tablets (1600 mg) to 3 tablets (2400 mg) on 5/5/17; however, the facility staff failed to correct the incorrect printed dosage on the June 2017 MAR.
Continued review of the mar revealed the resident was receiving the correct dosage; although the total dosage was printed incorrectly on the June 2017 MAR.
Understanding Severity Codes (click to expand)
Life-Threatening (Immediate Jeopardy)
J - Isolated
K - Pattern
L - Widespread
Actual Harm
G - Isolated
H - Pattern
I - Widespread
Potential for Harm
D - Isolated
E - Pattern
F - Widespread
No Harm (Minor)
A - Isolated
B - Pattern
C - Widespread
Questions to Ask on Your Visit
- "Can I speak with families of current residents?"
- "What's your RN coverage like on weekends and overnight?"
Our Honest Assessment
Strengths
- • No major safety red flags. No abuse findings, life-threatening violations, or SFF status.
- • No fines on record. Clean compliance history, better than most Maryland facilities.
- • 37% turnover. Below Maryland's 48% average. Good staff retention means consistent care.
Concerns
- • 66 deficiencies on record. Higher than average. Multiple issues found across inspections.
- • Grade C (50/100). Below average facility with significant concerns.
Bottom line: Mixed indicators with Trust Score of 50/100. Visit in person and ask pointed questions.
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About This Facility
What is Future Care Homewood's CMS Rating?
CMS assigns FUTURE CARE HOMEWOOD an overall rating of 2 out of 5 stars, which is considered below average nationally. Within Maryland, 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 Future Care Homewood Staffed?
CMS rates FUTURE CARE HOMEWOOD's staffing level at 4 out of 5 stars, which is above average compared to other nursing homes. Staff turnover is 37%, compared to the Maryland average of 46%. This relatively stable workforce can support continuity of care.
What Have Inspectors Found at Future Care Homewood?
State health inspectors documented 66 deficiencies at FUTURE CARE HOMEWOOD during 2017 to 2025. These included: 62 with potential for harm and 4 minor or isolated issues. While no single deficiency reached the most serious levels, the total volume warrants attention from prospective families.
Who Owns and Operates Future Care Homewood?
FUTURE CARE HOMEWOOD is owned by a for-profit company. For-profit facilities operate as businesses with obligations to shareholders or private owners. The facility is operated by FUTURE CARE/LIFEBRIDGE HEALTH, a chain that manages multiple nursing homes. With 141 certified beds and approximately 135 residents (about 96% occupancy), it is a mid-sized facility located in BALTIMORE, Maryland.
How Does Future Care Homewood Compare to Other Maryland Nursing Homes?
Compared to the 100 nursing homes in Maryland, FUTURE CARE HOMEWOOD's overall rating (2 stars) is below the state average of 3.0, staff turnover (37%) is near the state average of 46%, and health inspection rating (2 stars) is below the national benchmark.
What Should Families Ask When Visiting Future Care Homewood?
Based on this facility's data, families visiting should ask: "Can I visit during a mealtime to observe dining assistance and food quality?" "How do you handle medical emergencies, and what is your hospital transfer rate?" "Can I speak with family members of current residents about their experience?"
Is Future Care Homewood Safe?
Based on CMS inspection data, FUTURE CARE HOMEWOOD has a clean safety record: no substantiated abuse findings (meaning no confirmed cases of resident harm), no Immediate Jeopardy citations (the most serious violation level indicating risk of serious injury or death), and is not on the Special Focus Facility watch list (a federal program monitoring the lowest-performing 1% of nursing homes). The facility has a 2-star overall rating and ranks #100 of 100 nursing homes in Maryland. While no facility is perfect, families should still ask about staff-to-resident ratios and recent inspection results during their visit.
Do Nurses at Future Care Homewood Stick Around?
FUTURE CARE HOMEWOOD has a staff turnover rate of 37%, which is about average for Maryland 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 Future Care Homewood Ever Fined?
FUTURE CARE HOMEWOOD has no federal fines on record. CMS issues fines when nursing homes fail to meet care standards or don't correct problems found during inspections. The absence of fines suggests the facility has either maintained compliance or corrected any issues before penalties were assessed. This is a positive indicator, though families should still review recent inspection reports for the full picture.
Is Future Care Homewood on Any Federal Watch List?
FUTURE CARE HOMEWOOD 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.