WILLIAMSPORT NURSING AND REHABILITATION CENTER
Non profit - Corporation
121 Beds
Independent
Data: November 2025
Trust Grade
35/100
#219 of 219 in MD
Last Inspection: June 2022
Over 2 years since last inspection. Current conditions may differ from available data.
Overview
Williamsport Nursing and Rehabilitation Center has received a Trust Grade of F, indicating a poor rating with significant concerns about care and services provided. It ranks #219 out of 219 facilities in Maryland, placing it in the bottom tier, and #10 out of 10 in Washington County, meaning there are no local options that are better. The facility is showing some improvement, as the number of issues reported decreased from 36 in 2022 to 10 in 2025. However, staffing is a notable weakness, with a low rating of 1 out of 5 stars and a concerning turnover rate of 54%, which is higher than the state average. Specific incidents of concern include a nurse administering treatment without a physician's order that led to a resident's injury and failures in monitoring medication side effects as prescribed, which could compromise resident safety.
- Trust Score
- F
- In Maryland
- #219/219
- Safety Record
- Moderate
- Inspections
- Getting Better
- Staff Stability ⚠ Watch
- 54% turnover. Above average. Higher turnover means staff may not know residents' routines.
- Penalties ✓ Good
- No fines on record. Clean compliance history, better than most Maryland facilities.
- Skilled Nurses ○ Average
- Each resident gets 39 minutes of Registered Nurse (RN) attention daily — about average for Maryland. RNs are the most trained staff who monitor for health changes.
- Violations ⚠ Watch
- 85 deficiencies on record. Higher than average. Multiple issues found across inspections.
35/100
Bottom 1%
Needs review
36 → 10 violations
★☆☆☆☆
1.0
Overall Rating
★☆☆☆☆
1.0
Staff Levels
★★★☆☆
3.0
Care Quality
★☆☆☆☆
1.0
Inspection Score
↔
Stable
2022: 36 issues
2025: 10 issues
The Good
-
Full Sprinkler Coverage · Fire safety systems throughout facility
-
No fines on record
Facility shows strength in fire safety.
The Bad
1-Star Overall Rating
Below Maryland average (3.0)
Significant quality concerns identified by CMS
Staff Turnover: 54%
Near Maryland avg (46%)
Higher turnover may affect care consistency
The Ugly 85 deficiencies on record
1 actual harm
Jul 2025
5 deficiencies
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0573
(Tag F0573)
Could have caused harm · This affected 1 resident
Based on record reviews and interviews, it was determined that the facility failed to honor the resident's/resident representative's right to access personal and medical records. This was evident for ...
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Based on record reviews and interviews, it was determined that the facility failed to honor the resident's/resident representative's right to access personal and medical records. This was evident for 1 (Resident #133) of 2 residents reviewed for neglect. The findings include:A review of the intake information related to MD00217274 indicated that Resident #133's representative had requested medical records after the resident's death and was wrongfully denied the request.In an interview with the resident representative on 7/17/25 at 12:31 PM, s/he reported filling out a medical records request form at the front desk of the facility. Then after some time, had received a phone call from a facility staff informing him/her that the request was denied and no further explanation was provided.The Director of Nursing (DON) was interviewed on 7/23/25 at 2:16 PM. During the interview, she reported the process to request medical records and indicated that a record request form is filled out and submitted to the medical records coordinator (Staff #44) to be processed.On 7/23/25 at 2:45 PM, Staff #44 was interviewed. During the interview, she reported that she had been with the facility since February of 2025. She also provided a copy of the records request form to the surveyor and reported that she kept the filled-out forms for her records.When Staff #44 was asked about resident #133, she immediately pulled out the record request form that was filled out by the resident representative dated 4/28/25 and indicated that the DON had already informed her of what the surveyor was looking for. Staff #44 reported that the medical records request was denied because the representative only had a financial Power of Attorney (POA) and was ultimately decided by a third-party company (Rytes company) that the representative lacked the clearance to obtain the medical records.Staff #44 further explained the process for records request, indicating that once the form is filled out, she sends them to Rytes company via email for determination, then after Rytes company reviews the request and the resident's medical record, they would inform Staff #44, via email, if the records can be released.Staff #44 provided the surveyor with a copy of the email received on 4/29/25 from Rytes company, addressed only to her, stating records could not be released due to: The request lacks supporting documents demonstrating that the person signing the authorization and/or making the request is the personal representative of the resident and has the authority to request/release medical records. Qualifying documents could include a power of attorney for healthcare, health care surrogacy or proxy, guardianship document or advanced directive. Instructions on the email stated, In the event that you have additional relevant documents in your file, please provide to Rytes by responding to this email with the additional documents.Subsequently, Resident #133's medical records were reviewed with Staff #44 on 7/23/25 at 2:58 PM. The review revealed the resident's advanced directive with an upload date of 3/19/25, that stated the representative's name as appointed POA for healthcare in the event that the resident cannot make healthcare decisions him/herself. Staff #44 reported that she did not see the advanced directive because she does not review resident records. She indicated that she solely relies on Rytes company to figure that out.On 7/23/25 at 3:41 PM, the findings were discussed with the Regional Director of Clinical (Staff #9). Staff #9 confirmed that both Rytes company and Staff #44 had complete access to Resident #133's medical record that included the advanced directive.Staff #9 agreed that based on the advanced directive, the representative should have been deemed eligible for the medical records request by Rytes company. Also, the medical records coordinator should have reviewed Resident #133's medical record and provided the advanced directive document to Rytes company, as instructed in the email and inform the Director of Nursing and Nursing Home Administrator. Staff #9 verbalized understanding of the concern and stated, I will contact Rytes and find out what happened.On 7/24/25 at 8:56 AM, Staff #9 reported that she had talked to staff from Rytes company and investigated the concern. They indicated that they had made a mistake and were looking at the wrong resident. Staff #9 indicated that she had instructed Staff #44 to contact Resident #133's representative about providing the medical records as initially requested.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Free from Abuse/Neglect
(Tag F0600)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, it was determined that the facility failed to protect residents from verbal and psychosoc...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, it was determined that the facility failed to protect residents from verbal and psychosocial abuse. This was evident for two (Resident's #13 and #52) out of six residents reviewed for abuse.The findings include:1. Resident #13 has a medical history of heart failure, type 2 diabetes, chronic kidney disease, anxiety, and depression.On 7/15/2025 at 2:06 PM, the surveyor reviewed Facility-Reported Incident (FRI) #335325 in which Resident #13 alleged they were subjected to verbal and emotional abuse. The facility investigated the allegation and substantiated findings of verbal and psychosocial abuse by a nursing assistant (GNA #20).According to the facility report, Resident #13 stated that GNA #20 consistently acted rudely, refused to assist, stated she did not have time to help, and told the resident to stop going home because all [you] do is fall. The facility investigation included a statement from GNA #20, who admitted to making inappropriate comments, including that other staff avoided caring for the resident and would ask to switch assignments. Specifically, GNA #20 stated, People [other GNAs] ask to switch [assignments] with me and make me take [Resident #13]. Another staff member, GNA #39, corroborated the abuse, stating that she heard GNA #20 say to Resident #13, This is why no one comes in [your room] and no one likes you.On 7/16/2025 at 8:51 AM, the surveyor interviewed Resident #13 regarding the incident. The resident stated that GNA #20 told them that they were disliked by both staff and other residents and alleged that the GNA ignored their call bell in retaliation. Resident #13 further stated that the GNA called them ugly and that the verbal abuse caused them to cry. They initially responded with anger but later became emotional, stating, I cussed them out, but then I cried-it was really hurtful. The resident reported that GNA #20 resigned while under investigation. Resident #13 stated, I used to be fearful to be here, but things have improved.On 7/21/2025 at approximately 2:00 PM, the surveyor interviewed the Nursing Home Administrator (NHA) regarding the facility's process for handling allegations of abuse. The NHA explained that any staff member accused of abuse is immediately suspended pending an internal investigation, which includes collecting written statements from staff and other residents and conducting a full examination and assessment of the involved resident. When asked about the incident involving Resident #13, the NHA confirmed familiarity with the case and stated that the employee no longer worked at the facility. The surveyor explained that despite the investigation and reporting being completed, the incident still constituted a deficiency, as the facility failed to prevent the abuse from occurring. The NHA verbalized understanding.2. Resident #52 has a history of insulin-dependent type 1 diabetes, heart failure, asthma, chronic obstructive pulmonary disease (COPD), anxiety, depression, syncope (fainting), and chronic pain.On 7/15/2025 at 1:56 PM, the surveyor reviewed Facility-Reported Incident (FRI) #335296, in which Resident #52 alleged verbal and psychosocial abuse. The facility investigated and determined the allegations were substantiated for both verbal and psychological abuse.According to the complaint, Resident #52 reported to the evening shift nurse supervisor (Nurse #40) that another nurse (Nurse #38) made threatening and inappropriate comments. Specifically, the nurse reportedly said, Be careful how you treat people who are going to be giving you insulin.Review of the facility's investigation revealed that the facility believed Nurse #38's statements were considered threatening and intimidating. The facility's report stated: The facility concludes that employee [Nurse #38] was in violation of abuse. Abuse is defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish. Abuse also includes deprivation by an individual, including a caretaker, of goods or services necessary to maintain physical, mental, and psychosocial well-being.The report further detailed specific statements made by Nurse #38 that supported the abuse finding, including: Cursing in the hallway is not going to get me to you any sooner, and If it were me and I wanted my medication, I would be a little nicer. The facility determined that these remarks were delivered in a tone and manner that could cause fear and intimidation, especially given that the resident was dependent on the nurse for critical medications. The report noted that Resident #52 explicitly asked the nurse, Is that a threat? and expressed feeling fearful because of the interaction.On 7/15/2025 at 2:49 PM, the surveyor interviewed Resident #52, who stated, They fired the person that threatened to withhold my medications. I feel safer now that he is gone.On 7/21/2025 at 1:47 PM, the surveyor interviewed Resident #52 and their spouse. The spouse, tearfully, stated they [the spouse] were in constant anguish worrying over the care [Resident #52] is receiving and expressed ongoing concern for the resident's safety. They further stated that they were fearful to report issues for fear that [Resident #52] will be retaliated upon.On 7/21/2025 at approximately 2:00 PM, the surveyor interviewed the Nursing Home Administrator (NHA) regarding the abuse allegation. The NHA explained that when an abuse report is received, the implicated employee is suspended pending investigation. The facility collects statements from staff and residents and performs a full examination and assessment of the resident involved. The NHA confirmed that she was familiar with the case involving Resident #52 and that the employee in question no longer worked at the facility. The surveyor explained that despite the investigation and reporting being completed, the facility remained responsible for preventing abuse and ensuring the safety of residents, including protection from [NAME] employees. The NHA verbalized 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 F0730
(Tag F0730)
Could have caused harm · This affected 1 resident
Based on record review and staff interviews it was determined that the facility failed to ensure Geriatric Nursing Assistants (GNAs) received an annual performance review and 12 hours/year of in-servi...
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Based on record review and staff interviews it was determined that the facility failed to ensure Geriatric Nursing Assistants (GNAs) received an annual performance review and 12 hours/year of in-service training for 2 (GNA #20 and GNA #21) out of 2 employee records reviewed during the survey.The findings include:Geriatric Nursing Assistants (GNA) require a performance appraisal to be completed at least every 12 months to identify the potential for and receive at least 12 hours/year of in-service education.
On 7/23/25 between 1:00 and 4:00 PM six employee training records were reviewed.
On 7/24/25 at 9:18 AM in an interview with the Director of Nursing (DON) it was revealed that the facility uses Relias, an online training and education application. It was also revealed that the Staff Development Coordinator (SDC) tracks employees’ compliance of the training required.
On 7/24/25 at 9:31 AM in an interview with the SDC (RN #19) it was revealed that her position was started in April 2025. She acknowledged that it was her responsibility to track staff compliance via Relias.
On 7/24/25 at 1:00 PM, the DON acknowledged that the employees’ files lacked documentation of required annual performance reviews and 12 hours/year in-service for calendar years 2022-2025 and that she could not locate further documentation otherwise. This concern was communicated to the DON.
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 F0760
(Tag F0760)
Could have caused harm · This affected 1 resident
Based on pertinent document review and interview it was determined that the facility failed to provide the residents with medications as ordered by the physician. This was evident for 1 Resident (resi...
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Based on pertinent document review and interview it was determined that the facility failed to provide the residents with medications as ordered by the physician. This was evident for 1 Resident (resident #135) out of 4 residents reviewed for neglect during a survey. The findings include: On 7/22/25 8:00 the Review of a complaint submitted from a county agency revealed a concern that Resident #135 did not receive her/his medications on time.On 7/22/25 at 10:10 AM the surveyor requested the medication administration audit for Resident # 135 for the following dates: 2/26/25 through 3/03/25 07/22/2025 11:31 AM the Nurse Unit Manager (Staff # 8) was interviewed. She provided interpretation of the medication administration audit. She reported that the first column indicated what time the medication was ordered the second column indicated what time the medication was administered.On 7/22/2025 11:22 AM a review of the audit included but was not limited to the following medications not being administered according to professional standards.Medication: hydroxyzine HCL Oral Tablet, give 1 tablet by mouth every 6 hours for anxiety for 14 days. Ordered administration time 12:00 PM 3/1/25. The medications was administered at 2:02 PM on 3/1/25. An additional dose of hydroxyzine HCL was ordered to be administered at 6:00 PM. However, it was administered at 3:39 PM, less than 2 hours from the first dose. On 7/22/25 1:05 PM during an interview the Assistant Director of Nursing (ADON), (Staff #29) confirmed that medications administered greater than 1 hour before or 1 hour after the ordered administration time were considered too early or too late. The surveyor and ADON reviewed the medication audit sheets that were provided. The ADON confirmed that Hydorxyzine was administered less than 2 hours from its previous doses, which is a medication error.On 7/22/25 11:30 Further review of the Medication Administration audit included, but were not limited to the following medications which were administered late;1.On 2/26/25 Resident # 135 had an order for Doxycycline Monohydrate 100mg capsule (antibiotic) to be administered at 8:00 AM and 10:00 PM for pneumonia, However the medication was documented as administered at 12:00PM. 2. On 2/26/25 Resident # 135 had an order for Entresto oral tablet 0.5 tablet by mouth two times a day for atrial fibrillation to be administered at 8:00 AM, however the documented time of administration was 11:07 PM. 3. On 2/26/25 Resident #135 had an order for Trimethoprim oral tablet 100 mg by mouth once a day for urinary tract infection to be administered at 8:00AM, However, the medication was administered at 11:08 PM4. On 3/1/15 Resident #135 had an order for Entresto oral tablet 0.5 tablet by mouth two times a day for atrial fibrillation to be administered at 8:00 AM, however the documented time to administration was 11:27 PM.On 7/24/2025 at 1:11 PM the above concerns were shared with the Director of Nursing. She confirmed the above listed medications were not administered as ordered.
MINOR
(C)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Minor Issue - procedural, no safety impact
Staffing Information
(Tag F0732)
Minor procedural issue · This affected most or all residents
Based on observation, interview, and record review it was determined that the facility failed to post nursing staffing data on a daily basis and failed to ensure 18 months of posted nursing data were ...
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Based on observation, interview, and record review it was determined that the facility failed to post nursing staffing data on a daily basis and failed to ensure 18 months of posted nursing data were retained. This was evident for 5 of 5 nursing units.The findings include:On 7/15/25 at 8:00 AM surveyors entered the facility and observed a posted nursing staffing document at the receptionist's desk that was dated 7/10/25. The receptionist was questioned about the posting date and said she would provide an updated posting. Within the hour an updated nursing staff posting document was provided that indicated it was for 7/15/25.On 7/24/2025 at 12:14 PM an interview was conducted with the Director of Nursing (DON) to review that the daily nursing staff posting on 7/15/25 displayed data for 7/10/25. She explained that the Staff Scheduler (Staff #) posted that information and that she did not work weekends. However, she concurred that 7/15/25 was a Tuesday and that the posting for that day was not present. When the DON was asked for copies of nursing staff posted data for the previous six months, she said that the facility did not keep records of the daily nursing staff posting. She further explained that the facility's previous ownership had kept the records electronically and she did not have access to that information. She confirmed the deficiency that the facility did not post nursing staff daily and did not retain records of the nursing staff posting.
Apr 2025
5 deficiencies
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Grievances
(Tag F0585)
Could have caused harm · This affected 1 resident
Based on interview and record review it was determined that the facility failed to have a process to ensure that all grievances were investigated and received a response in a timely manner. This was e...
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Based on interview and record review it was determined that the facility failed to have a process to ensure that all grievances were investigated and received a response in a timely manner. This was evident for 2 (#87 and #95) of 2 residents reviewed for the grievances.
The findings include:
1) During an interview with the Director of Nursing (DON) on 4/2/25 at 8:08 AM, she reported that Resident #87 had requested to speak with a surveyor. The DON reported that this resident had an ongoing complaint about the number of staff assigned to the unit. She stated that when the resident used his/her call light, they expected it to be answered right away. She stated that when she had pulled the audit reports the resident's wait time was about 16 minutes. The DON stated they offered the resident a room change, but s/he had declined.
An interview with Resident #87 on 4/2/25 at 8:46 AM, revealed that s/he had concerns with the number of staff assigned to their unit because s/he waited extended times for call light response. When asked if the resident had reported this concern to facility staff, the resident stated s/he had multiple times, but they did not listen.
The extended wait time for call lights was confirmed on 4/2/25 at 10:00 AM when a review of the call bell audits for 3/20/25 - 4/1/25 was conducted. Resident #87 waited 30 minutes to 3 hours for his/her call light to be answered.
A subsequent interview with the DON on 4/2/25 at 12:43 PM DON revealed she was not sure she had written a grievance regarding the resident's complaints about staffing and call light response times. She stated she does not write a grievance when she can immediately fix the issue.
The DON confirmed that she had not written a grievance for Resident #87's concerns regarding staffing and call light response times at the time of exit on 4/3/25 at 3:00 PM.
2) A review of the facility's Grievance Logs for the last 3 months revealed that on 1/5/25, Resident #95 reported a long wait time for a call light response during a meal. Per the report form this was not addressed or responded to by the facility.
Another grievance form dated 1/13/25, read that Resident #95 had turned on his/her call light at 5:30 PM and by 7:30 PM the resident started calling out to staff because no one answered it. The facility educated the staff member assigned that evening, however failed to show the incident had been investigated to determine the root cause and implement a plan of correction.
At the time of these grievances the call bell system did not have a mechanism to run call bell audits. However, a review of the current call bell response times for Resident #95 on 4/2/25 at 10:00 AM revealed that the bathroom call light had rang for 1.5 hours on one occasion and the resident's call light at the bed rang for 30 - 60 minutes at times.
An interview with the Social Services Associate #16 on 4/2/25 at 1:46 PM revealed she would make a copy of the grievance form and given to the appropriate department head. She confirmed the incident on 1/5/25 was sent to the dietary department, however she was not sure about the nursing department regarding the call light response. She confirmed that the bottom of the form was to be filled out by Social Services staff and then given to the Nursing Home Administrator (NHA) but was unsure if that had been done these two grievances.
An interview with the NHA on 4/3/25 at 10:10 AM revealed that the form used to write up the grievances on 1/5/25 and 1/13/25 had been updated when she came in 11/2024. She was unable to provide a rationale for the reason these forms were not completed and the grievances responded to timely. When asked if a resident's concerns about call lights being answered timely should be written as a grievance, such as with Resident #87, she stated it should be because it cannot be resolved immediately.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0602
(Tag F0602)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview; it was determined that the facility failed to protect a resident (resident #59) from...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview; it was determined that the facility failed to protect a resident (resident #59) from misappropriation of personal funds from a facility staff member. This was evident for 1 of 94 residents reviewed during an complaint survey.
The findings include:
The surveyor reviewed a complaint (MD00186172) sent to the State of Maryland's Office of Health Care Quality in 12/22 alleging that facility staff made unauthorized charges on resident #59's credit card.
Medical record review for resident #59 on 3/31/25 at 11:00am revealed the resident was transferred from the facility on 11/3/22 for a change in condition. The resident was expected to return to the facility, so the resident's belongings remained in the facility.
On 3/31/25 at 11:20am, The surveyor interviewed the Administrator regarding the allegation of facility staff making unauthorized charges to resident #59's credit card in 11/22. The Administrator provided the surveyor with the facility investigation into the misappropriation of resident #59's credit card.
The surveyor reviewed the facility investigation on 3/31/25 at 1:30pm. The investigation that LPN #18 admitted to making unauthorized charges to resident #59's credit card to purchase a $100.00 Amazon Gift Card when he/she was interviewed by the [NAME] County Sherriff's Office. LPN#18 also admitted that he/she took possession of the resident's credit card and driver License on 11/4/22.
Interview with the Director of Nursing (DON) on 4/1/25 at 10:30am revealed that LPN [NAME] was employed with the facility as a agency LPN on 11/4/22. LPN #18 was placed on a do not call/do not return list after the facility became aware of the misappropriation of resident #59's credit card in 11/22. The facility made the agency aware of LPN #18's misappropriation of the resident's credit card and the agency reported LPN #18 to the Maryland Board of Nursing.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Accident Prevention
(Tag F0689)
Could have caused harm · This affected 1 resident
Based on medical record review and staff interview, the facility staff failed to provide supervision to prevent an accident (Resident #61) This was evident for 1 of 94 residents reviewed during a comp...
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Based on medical record review and staff interview, the facility staff failed to provide supervision to prevent an accident (Resident #61) This was evident for 1 of 94 residents reviewed during a complaint survey.
The findings include:
On 4/14/23, the facility reported an incident (Intake # MD00191371). Resident # 61 received a blister/burn from an incorrectly placed warm compress.
Medical record review for resident #61 on 4/1/25 at 8:40am revealed a progress note dated 4/15/23 at 1:45pm which reported that the resident sustained a blister/burn to his/her right lower lateral foot after facility nursing staff applied a resident- requested warm compress.
Surveyor review of the facility's investigation of the reported incident on 4/1/25 at 9:30am revealed the nursing staff reported an observed right lateral foot blister measuring 2.5cm x 1.2 cm on 4/15/23. Nursing staff applied a skin barrier ointment to the blister. Resident #61 did not complain of any pain. Nursing staff statement on 4/18/23 reported that the warm compress was applied to resident #61's right foot after request. The warm compress was secured with a ace bandage. There were no observed issues with the resident's skin or complains of discomfort after the application of the compress. The facility investigation also contained a statement of admission that nursing staff failed to monitor condition of the resident #61's skin after the warm compress was applied. The facility investigation also contained a policy dated 5/8/23 which instructs nursing staff on the facility procedure on how to apply a warm compress and expectations on how to monitor for resident safety.
The surveyor interviewed the Director of Nursing (DON) on 4/1/25 at 11:40pm regarding the results of the facility investigation regarding resident #61's right foot blister. The DON admitted that facility nursing staff failed to monitor the resident's skin after application of the warm compress. This failure to monitor for the resident's safety led to the creation of new policy for the application and monitoring of warm compresses.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0725
(Tag F0725)
Could have caused harm · This affected 1 resident
Based on interview and record review it was determined that the facility failed to ensure that there were enough staff on duty to answer call lights in a timely manner for the residents. This was evid...
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Based on interview and record review it was determined that the facility failed to ensure that there were enough staff on duty to answer call lights in a timely manner for the residents. This was evident for 2 of 3 complaints for call bell response times.
The findings include:
1) An interview with Resident #87 on 4/2/25 at 8:46 AM, revealed the resident had concerns about the call light response times. The resident recalled that s/he had waited a few hours for staff to answer his/her call light on a day in the last couple of weeks. The resident could not recall the exact date and thought it occurred between breakfast and lunch. The resident reported s/he needed assistance with incontinence care.
The extended wait time for call lights was confirmed on 4/2/25 at 10:00 AM when a review of the call bell audits for 3/20/25 - 4/1/25 was conducted. Resident #87 waited 30 minutes to 3 hours for his/her call light to be answered.
2) An interview with Resident #95 on 4/3/25 at 9:01 AM, revealed that s/he had extended wait times when s/he put his/her call light to use the bathroom. The resident reported that at times s/he would not make it to the bathroom before having an accident. Furthermore, once the resident was on the toilet, s/he reported sitting there for an extended time until someone could help him/her back to bed or chair. The resident reported that once staff gave out the meal trays, it was difficult to find any staff if s/he needed ketchup, because no one was around. In addition, on shower days the residents' bed linens were not always changed because staff did not have the time to complete both tasks.
During an interview with Geriatric Nursing Assistant (GNA) #16 on 4/3/25 at 8:49 AM, she reported that during breakfast it was hard to answer call lights and get the food out to residents while it was hot. She reported that she had a resident who needed fed and was finishing up breakfast at the time of this interview. GNA #16 reported they had 1 GNA for upstairs, 1 GNA downstairs, and 1 float GNA, but the float GNA had been pulled for another assignment. The GNA stated that some residents will not get their showers until the afternoon because it was difficult to get them done in the morning.
On 4/2/25 at 12:08 PM a review of the call bell audits for C wing unit for 3/21/25 - 3/24/25 and 4/1/25 - 4/2/25 revealed there were multiple days and timeframes that residents waited 30 minutes to 3 hours for call light responses. The schedules were reviewed for the corresponding days and determined that they consistently staffed 1 nurse and 2 GNAs per shift. On some shifts they scheduled a Certified Medicine Aid (CMA) to help with medications and some shifts they had a 3rd GNA scheduled.
The Director of Nursing (DON) was interviewed regarding her expectations for call light response times on 4/2/25 at 12:43 PM. She reported that call lights should be answered within a reasonable timeframe, but no later than 20 minutes. Reviewed the findings of the call light response times. When asked how she determined the level of staffing needed, she stated it was based on the required staff to resident ratios. The DON stated she thought it was ideal to have 3 GNAs on day and evening shift on C wing unit, but at times it was difficult to staff at that level. She reported that on the days there were 2 GNAs the staffing was adequate, and staff should work as a team and provide care. However, when shown the audits for call light responses, she was unable to provide a rationale for the concern.
On 4/3/25 at 10:10 AM the call light audits were reviewed with the Nursing Home Administrator. She reported that she did not specify a time frame for answering call lights but expected them to be answered timely. Reviewed the concerns with her.
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 F0760
(Tag F0760)
Could have caused harm · This affected 1 resident
Based on the review of a complaint, medical record review and interview with residents and staff, it was determined that the facility staff failed to administer medications to residents without any si...
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Based on the review of a complaint, medical record review and interview with residents and staff, it was determined that the facility staff failed to administer medications to residents without any significant medication errors by inappropriately administering insulin to 2 residents that were not diabetic. This was evident during the review of a complaint that affected 2 of 2 residents during a medication pass.
The findings include:
Complaint #MD00190191 was initiated on 3/27/25 at 11:31 AM regarding Resident #36. The allegation was that s/he was given insulin on 3/17/23 inappropriately as s/he is not diabetic. According to medical record review at this time, Resident #36 was admitted to the facility over 5 years ago for care related to a kidney/pancreas transplant, Resident #36 is also diagnosed as legally blind and monitored for hypoglycemia. Second, to the transplant, Resident #36 is not considered diabetic and does not take any insulin products.
Review of the complaint #MD00190191 on 3/27/25 at 11:40AM revealed an allegation that on 3/17/23 Resident #36 was 'stuck in the arm with a needle without warning.' The complaint further reported that the resident asked the nurse what she had injected into [his/her] arm. LPN #17 reported that she gave Resident #36 the scheduled insulin. Resident #36 stated 'I am not diabetic.' LPN #17 left the room, according to the resident, and returned with a glucose tablet (given to treat low blood sugar).
The DON was interviewed on 3/27/25. The facility had not completed an internal investigation into this incident or reported it to the Office of Health Care Quality. The only report that they had was a report to the Board of Nursing regarding the agency LPN #17 who inappropriately gave Resident #36 insulin.
Resident #36 was interviewed on 3/27/25 at 12:15 PM regarding the incident. S/he stated that his/her glucose was monitored hourly all day. S/he reported that at first, they could not keep the glucose up, it would go to 115mg/dl, then drop, it was stressful. Resident #36, then stated that s/he was not the only one that this occurred to and named another resident who was inappropriately administered insulin on 3/17/23.
Resident #86's medical record was reviewed on 4/1/25 at 12:32 PM. Medical diagnosis for Resident #86 included chronic obstructive pulmonary disease, anemia, dysphagia and heart disease but no diabetes diagnosis.
A change in condition note was entered on 3/17/23 at 07:35 AM for Resident #86 noting that the resident stated, I don't know what she gave me, but it was a shot, and she gave it to me in my stomach. Resident #86's glucose was checked and was reading 99mg/dl at the time.
Resident #86's glucose too was monitored hourly and treated as needed on 3/17/23.
The letter sent to the Maryland Board of Nursing regarding LPN # 17 stated; 2 residents at our facility insulin incorrectly. Neither resident is to receive insulin, Resident #36 is hypoglycemic, so s/he receives blood sugar checks, but does not receive insulin, Resident #86 is not diabetic at all but [his/her] roommate is. The nurse in question admitted giving Resident #86 the dose of insulin stating that she got the residents mixed up. The nurse in questions stated that she did not give Resident #36 medication, but the alert and oriented Resident maintains that s/he was given insulin in shot form.
The concerns for the significant medication errors were reviewed with the facility Administrator and the DON throughout the survey and again with the DON on 4/3/25.
Jun 2022
36 deficiencies
1 Harm
SERIOUS
(G)
Actual Harm - a resident was hurt due to facility failures
Quality of Care
(Tag F0684)
A resident was harmed · This affected 1 resident
Based on surveyor observation, record review, and interviews with residents and staff, it was determined that the facility staff failed to ensure that care and services were provided to assist all res...
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Based on surveyor observation, record review, and interviews with residents and staff, it was determined that the facility staff failed to ensure that care and services were provided to assist all residents in achieving their highest practicable level of wellbeing. This was evidenced by: 1) facility staff's failure to ensure that each resident received treatment and care in accordance with professional standards of practice as evidenced by a nurse providing a treatment without a physician's order which resulted in an injury to a resident requiring treatment at an emergency room (Resident #250) 2) failure to ensure that tests for monitoring for potential medication side effects were completed as ordered and the failure to obtain blood sugars four times a day as ordered, that was evident for 2 (Resident #74, #59) out of 7 residents selected for unnecessary medication review, 3) the facility staff's failure to ensure that arm protectors were provided as prescribed by the physician for 1 (#35) of 13 residents reviewed for Abuse, 4) the facility staff failure to identify and follow up when a resident had a change in physical status for 1 (#26) of 28 residents observed during initial resident observations, and 5) the facility staff failure to arrange and provide a follow-up appointment as per a consulting specialist's recommendation for 1 (#38) of 4 residents reviewed for Urinary Catheter or UTI.
The findings include:
1) Based on review of complaint #MD00165339, medical record review and complainant and staff interview, it was determined that the facility staff failed to ensure that each resident received treatment and care in accordance with professional standards of practice as evidenced by a nurse providing a treatment without a physician's order which resulted in an injury to the resident's ear leading to an emergency room visit. This was evident for 1 (#250) of 12 residents reviewed for abuse.
The findings include:
On 6/10/22 at 3:41 PM, review of complaint #MD00165339 was conducted. In the complaint , the complainant reported that, while Resident #250 resided in the facility, the complainant received a phone call from the facility and was told that Resident #250 had a cut on the ear that was bleeding, and the resident was sent to the emergency room. The complainant stated that he/she was told that a staff person scratched Resident #250's ear while using a tool to clean the resident's ear.
On 6/10/22 at 3:45 PM, a review of Resident #250's medical record revealed that Resident #250 was admitted to the facility in January 2021 for rehab following an acute hemorrhagic stroke (bleeding in brain) resulting in right sided hemiplegia (paralysis) and aphasia (difficulty with language or speech, usually caused by brain damage), and indicated that the resident was vulnerable, immobile and had difficulty communicating. On 1/8/21 at 3:09 PM, in an admission Summary note, the nurse documented that Resident #250's right arm was flaccid (limp), his/her right leg was weak, and the resident was aphasic, with garbled or whispered speech and difficult to understand.
A review of Resident #250's medical record was continued on 6/13/22 at 9:00 AM.
In a nurse's note written on 3/4/21 at 10:19 PM, it was documented that Resident #250 was having steady bleeding with clots from his/her right ear that started at 7:00 PM, and the CRNP (certified registered nurse practitioner) was notified.
In a later note, on 3/5/21 at 12:00 AM, the nurse wrote that the bleeding had continued with clots of blood noted at the ear canal, the NP (nurse practitioner) was notified, an order was given to send Resident #250 to the ER (emergency room) for evaluation, and the resident was transferred to the hospital.
In an ED (emergency department) Provider note, with a discharge date of 3/5/22 at 2:09 AM, the PA (physician's assistant) wrote that Resident #252 was sent to the ER for bleeding from the right ear, and that per report, the resident had bleeding from right ear canal after nursing home staff tried to clean the ear. In the summary statement, the PA wrote that the nursing report stated the bleeding began after the ear was being cleaned and there was evidence of an abrasion within the ear canal. The PA also indicated the resident was being discharged back to the facility with instructions that included no foreign objects within the ear canal.
In an incident note, on 3/5/21 at 7:10 AM, the nurse indicated that he/she received in report that Resident #250's ears had been cleaned on dayshift, and the 3-11 shift nurse reported the resident had been bleeding from the right ear. The nurse wrote that when he/she came on shift, the bleeding continued with clots of blood noted at ear canal, the NP was notified, and the resident was sent to the ER for evaluation. The nurse wrote that, on 3/5/21 at 3:52 AM, when the ER was called for an update, he/she was notified Resident #250 had a laceration in the ear canal and was on his/her way back to the facility.
In a physician progress note on 3/5/21 at 3:49 PM, the physician wrote Resident #250 was seen for parotitis (painful swelling of parotid (salivary) glands) and right ear bleeding. The physician wrote that yesterday [3/4/21], the resident's ears were cleaned out by a nurse (RN Staff #3) after which the resident's ear started to bleed with clots. Resident #250 was sent to the emergency department and was found to have an abrasion of the ear canal and the ear was packed. The physician wrote that when he/she removed the resident's ear pack, there was a gelatinous clot.
Resident #250's medical record indicated that a facility nurse provided a treatment to Resident #250's right ear which resulted in a resulting in an injury (abrasion) to the resident's right ear canal, however, continued review of the medical record failed to reveal a physician's order for any treatments to Resident #250's ears. In addition, the nurse who provided the treatment to Resident #250's ears failed to document the reason for the treatment, the treatment performed or the resident's response to the ear treatment.
On 6/13/22 at 1:37 PM, during an interview, when asked about Resident #250's right ear canal abrasion, Staff #5, PA indicated that an RN had cleaned Resident #250's ear and caused trauma. Staff #5 stated that a nurse took a curette (ear cleaning tool) and took it upon him/herself to clean the ear. Staff #5 stated that he/she had not instructed the nurse to clean out the resident's ears and to his/her knowledge, no one gave the nurse an order to clean out the resident's ears, and that he/she would never advise a nurse to use a curette to clean out a resident's ears. Staff #5 stated that the nurse who cleaned out Resident #250's ears said he/she saw the ear wax and wanted to get it. Staff #5 identified the nurse as an RN, Staff #3.
On 6/13/22 at 3:40 PM, during an interview, the DON (Director of Nurses) stated that nurses were not to clean resident ears with a curette. The DON stated that Staff #3, the person implicated as the staff nurse who cleaned the Resident #250's ears with a curette without a physician's order, had not been disciplined for the action, however, following the incident, a new policy related to ear cleaning and irrigation was implemented and house wide education was conducted with the clinical staff about the new policy. At that time, the DON indicated that he/she had not been the DON at the time of the incident.
On 6/15/22 at 10:29 AM, a phone interview was conducted with Staff #3. At that time, Staff #3 stated he/she could not recall the incident related to cleaning Resident #250's ears which resulted in a right ear canal abrasion. Staff #3 stated he/she did not believe he/she would do that or go off a shift had there been a problem. When asked if he/she cleaned resident ears, Staff #3 stated he/she would clean a resident's ear if needed and would use an otoscope (tool used to visualize and examine the ear canal) to assess the situation. If the ear needed to be cleaned, Staff #3 stated he/she would use an otoscope & curette to clean the ear. Staff #3 indicated he/she had provided the treatment weekly at a different out of state facility. When asked if the treatment required a physician's order, Staff #3 stated he/she was unsure if it required an order or if it was a nursing measure, and indicated curettes were available at the current facility and believed the nurses used the curettes to clean resident ears. When asked again if he/she recalled the situation, Staff #3 did not recall the situation and did not believe he/she would do that and would have remembered if he/she had notified the physician. Staff #3 stated he/she was never made aware of the incident, or received education about the incident, and would have remembered if he/she had been.
On 6/15/22 at 11:31 AM, during a second interview, Staff #5, PA stated he/she had not talked directly to Staff #3 about the incident. Staff #5 stated that Staff 7, who was the DON at that time, called the PA and asked if he/she had given Staff #3 a curette to clean the resident's ear, which he/she had not. Staff #5 stated that he/she knew Staff #7, was addressing it and the PA had never given an order for a nurse to use a curette and did not believe it was in the nurse's scope of practice.
On 6/15/22 at 12:47 PM, during a phone interview, Staff #7, RN stated that he/she was the DON at the time of the incident. Staff #7 stated that one of the nurses had cleaned out the Resident #250's ear with a curette and caused the bleeding. Staff #7 stated he/she was told about the incident by the nursing staff the next day and did speak with Staff #3 about the incident. Staff #7 indicated that at that time, it was realized there was no policy, so a facility policy was created to have nurses clean out resident ears by flushing and that he/she would expect a physician order prior to implementing the treatment. Staff #7 stated that following the incident, Staff #3 had received specific education which was similar to that education the clinical staff received and indicated the majority of the nurses were educated and there were signature sheets.
On 6/15/22 at 1:00 PM, the facility's policy for ear irrigation, dated 3/10/21 and evidence of the staff education provided following the above incident was reviewed. The policy was designed to address the needs of the residents at the facility when cerumen build up is evident in the ear canal and requires intervention. Ear irrigation is the only approved procedure to remove cerumen from the ear canal. The policy indicated that an order from a medical provider would be needed for ear irrigation and included the statement Do not insert an object into the ear canal, such as Q-tip or plastic curette.
Review of the facility's On the Spot Education, dated 3/5/21, stated staff nurses, GNA (geriatric nursing assistant), CMA (certified medication aide) or any other staff member are not to clean resident's ears with anything other than soap and water, do not place Q-tip or any other device and attempt to remove ear wax/debris. If there is a concern of wax build up/debris or any other inner ear concern report this issue/concern with the providers. Do not attempt to remove wax/debris or anything else manually. The sign-in sheet was signed by 3 nurses and 6 GNAs and did not include Staff #3's signature.
On 6/15/22 at 2:28 PM, the DON & ADON (assistant director of nurses) were made aware of the above findings and confirmed there was no further evidence to indicate that the all the clinical nursing staff, including Staff #3, had been educated on the facility's policy and the process to follow when a resident needs his/her ears cleaned.3) Resident #35 was observed on 6/6/22 at 2:31 PM. He/She was lying in bed and had several small dark spots and small scabbed spots over the backs of his/her hands and forearms. His/her skin appeared thin. A small piece of white elastic mesh stockinette approximately 4-5 inches long covered a dressing on the resident's left forearm approximately midway between his/her wrist and elbow. The resident indicated that he/she did not wish to speak to the surveyor.
Resident #35's medical record was reviewed on 6/14/22 at 9:59 AM. The record included a physician's order for Eliquis 2.5 milligrams by mouth twice a day. Eliquis is an anticoagulant (blood thinner) medication used to treat and prevent blood clots and stroke. The side effects of Eliquis include easy bruising and bleeding. The record also included a physician's order, written 4/13/22, for arm protectors to bilateral (both) arms at all times. May remove for bathing. Please document if resident declines application. The reason for the order was indicated as For fragile skin.
The record contained a Plan of Care for: Skin tear to left forearm and potential for further tissue impairment.
The interventions included but were not limited to: Geri-sleeves (arm protectors) to be worn daily; May remove for bathing. This intervention was initiated 4/13/22.
A review of the 6/2022 Treatment Administration Record (TAR) revealed the order for arm protectors,with spaces labeled Day Eve and Night, for the nurse to sign off that they completed this order each shift. The TAR was not signed for dayshift at that time. However, a review of Resident #35's nursing progress notes failed to reveal documentation as to why the resident was not wearing his/her arm protectors on 6/6/22 when observed by the surveyor.
Additional observations of Resident #35 were made on 6/14/22 at 2:32 PM and 6/15/22 at 11:47 AM. During each of these observations, Resident #35 was lying in bed without arm protectors in place, the elastic mesh stockinette was in place on his/her left forearm.
Further review of the 6/2022 TAR on 6/15/22 at 12:32 PM revealed that the order for arm protectors was signed off every shift from 6/1/22 - 6/15/22 including day shift on 6/6/22, 6/14/22 and 6/15/22 when the surveyor observed the resident without the arm protectors. No documentation was found in the record to indicate that the resident was not wearing them and why.
During an interview on 6/15/22 at 1:28 PM, Staff #56 reviewed and confirmed that she signed off Resident #35's arm protectors for the current shift. She then observed Resident #35 with the surveyor and confirmed that the resident was not wearing arm protectors. When asked who was responsible for putting the arm protectors on Resident #35, she stated technically if I'm signing them off, I should be putting them on but usually the girls will put them on. When asked how she verifies that they are on the resident she stated, it would be by sight. In an interview on 6/15/22 at 1:36 PM, Staff #50 a GNA (Geriatric Nursing Assistant), reviewed Qshift (the GNA's electronic documentation tool) with the surveyor and Staff #56. Staff #50 indicated that Resident #35's arm protectors were not listed for the GNA's to apply. The Director of Nursing and Assistant Director of Nursing were made aware of these findings on 6/15/22 at 1:44 PM.
4) Resident #26 was observed on 6/6/22 at 11:54 AM with a brown area on his/her lower left cheek. The area was approximately 1.5 long x .5 cm wide, and the edges appeared slightly pink-red. When asked, the resident did not seem to be aware of the area and indicated that he/she was not sure what it was.
Resident #26's medical record was reviewed on 6/22/22 at 10:30 AM. A physicians order was written on 7/12/18 for: Concurrent Review: Appraise and observe resident daily for changes in physical or mental status every shift. Document yes or no if changes are observed. If a change has occurred, the change should be documented in the form of a nurses note.
No documentation was found in the record to indicate that the area on the resident's left cheek was identified and addressed by staff. Review of Hospice documentation revealed a Hospice Nurse progress note dated 6/16/22. Under Wound(s) identified NO was noted.
Resident #26 was observed again on 6/22/22 at 3:55 PM. The area was still present on his/her left cheek and appeared to be unchanged since first observed on 6/6/22.
Further review of the medical record, on 6/22/22 at 4:00 PM, again failed to reveal documentation indicating that staff identified and addressed the area. Staff #1, a Licensed Practical Nurse, was present and when asked if she was aware of a scratch or abrasion on Resident #26's left cheek area she stated No and confirmed there was no treatment ordered. She was made aware of the surveyor observations and that it was first observed by the surveyor on 6/6/22. The Director of Nursing (DON) and Assistant Director of Nursing (ADON) were made aware of the above findings on 6/22/22 at 4:53 PM and indicated that they would look for additional information. On 6/23/22 at 8:39 AM, the DON & ADON confirmed that they were unable to find documentation that staff identified and addressed the area on Resident #26's left cheek.
5) During an interview on 6/7/22 at 11:50 AM, Resident #38 stated that he/she had a UTI (Urinary Tract Infection) that I can't seem to get rid of.
Resident #38's medical record was reviewed on 6/21/22 at 9:28 AM. The record revealed that Resident #38 was seen by an Infectious Disease specialist for a consult related to his/her recurrent UTI's on 2/10/22 at 9:00 AM. The consultants' findings indicated: Recurrent UTI, urinary incontinence, and chronic dysuria (painful or difficult urination). The Recommendations included:
1) Start Keflex (an antibiotic) 250 mg (milligrams) at bedtime.
2) Start Claritin 10 mg once daily to prevent rash.
3) if no improvement of dysuria, then d/c (discontinue) Keflex.
4) if dysuria improves then continue Keflex long term & f/u (follow up) 3 months.
Review of the physicians' orders revealed an order which started on 2/11/22 for Keflex Capsule 250 mg by mouth at bedtime for Prophylactic UTI. The order was active and ongoing.
Further review of the medical record revealed that sident #38 had a Cystoscopy and a Urologist consult on 4/12/22. The recommendations from the Urologist included, but were not limited to, Prophylactic ABX (antibiotics) daily.
However, no consultation report was found for a 3 month follow up visit with the Infectious Disease Physician in 5/22 as per their recommendations on 2/10/22.
Staff #1, a charge nurse, was interviewed on 6/21/22 at 10:38 AM. She was asked where the surveyor could find the consultation report for Resident #38's 3-month Infectious Disease follow up appointment. She indicated that it would be in the record. Upon looking, she was not able to find it. She indicated that transportation schedules the appointments.
In an interview on 6/21/22 at 10:56 AM, the ADON was asked to explain the process for scheduling follow up appointments when recommended by a consulting provider. She indicated that the staff receiving the consultation report initiates a transportation request form, the provider signs off on the form and it is given to transportation to schedule. She was made aware that the surveyor was unable to find a report of the follow up visit and indicated she would look for the report. Staff #58, the transportation director, was interviewed on 6/21/22 at 10:59 AM. She was unable to confirm that the resident had a follow up appointment with the infectious disease practitioner as recommended.
In another interview, on 6/21/22 at 1:55 PM, the ADON was asked if she was able to find documentation of a follow up Infectious Disease visit for Resident #38 in 5/22. She indicated that it was not done, that when the resident returned from the appointment on 2/10/22 the nurse took the orders off for the medications, but did not complete the transportation request form, so transportation did not schedule an appointment and it was not done.
2a) On 6/9/22, review of Resident #74's medical record revealed that the resident had resided at the facility for several years. The resident's diagnoses included, but were not limited to, non-Alzheimer's dementia; anxiety, depression and a psychotic disorder not related to schizophrenia. The resident had been receiving the antipsychotic medication Seroquel for more than one year.
Further review of the medical record revealed an order, dated 8/8/21, for an EKG (electrocardiogram) annually in May to assess for QT prolongation due to Seroquel usage.
An EKG is a diagnostic medical test that records the electrical signal from the heart to check for different heart conditions. QT prolongation may indicate a heart signaling disorder than can cause irregular heartbeats.
Further review of the medical record failed to reveal documentation to indicate that an EKG had been completed when due in May 2022.
On 6/13/22, surveyor reviewed with the Assistant Director of Nursing (ADON) that no results for the EKG could be found in the medical record. On 6/14/22 at 2:54 PM, the ADON confirmed that no EKG had been completed as ordered.
2) Further review of the medical record revealed a physician order, dated 3/10/22, for an AIMS (Abnormal Involuntary Movement Scale) assessment to be completed every four months. The order included a notation that the resident is on Seroquel.
AIMS is a rating scale used to measure involuntary movements known as tardive dyskinesia (TD). TD is a disorder than can develop as a side effect of antipsychotic medication usage.
On 6/13/22, further review of the medical record failed to reveal documentation of an AIMS assessment. The ADON was informed that no AIMS assessment was found in the medical record.
On 6/15/22 at 2:26 PM, the DON confirmed that there were no AIMS assessments for the resident.
On 6/24/22 at 12:30 PM, surveyor reviewed the concern with the DON and ADON regarding the failure to complete the ordered EKG and AIMS testing.
2b) On 6/21/22, review of Resident #59's medical record revealed a diagnosis of diabetes and orders for insulin injections. The insulin orders also included instructions to hold (not administer) if the fingerstick blood sugar level was below 120.
Further review of the medical record revealed an order, with a start date of 5/11/22, for Fingerstick Blood Sugar levels four times a day and to contact the provider if the level was less than 70 or greater than 400. Review of the Medication Administration Record (MAR) revealed that the Fingerstick Blood Sugar levels were being documented as being completed twice a day at 8:00 AM and 4:00 PM. Further review of the medical record failed to reveal documentation to indicate that the blood sugar levels were being obtained more than twice a day.
On 6/22/22, the surveyor reviewed the concern with the DON and ADON regarding the failure to obtain the blood sugar levels four times a day as ordered by the provider. As of time of exit on 6/24/22 at 2:45 PM, no additional documentation was provided to indicate that the blood sugars were being obtained as ordered. (Cross reference F757)
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, record review, and interview, it was determined that the facility failed to allow residents to exercise their rights as evidenced by staff throwing away old newspapers that belon...
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Based on observation, record review, and interview, it was determined that the facility failed to allow residents to exercise their rights as evidenced by staff throwing away old newspapers that belonged to a resident who had asked staff not to throw them away. This was evident for 1 (#63) of 61 residents reviewed.
The findings include:
On 6/6/22 at 3:16 PM during an interview with Resident #63 regarding the care and services that he/she received, Resident #63 reported that he/she had some old newspapers that had been thrown away by Geriatric Nursing Assistant (GNA) #9 after Resident #63 had told her not to throw them away. Resident #63 reported that the cleaning person had come in and emptied the trash and now his/her papers were gone and he/she had wanted to keep them. Resident #63 stated that he/she had not reported this incident to facility staff.
On 6/6/22 at 3:30 PM this incident was reported to the Director of Nursing (DON) and Assistant Director of Nursing (ADON) immediately following the interview.
A follow up interview was conducted with the ADON on 6/14/22 at 8:39 AM which revealed she had reported the incident to the state agency, interviewed the resident, and obtained a statement from GNA #9. The ADON stated that Resident #63 had reported that GNA #9 had thrown away some newspapers that he/she had asked her not to throw away. The ADON also reported that GNA #9 had admitted that she had thrown away the newspapers and that Resident #63 had asked her not to do so. The ADON stated that she had provided education to GNA #9 regarding resident property and resident rights.
Cross Reference: F610
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0552
(Tag F0552)
Could have caused harm · This affected 1 resident
Based on medical record review, staff interview, and resident interview, it was determined that the facility failed to fully inform the resident in a manner that they could understand of the reason fo...
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Based on medical record review, staff interview, and resident interview, it was determined that the facility failed to fully inform the resident in a manner that they could understand of the reason for their special contact isolation isolation secondary to a possible C-Diff infection. This was evident for 1 (#513) of 15 residents reviewed.
The finding includes:
On 6/7/22 at 12:40 PM, an interview was conducted with Resident #513. During the interview, the resident stated, I don't know why I need to be isolated, nobody explained why or how long I need to. I had no issue when I was in the hospital.
On 6/13/22 at 9:39 AM, a review of the medical records revealed the resident was admitted to this facility on 5/28/22 for rehabilitation. The resident's BIMS (Brief Interview for Mental Status) score was 15/15 on admission, indicating the resident was cognitively intact. Further record review revealed that Resident #513's physician ordered special contact isolation to be maintained for possible C.diff on 6/4/22.
C. diff (also known as Clostridioides difficile or C. difficile) is a germ (bacterium) that causes severe diarrhea and colitis (inflammation of the colon). (Center of Disease Control)
However, no documentation related to Resident #513's condition was given to the resident self or Representative Party (RP).
Further review of the medical record failed to reveal documentation to indicate that either the resident or the Representative Party (RP) were informed that isolation had been ordered due to possible C-diff infection.
On 6/13/22 at 11:38 AM, an interview was conducted with the Director of Nursing (DON). She was asked to provide documentation for the resident's medical condition related to isolation. The DON confirmed there was no documentation in the resident's medical record regarding C-diff. She also added that there was documentation in the physician's note about possible C.diff, but the note did not include that the resident or RP were notified. At 11:45 AM on 6/13/22, the DON submitted a copy of the result for C.diff for Resident #518 dated 6/8/22; it was not detected.
During an interview on 6/13/22 at 2:00 PM, the DON agreed that the facility failed to inform the resident or the RP of the reason for Resident #513's contact isolation secondary to a possible C-Diff infection.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Notification of Changes
(Tag F0580)
Could have caused harm · This affected 1 resident
Based on medical record review and family and staff interview, it was determined that the facility staff failed to notify the physician when a resident's blood pressure was high. This was evident for ...
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Based on medical record review and family and staff interview, it was determined that the facility staff failed to notify the physician when a resident's blood pressure was high. This was evident for 1 (#251) of 4 residents reviewed for complaints. The findings include:
On 6/9/22 9:00 AM, at a review of complaint #MD00175512 was conducted. In the complaint, the complainant reported concerns related to the care that Resident #251 received while they resided in the facility. At that time, a review of Resident #251's medical record revealed that the resident was admitted to the facility in October 2021 with multiple diagnosis including, but not limited to Hypertension, and had a history of Coronary (heart) artery disease, and had Coronary artery bypass grafting (surgery where a healthy blood vessel taken from another part of the body is used to make a new path for blood around a blocked artery leading to the heart.
On 6/9/22 at 9:40 AM, during a phone interview, the complainant reported that following Resident #251's discharge from the facility, the complainant requested a copy of the resident's medical records. The complainant stated that he/she was concerned because Resident #251 had heart issues and the medical record showed that sometimes the resident's BP (blood pressure) would be high and the facility staff would not recheck his/her BP again until the next morning. The complainant indicated this happened 4 or 5 times and the facility staff never called an ambulance or the family
Per the FDA (Food and Drug Administration) Normal blood pressure is 120/80 or lower. Blood pressure is considered high (stage 1) if it reads 130/80. Stage 2 high blood pressure is 140/90 or higher.
On 6/10/22 at 10:00 AM, a review of Resident #251's blood pressures recorded in his/her EMR (electronic medical record) was conducted. The EMR documented that Resident #251's blood pressure was 180/88 on 12/4/21 at 7:40 PM, 180/80 on 12/9/22 at 7:56 PM, 160/94 on 1/2/22, 200/100 on 1/16/22, 186/76 on 1/18/22, 160/79 on 1/20/22 and 164/82 on 1/25/22 a 7:26 PM. Continued review of the medical record revealed that, after each of the elevated blood pressures, there was no documentation to indicate that a follow-up BP had been obtained and the next documented blood pressure was recorded the following day. In addition, continued review of the medical record failed to reveal documentation that the physician was notified when Resident #251 had abnormal blood pressures.
The Director of Nurses was made aware of the above concern on 6/10/22 at 1:42 PM.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Safe Environment
(Tag F0584)
Could have caused harm · This affected 1 resident
Based on interview and observation, it was determined that facility staff failed to provide housekeeping services necessary to maintain a sanitary and comfortable interior. This was evidenced by the f...
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Based on interview and observation, it was determined that facility staff failed to provide housekeeping services necessary to maintain a sanitary and comfortable interior. This was evidenced by the facility's failure to ensure that the resident's bathroom walls were clean and sanitary for 1 (#18) of 7 residents reviewed for general concerns.
The findings include:
An interview was conducted with Resident #18 and his/her friend on 6/16/22 at 2:18 PM after the resident indicated that he/she would like the friend to participate in the interview. During the interview, the resident's friend indicated that housekeeping was in and out of the resident's room in 5 minutes and that many times, the floors had not been cleaned. The friend reported that there was a spot on the wall in the bathroom between the toilet and the sink, that it had been there for a while, and no one had cleaned it. Resident #18 added that he/she utilizes a bedpan and staff empty it in the toilet in the bathroom, Resident #18 stated they must have splashed it on the wall.
An observation was made of the bathroom on 6/16/22 at 3:18 PM. A dry brown substance covered an area approximately 3 cm (centimeters) long by 1 cm wide. The substance was located on the wall to the left of the toilet on the corner between the toilet and the sink, approximately 2 ½ feet above the floor.
The Director of Nursing and Assistant Director of Nursing observed and confirmed these findings on 6/16/22 at 3:27 PM.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Grievances
(Tag F0585)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2) During an interview on 6/7/22 at 11:35 AM, Resident #38 indicated when asked that he/she had 2 clothing items that recently w...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2) During an interview on 6/7/22 at 11:35 AM, Resident #38 indicated when asked that he/she had 2 clothing items that recently went missing. He/She described the items as 1 specific red article of clothing and 1 specific purple article of clothing. The resident confirmed that he/she reported the missing items to facility staff. Resident #38 went on to say that there is a new lady, Staff #61, in charge of putting clothing away and checking for things, that staff said they would look for the missing items, that they never found them and never got back to him/her about them. He/She confirmed that his/her clothing was laundered by the facility and was labeled with his/her name.
An interview was conducted with Staff #61 on 6/15/22 at 12:40 PM. She was asked to explain the procedure that was followed when a resident reported missing clothing. She indicated that she and the Social Worker work together on it. She explained that she goes room to room and checks all of the resident clothing to see if anything was put in the wrong closet. She stated, we don't have much that gets misplaced, and we usually find it. She indicated that most of the time her job is to monitor the resident's clothing. She indicated that the aides used to put the clothing away but sometimes it didn't get done, and that she started putting resident clothing away on 5/1/22. She explained that the facility purchased a clothing label printer and a [NAME] that she used to label all resident clothing, she went room to room and labeled all of the resident's clothing and she applied labels to all clothing of newly admitted residents upon admission whether they were labeled by the family or not.
An interview was conducted with Staff #2 a Social Work Assistant on 6/15/22 at 1:49 PM regarding Resident #38's missing clothing items. She was asked to describe the process when Staff #61 was not able to find the missing items. She indicated that Social Work staff will look for the missing items as well. That they will check laundry, resident rooms, the nurses station. She stated, if it's not found, we will reimburse, have to keep the timeframe in mind - on a couple of occasions, a resident would report a missing clothing item from about a year ago, we would really have a hard time finding them at that point. She was asked specifically about the red item and the purple item that Resident #38 reported missing. She indicated that she remembered hearing about them. She was unable to find reports for Resident #38's missing clothing at that time.
In another interview on 1:57 PM on 6/15/22 Staff #61 stated that Resident #38 had been missing the red item a long while, probably at least 4 months ago. She indicated that Resident #38 reported the purple item missing prior to 3/30/22 but was not sure of the date. She was asked what she did when she was unable to find the items. She stated, I let the resident and Social Worker know.
On 6/15/22 at 2:05 PM, Staff #2 provided the surveyor with a Missing and Damaged Items Reporting Form dated 3/7/22. Review of the form revealed Resident called to report a purple (item) missing he/she said he/she had it on last week. The form indicated that the only area that was searched was the laundry on 3/7/22. Additional measures taken indicated: more than 30 days. Noted at the bottom of the page was: 3/7/22 Still missing, not in laundry - signed by Staff #2; 3/21/22 Continues to be missing; 4/5/22 - Lost more than 30 days, missing laundry searched & laundry aware - Signed by Staff #21 a Social Work Associate.
When asked to review the form, Staff #2 confirmed that Resident #38 did report the missing purple item promptly to staff and that the notation that it was lost more than 30 days reflected time that lapsed after the resident reported the item missing. The form failed to reflect that any areas other than the laundry were searched or that the facility investigated the resident's grievance. The documentation did not summarize the pertinent findings, include conclusions, actions that were or were not taken, nor the date that the resident was provided with a written decision.
Another interview was conducted on 6/15/22 at 2:32 PM with Staff #21 and Staff #2 who provided a Missing and Damaged Items Report pertaining to Resident #38's red clothing item. This form dated 1/3/22 indicated that Resident #38's family member reported missing (item) short sleeve cotton - size 1x-2x about 2 weeks ago, sent to laundry, signed by Staff #21. Noted at the bottom on 1/3/22: Laundry checked, room & missing items. It was initialed by Staff #21. The entries were written in blue ink. However, in the description Red [NAME] Print and that the resident was contacted were both written in black ink. The additions in black ink were not dated to reflect when they were added. The form did not include documentation that the facility investigated the resident's grievance, nor summarize pertinent findings, conclusions and actions that were or were not taken, nor did it reflect the date that the resident/representative were provided with a written decision.
Staff #21 and #2 were asked if the resident was reimbursed for either of the missing items. Staff #2 stated In the past we spoke to family members and ask them to buy a comparable item and submit a receipt. They confirmed that Resident #38 was not reimbursed for the missing clothing items.
A review of a Resident Council Concern Form revealed that Resident #38 reported at the 6/2/22 Resident Council Meeting that he/she had 3 missing clothing items. The Section Follow up/Resolution indicated: Items missing longer than 30 days so unable to locate due to time. Resident educated to relate missing items ASAP. The documentation was unclear as to how the facility determined when the items went missing or if the items reported on 6/2/22 included the items that Resident #38 had previously reported but not received a follow up determination. There was no evidence that the facility attempted to investigate this grievance.
Staff #26, the Director of Social Work, was made aware of these findings on 6/23/22 at 11:00 AM. She stated we should have gone back with these things. Residents are asked to report promptly so that they can be found timely.
A review of the facility's Policy and Procedure for Missing and Damaged Items revealed: 9) The Social Services Department will delegate investigation of laundry to Housekeeping Supervisor for investigation. Once investigation is completed, Housekeeping Director will return outcomes/resolution to the Social Services Department. 10) The Social Services Department will finalize the investigation and notify the Resident and or family member of outcomes/resolutions.
The Director of Nursing and Assistant Director of Nursing were made aware of these findings on 6/23/22 at 2:10 PM.
Based on review of medical records and investigative documentation and interviews, it was determined that the facility failed to have an effective system in place to ensure that grievances were thoroughly investigated and failed to ensure documentation of investigation follow up. This was found to be evident for 1 (#28) of 13 residents reviewed for abuse during the survey and 1 (#38) of 3 resident's reviewed for Personal Property.
The findings include:
1) Review of Resident #28's medical record on 6/7/22 revealed a Brief Interview for Mental Status (BIMS) score of 15/15, indicating the resident was cognitively intact. The resident was observed to be alert and oriented and was able to be interviewed as part of the initial survey process.
On 6/15/22, review of the Concern Reports pertaining to Resident #28 revealed two reports for May 2022. The first one was dated 5/27/22 and was in reference to a letter the resident's family member had submitted regarding an employee that had been talking disrespectfully. The letter identified GNA #10. A signed statement from GNA #10 was found but no documentation was found to indicate the resident was interviewed. The concern form indicated the GNA would no longer be working with the resident and that the family member had been notified and was satisfied with the outcome.
On 6/15/22 at 2:24 PM, the Director of Nursing (DON) reported that, on 5/27/22, a GNA (she could not recall who) brought her the letter from the family member, and then GNA #10 arrived in her office. GNA #10 made a statement and was provided some education. When asked if she had interviewed the resident regarding this issue, the DON reported: not to my knowledge. Surveyor reviewed the concern that they failed to interview an alert and oriented resident to clarify what disrespectful meant.
Further review of the 5/27/22 Concern Report revealed it was signed as reviewed by the Director of Social Services on 5/31/22, and had also been signed as reviewed by the Administrator and the Director of Nursing.
On 6/16/22 at 2:21 PM, the Director of the Social Service Department (#26) reported she is given the Concern Reports to review once they are resolved. She went on to report that, after she reviews them, and is convinced that they are resolved, she takes them to the Administrator for review. Surveyor then requested that the Social Service Director review the documentation for the 5/27/22 Concern Report. Social Service Director confirmed that, if she had realized they had not spoken with the resident, she would have brought the form back to them (nursing department).
On 6/16/22 at 4:00 PM, the Administrator confirmed that he was the grievance officer. Surveyor reviewed the concern with the Administrator that staff had failed to follow up with an alert and oriented resident after a note was received that a GNA had spoken disrespectfully to the resident.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Free from Abuse/Neglect
(Tag F0600)
Could have caused harm · This affected 1 resident
Based on record review and interview, it was determined that the facility failed to ensure that their residents were free of abuse as evidenced by staff to resident abuse that was substantiated. This ...
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Based on record review and interview, it was determined that the facility failed to ensure that their residents were free of abuse as evidenced by staff to resident abuse that was substantiated. This was evident for 1 (#61) of 11 residents reviewed for abuse. The findings Include:
A medical record review for Resident #61 on 6/14/22 at 7:40 AM revealed an annual MDS, with an Assessment Reference Date of 4/22/22, which documented in section C that resident had scored a 13 out of 15 on a Brief Interview for Mental Status (BIMS - a standardized test to determine a resident's level of cognitive functioning) which indicated an intact cognition. Section E documented that Resident #61 had physically agressive behaviors directed towards others such as hitting and kicking. Also, it was noted that these behaviors occurred 1-3 days during the 7 days reviewed, and that it interfered with care. In section G it was documented that Resident #61 was totally dependent on staff to provide care.
On 6/13/22 at 3:38 PM, a review of the Facility's Investigation file for the self-report MD00174072 revealed that, on 11/7/21 at 2:09 PM, Resident #61 had reported to another employee that Geriatric Nursing Assistant (GNA) #68 had made comments to him/her about GNA #68's daughters eating everything on their plates while feeding the resident and shoving a sponn into their mouth. In addition, GNA #68 called Resident #61 a liar and these comments upset him/her. GNA #68 was suspended pending the investigation. The self-report was sent to the state agency on 11/8/21 at 1:55 PM. Witness statements were collected from staff and residents and the facility substantiated Resident #61's allegation of abuse, terminated GNA #68, and reported the abuse to the certification board.
On 6/13/22 at 4:00 PM, a review of GNA #68's employee file revealed that she had Elder Abuse training upon hire, however, had not completed the training annually as required.
An interview with the Administrator on 6/16/22 at 4:01 PM revealed that he was the facility's Abuse Coordinator. During this interview he reported that he does not feel that the staff were abusing residents. In addition, the NHA reported that staff have abuse training upon hire and annually. Administrator was made aware of concerns at this time.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0604
(Tag F0604)
Could have caused harm · This affected 1 resident
Based on record review and staff interviews, the facility failed to maintain an environment free of physical restraints. This was evident for 1 (#509) of 11 residents reviewed for abuse.
The findings ...
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Based on record review and staff interviews, the facility failed to maintain an environment free of physical restraints. This was evident for 1 (#509) of 11 residents reviewed for abuse.
The findings include:
A physical restraint is any manual method, physical or mechanical device/equipment or material that limits a resident's freedom of movement and cannot be removed by the resident in the same manner as it was applied by staff.
A gait belt or transfer belt is an assistive device put on a person who has mobility issues, by a care giver, prior to moving the person and can be used to help a person transfer from one surface to another, stand, or walk around.
On 6/23/22 02:31 PM, a facility reported incident #MD001793 was reviewed. The facility's self-report indicated that the report was for abuse, and included documentation that, on 6/17/22 at approximately 7:00 PM, a nurse entered Resident #509's room and witnessed that Resident #509 had a gait belt around his body as well as his/her chair, confining the resident to the chair.
Review of the facility's investigations into the incident, revealed in a written witness statement, the nurse wrote that on 6/17/22 at approximately 6:00 PM, when the nurse and a GNA began to provide care Resident #509, the nurse noticed that a gait belt was around Resident #509 and around the resident's wheelchair and the gait belt was properly hooked confining the resident to the chair.
At that time, a review of Resident #509's medical record revealed the resident was admitted to the facility at the end of May 2022 following an acute hospitalization
Review of Resident #509's most recent Minimum Data Set (MDS) assessment, dated 6/2/22 documented Resident # 509 had moderate impairment in cognition, was dependent on staff for ADLs (activities of daily living), required extensive assistance for bed mobility, transfer, and dressing and displayed no behaviors during the 7-day assessment period.
On 6/23/22 at 10:40 AM, during an interview, the Associate Administrator spoke about the incident and stated that the facility's investigation was unable to determine who the person was that restrained Resident #509 with the gait belt.
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
2)During an interview with Resident #71 during the initial pool process on 6/6/22 at 2:26 PM, Resident #71 verbalized some concerns regarding the way the staff treated him/her during care. Resident #7...
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2)During an interview with Resident #71 during the initial pool process on 6/6/22 at 2:26 PM, Resident #71 verbalized some concerns regarding the way the staff treated him/her during care. Resident #71 reported that these concerns had been brought to Social Services Associate #21's attention.
An interview with SSA #21 on 6/15/22 at 2:30 PM revealed that she had received some concerns form Resident #71 via email and would provide copies of the emails.
On 6/15/22 at approximately 3:00 PM, a review of the email that Resident #71 had sent to SSA #21 on 5/5/22 at 12:00 PM revealed that Resident #71 had alledged that GNA #46 had been rough while providing incontinence care and had left Resident #71 in a bed with urine-soaked pad and sheets. Further review revealed that SSA #21 failed to immediately report the concern to the Administrator but had forwarded the email on 5/6/22 at 2:03 PM to the Social Services Director, Director of Nursing, Assistant Director of Nursing, and Registered Nurse #40. Review of the Concern Form completed by the ADON on 5/6/22 revealed that she determined Resident #71 had meant GNA #46 was impatient and rude with him/her during care. However, the ADON failed to address the concern with GNA #46 failing to provide care and services needed by allowing Resident #71 to lay in urine-soaked bed linens and failed to report the allegation of abuse to the state agency.
3) On 6/13/22 at 3:38 PM, a review of the Facility's Investigation file for self-report MD00174072 revealed that the facility's self-report form which had documentation that the facility was made aware on 11/7/22 at 2:09 PM of an allegation of abuse from Resident #61. The Resident reported that Geriatric Nursing Assistant (GNA) #68 had made comments to them about the fact that her daughters eat all the food on their plates, called the Resident a liar, and shoved the spoon in his/her mouth while feeding. However, the facility failed to report the allegation of abuse to the state agency until 11/8/21 at 1:55 PM almost 24 hours after the allegation was made.
4) Complaint #MD00161874 was reviewed on 6/9/22 at 10:47 AM. The complaint was received by the State Agency from Adult Protective Services (APS). The complaint indicated that APS received an allegation from an anonymous caller that Resident #35 was fine when visited on 12/24/20 and observed with bruising on the face and neck on 12/27/20, and that the resident said that he/she was punched in the face in the middle of the night by a big black lady.
The Director of Nursing was asked to provide documentation regarding any incidents related to Resident #35 from December of 2020. Documentation was provided to the surveyor and reviewed on 6/10/22 at 8:00 AM.
The facility's documentation included an email communication, dated 1/4/21 at 2:52 PM, between Social Work Associate (SSA) Staff #2, Previous Director of Nursing (DON) Staff #7, and the former Assistant Director of Nursing (ADON) Staff #54. Staff #2 indicated in the email that she received a call from the Ombudsman regarding an APS referral she received. The email included The referral stated that this person visited the resident on December 24th and he/she was fine and came again on December 27th and the resident was badly bruised and had swelling. When asked what happened the resident stated, A big black lady came in and punched me in the face The email response from Staff #7 on 1/4/22 at 3:40 PM included I guess we should have reported this .at least we have an investigation on file and when he/she was interviewed originally, he/she didn't say this. On 1/4/21 at 4:05 PM, Staff #7 sent another reply in which he stated, Actually in looking at it we have a good note regarding his/her behaviors and that the bruise was self-inflicted so nothing to report. Staff #67 did an investigation just to be on the safe side, but it looks like everything is order.
The Surveyor contacted the State Agency Survey Coordinator and confirmed that the State Agency did not receive a facility report in December 2020 or January 2021 related to an allegation of abuse involving Resident #35.
There was no evidence that the facility submitted an initial report of abuse nor a follow up report to the State Agency once they were aware that an allegation of abuse had been made by Resident #35.
In an interview on 6/10/22 at 3:00 PM with the current DON and ADON, the ADON indicated that everything was handled by the previous DON Staff #7 and previous ADON Staff #54 and that they were not sure of exactly what was done. She added that she did not think that the facility reported the allegation of abuse to the State Agency.
In an interview on 6/10/22 at 10:55 AM, the Associate Administrator was made aware of the above concerns. She indicated that she was surprised that it wasn't reported or investigated because a surveyor had just been at the facility and the same thing had been identified at that time.
(Cross Reference: F600, F607, and F610.)
Based on review of medical records, facility investigation documentation and other pertinent documents, and interviews, it was determined that the facility failed to develop and implement abuse policies and procedures to ensure that facility staff appropriately identified and reported allegations of abuse to the Administrator immediately and to ensure that once the facility had been aware of an allegation of abuse that they reported it to the state agency within the required timeframes. This was evident for 4 (#28, #71, #61, and #35) of 13 residents reviewed for abuse during the survey. The findings include:
1) Review of Resident #28's medical record on 6/7/22 revealed a Brief Interview for Mental Status (BIMS) score of 15/15, indicating the resident was cognitively intact. The resident was observed to be alert and oriented and was able to be interviewed as part of the initial survey process.
On 6/14/22, review the facility reported incident MD00177857 revealed the resident reported to a nurse on 5/28/22 that on 5/26/22 GNA #13 stated you have a big butt.
On 6/14/22 at 8:35 AM, the ADON, who had submitted the report to the state agency, revealed that she identified the abuse allegation while she was reviewing the nursing notes from the weekend. The ADON confirmed she had reported to the state agency on Tuesday May 31.
Review of the nursing note, dated 5/28/22, revealed the following: resident report to this nurse and GNA [initials] that a male staff that was changing, her commented that [s/he] had a big bottom, resident stated the incident made [him/her] feel uncomfortable . The note included a brief description of the GNA and confirmation that it had occurred on Thursday night.
On 6/14/22 at 10:30 AM, surveyor reviewed the concern with the ADON that the incident had not been reported by the nurse on 5/28/22 to the supervisor or the Administrator.
On 6/17/22 at 9:16 AM, an interview with GNA mentor (#55) revealed that Resident #28 had reported a concern regarding GNA #13 having made comments that were unprofessional and not nice. GNA #55 stated: I wrote my statement and passed it along. On 6/17/22 at 11:20 AM, GNA #55 confirmed that her statement was in an email that was dated 5/27/22.
Review of the email, dated 5/27/22 at 12:41 PM, revealed it had been sent to the DON and the ADON. The email referenced several different issues on the same unit. Included in the text was: The staff asked me to stop and talk with [name of Resident #28], I did. [name of Resident #28] started telling me about the aide that was assigned to [him/her] last evening. [His/Her] opinion was he is very unprofessional, but his clinical skills are good Unfortunately, He made some pretty rude comments about [him/her] having a big butt. [ name of Resident #28] took offense to that .
Further review of the email revealed the ADON had acknowledged and responded to the email on 5/27/22 at 12:47 PM. Documentation indicates the DON had been included in the response email as well.
On 6/17/22 at 1:10 PM, The ADON stated that she takes responsibility for missing Resident #28's allegation in the email. The ADON acknowledged that she responded to the email, but stated that she does not recall it. The ADON also reported receiving many emails throughout the day. Regarding abuse allegations, the DON and ADON indicated that the expectation is that staff would notify the charge nurse and that the Administrator, and the DON would get a call. They also indicated that they had started training with staff regarding this issue.
No documentation was found to indicate that either the original or the response email had been forwarded to the Administrator. On 6/17/22 at approximately 2:00 PM, when asked if he had been aware of the 5/27/22 email regarding Resident #28's allegations, the Administrator reported that that he was not sure if he was aware of it or not and indicated he would need to follow up.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Investigate Abuse
(Tag F0610)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3) During the initial pool process, an interview was conducted with Resident #63 on 6/6/22 at 3:16 PM. Resident #63 reported tha...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3) During the initial pool process, an interview was conducted with Resident #63 on 6/6/22 at 3:16 PM. Resident #63 reported that Geriatric Nursing Assistant (GNA) #9 had come into his/her room and thrown away newspapers even though Resident #63 has asked GNA #9 not to throw them away. Resident #63 stated the cleaning person had come in and took out the trash and now the newspapers were gone, and he/she had not finished looking at them.
Immediately following the interview, the incident was reported to the Director of Nursing (DON) and Assistant Director of Nursing (ADON) on 6/6/22 at 3:16 PM.
On 6/7/22, GNA #9 was observed to be on duty and providing direct patient care.
On 6/14/22 at 8:39 AM, the DON and ADON were interviewed regarding the abuse allegation. They reported they had interviewed Resident #63 and the resident reported to them the same thing that had been reported to the surveyor. They reported that they obtained a statement from GNA #9 in which she had confirmed she had thrown away the newspapers even though Resident #63 had asked her not to because the newspapers had been old. The DON and ADON reported the conclusion of their investigation had been that GNA #9 had misappropriated Resident #63's belongings. They confirmed that additional staff who worked with GNA #9 and additional residents on GNA #9's assignment had not been interviewed. They reported the action taken was to educate GNA #9 regarding resident rights and misappropriation of resident property.
During an interview with GNA #9 on 6/14/22 at 9:40 AM, she denied that Resident #63 had asked her not to throw away the newspapers, but had kept the parts of the newspapers that Resident #63 had requested to keep. Also, GNA #9 reported there had been a witness to the incident and it was GNA #11 because she had been training her.
During an interview with GNA #11 on 6/14/22 at 9:47 AM, it was revealed that she had been in the room at the time of the incident and that GNA #9 told Resident #63 that they needed to the throw the old newspapers away and asked Resident #63 which parts he/she wanted to keep.
A subsequent interview with the DON and ADON on 6/14/22 at 10:12 AM, revealed that they had not been aware of a witness and had not directly asked GNA #9 if there had been one.
A medical record review for Resident #63 was conducted on 6/14/22 at 9:57 AM and revealed a clinician's progress note, dated 5/10/22, that documented Resident #63 had a stroke that left him/her paralyzed on one side of the body along with other chronic medical disease management. In addition, review of a Minimal Data Set (a standardized assessment tool) with an Assessment Reference Date of 1/29/22 revealed in section C that the resident's cognition level was intact.
Review of the facility's investigation file for the self-reported incident #MD00180313 on 6/14/22 at 10:04 AM revealed that the self-report had been sent to the State Agency on 6/6/22 at 4:58 PM and the final self-report with the results of the investigation was sent to the State Agency 1 ½ hours later at 6:29 PM. The documents included: self-report form, education form for GNA #9 regarding resident rights, a statement from GNA #9, a BIMS (Brief Interview for Mental Status which is a tool to measure a resident's level of brain function) assessment dated [DATE], for Resident #63 which indicated that the resident had been cognitively intact, and an Assessment of Decision-Making Capacity which indicated the resident had been deemed incapable by 1 physician. However, facility staff had failed to conduct a thorough investigation to determine if abuse had occurred and nor did they take the appropriate action needed and allowed GNA #9 to continue to work with vulnerable residents in the days following the incident.
4) A medical record review for Resident #83 on 6/13/22 at 9:37 AM revealed a progress note from Attending Physician staff #41 that documented Resident #83 was admitted for chronic medical condition management.
On 6/8/22 at 2:29 PM, a review of the facility's investigation file for self-report MD00177642 revealed that Geriatric Nursing Assistant (GNA) #18 and GNA #17 had reported an allegation of abuse to the charge nurse on 5/22/22 at 11:07 AM. GNA #18 wrote a statement that, on 5/22/22 at 7:50 AM, they went into Resident #83's room to set up his/her breakfast tray and Resident #83 reported he/she had a horrible night and that the caregiver last night had slammed him/her against the bedrails as she/he turned them, and pulled the resident's tongue with their hand. GNA #17 documented that Resident #83 became upset as he/she was telling them about the incident. A statement was obtained from GNA #17 who stated that while providing Resident #83 with morning care the resident told her about the overnight aide doing something to his/her tongue. Also in the investigation file was a statement from GNA #20, the alleged perpetrator, in which he had not reported the incident as described by Resident #83. GNA #20 was a contracted employee and asked not to return to the facility. However, the facility failed to interview staff who had worked the same shift as GNA #20 on the night of the alleged abuse and failed to interview any other residents that GNA #20 had cared for to determine if there had been any other incidents of abuse.
An interview with the Director of Nursing on 6/14/22 at 10:31 AM revealed the allegation of abuse was unsubstantiated. Reviewed concerns that a thorough investigation had not been done.
(Cross Reference F600, F607, and F609)
2) Complaint #MD00161874 was reviewed on 6/9/22 at 10:47 AM. The complaint was received by the State Agency from Adult Protective Services (APS). The complaint indicated that APS received an allegation from an anonymous caller that Resident #35 was fine when visited on 12/24/20 and observed with bruising on the face and neck on 12/27/20, and the resident said that he/she was punched in the face in the middle of the night by a big black lady.
Review of Resident #35's medical record on 6/9/22 at 10:47 AM revealed the resident had diagnoses which included Unspecified dementia, Vascular dementia with behavioral disturbance. The resident was followed by Psychiatric Services.
A behavior progress note, dated 12/26/2020 22:04, indicated: Behavior Note Late Entry: Note Text: Resident combative with staff, using inappropriate speech and name calling. This nurse witnessed resident flailing arms, balling up fist and yelling obscenities. This nurse was able to eventually calm resident to perform wound care to skin tear on left forearm. Resident had small self inflicted bruise to left side of jaw. Resident slept for remainder of shift following behaviors. Staff will continue to monitor - Nursing.
The Director of Nursing was asked to provide documentation regarding any incidents related to Resident #35 from December of 2020. Documentation was provided to the surveyor and reviewed on 6/10/22 at 8:00 AM.
The documentation included an email communication dated 1/4/21 at 2:52 PM, between Staff #2 a Social Work Associate, Staff #7 the previous Director of Nursing (DON) and Staff #54 the former Assistant Director of Nursing (ADON).
Staff #2 indicated in the email that she received a call from the Ombudsman regarding an APS referral she received. The email revealed: The referral stated that this person visited the resident on December 24th, and he/she was fine and came again on December 27th and the resident was badly bruised and had swelling. When asked what happened the resident stated, A big black lady came in and punched me in the face. The email response from Staff #7 on 1/4/22 at 3:40 PM included I guess we should have reported this .at least we have an investigation on file and when he/she was interviewed originally, he/she didn't say this.
On 1/4/21 at 4:05 PM, Staff #7 sent another reply in which he stated, Actually in looking at it we have a good note regarding his/her behaviors and that the bruise was self inflicted so nothing to report. Staff #67 did an investigation just to be on the safe side, but it looks like everything is order.
The documentation did not include an abuse investigation.
On 6/10/22 at approximately 11:00 AM, the surveyor requested a copy of the facility's investigation of the abuse allegation. The surveyor was provided with a bruise incident report which was not dated and did not identify the person who completed it. The facility failed to provide a copy of an abuse investigation.
An interview was conducted on 6/10/22 at 3:00 PM with the current DON and ADON
and they were made aware that the surveyor requested the facility's investigation regarding Resident #35's allegation of abuse but was provided with a bruise incident report. The ADON indicated that everything was handled by the prior DON and ADON and that they were not sure of exactly what was done. She added that she did not think that the facility reported the allegation of abuse to the State Agency.
An interview was conducted with Staff #67 on 6/13/22 at 10:16 AM. She confirmed that she completed the bruise incident report and obtained statements from staff regarding Resident #35's behaviors and having a self-inflicted bruise. She confirmed that she did not obtain statements regarding abuse. She indicated that she turned the statements and incident report over to the former DON and ADON and was not sure what was done with it after that. She was asked if the incident was reviewed in QA. She indicated that she was not sure, that she would check and follow up with the surveyor. No further information was provided.
The facility failed to provide evidence that they conducted a thorough investigation once they were made aware that an allegation of abuse had been made. In an interview on 6/10/22 at 10:55 AM, the Associate Nursing Home Administrator was made aware of the above concerns. She indicated that she was surprised that it wasn't reported or investigated because a surveyor had just been at the facility and the same thing had been identified at that time.
Based on review of medical records and investigative documentation and interviews, it was determined that the facility failed to have an effective system in place to ensure that abuse allegations were thoroughly investigated to determine if abuse occurred and take appropriate action. This was found to be evident for 4 (#28, #35, #63, and #83) out of 13 residents reviewed for abuse during the survey.
The findings include:
1) Review of Resident #28's medical record on 6/7/22 revealed a Brief Interview for Mental Status (BIMS) score of 15/15, which indicated that the resident was cognitively intact. The resident was observed to be alert and oriented and was able to be interviewed as part of the initial survey process.
On 6/14/22, review of the facility reported incident MD00177857 revealed that the resident reported to a nurse on 5/28/22 that, on 5/26/22, GNA #13 stated you have a big butt.
Interview with the Assistant Director of Nursing (ADON) on 6/14/22 at 8:35 AM revealed that she had spoken to the resident and got a witness statement from the person involved.
Review of the investigation documentation revealed a typed statement from GNA #13 obtained via telephone by [name #14]. dated 5/31/22, which indicated it was a verbal statement from GNA #13 obtained via telephone by [name #14]. No documentation was found on the statement to indicate who #14 was. During the 6/14/22 8:35 AM interview, the ADON reported that #14 was in charge of the agency that employs GNA #13. The ADON confirmed that she did not speak with GNA #13 and that they had not been back to the facility. The ADON also confirmed that no other residents were interviewed in relation to this investigation.
Further review of the investigation documentation failed to reveal documentation to indicate interviews were conducted with any other staff or residents.
On 6/14/22, review of the Corporate Abuse Policy Investigation and Reporting [provided during the survey, but fails to include a revision date] revealed:
Role of the Investigator:
1. The individual conducting the investigation will, as a minimum:
g. Interview staff members (on all shifts) who have had contact with the resident during the period of the alleged incident
i. Interview other residents to whom the accused employee provides care or services
On 6/14/22 at 8:45 AM, surveyor reviewed the concern that they failed to complete a thorough investigation with the ADON.
Review of the Concern Report, dated 5/31/22, revealed that it was in regard to the 5/26/22 incident with GNA #13. It was also noted to have been signed off as reviewed by the Director of Social Service, the Administrator and the Director of Nursing (DON).
On 6/16/22 at 4:00 PM, the Administrator confirmed that he was the abuse coordinator. When asked if the DON had received any specific training in conducting investigations, the Administrator reported: on the job training. The Assistant Administrator reported that the DON had taken a certified director of nursing course. After surveyor reviewed the timeline of the investigation, the Administrator confirmed that it was not an acceptable investigation and stated: it was a mistake.
On 6/17/22 at approximately 2:00 PM, the Administrator confirmed that he reviewed the complaint investigations.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Assessment Accuracy
(Tag F0641)
Could have caused harm · This affected 1 resident
2) On 6/6/22 at 11:33 AM, an observation of Resident #33 revealed the resident's fingers on both hands were bent in a closed fist position and appeared to be contracted with no splint or device in eit...
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2) On 6/6/22 at 11:33 AM, an observation of Resident #33 revealed the resident's fingers on both hands were bent in a closed fist position and appeared to be contracted with no splint or device in either hand.
A contracture is a condition of shortening and hardening of muscles, tendons or other tissue which often leads to deformity and rigidity of joints
On 6/23/22 at 2:00 PM, a review of the Resident #33's medical record revealed the resident has resided in the facility since 2016, has had a diagnosis of contractures since 2016 and documented the resident was totally dependent on staff for all activities of daily living and positioning. On 6/7/22, in a progress note, the PA (physician's assistant) documented that Resident #33's upper and lower extremities were noted to have contractures.
Review of Resident #33's quarterly MDS with an ARD (assessment reference date) of 3/26/22, revealed the MDS was inaccurate. Section G. Functional status, Section G0400. Functional Limitation in Range of Motion, Code for limitation that interfered with daily functions or placed resident at risk of injury documented Resident #33 had no impairment in either the upper or lower extremities. The MDS failed to accurately capture Resident #33's functional impairment.
(Cross reference to F 656)
Based on medical record review and interview, it was determined that the facility failed to ensure Minimum Data Set (MDS) assessments were completed to accurately reflect the resident's status as evidenced by failure to accurately identify a resident's range of motion status. This was found to be evident for 2 (#74, #33) of 4 residents reviewed for position and mobility. The findings include:
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 these individualized needs, and that the care is provided as planned to meet the needs of each resident.On 6/9/22, review of Resident #74's medical record revealed the resident had resided at the facility for several years. Since 5/3/22, the resident's diagnosis include contractures of left and right hip and both knees.
A contracture is a tightening of muscles that causes joints to become stiff and prevent normal movement of the joint. Contractures can place a resident at risk of developing pressure ulcers.
Review of the Minimum Data Set (MDS) section G0400 Functional Limitation in Range of Motion revealed the following directions: Code for limitation that interfered with daily functions or placed resident at risk of injury. This means ithat, f a contracture was present that interfered with daily living or placed the resident at risk for an injury, it should be coded (assessed) in this section of the MDS.
Review of the MDS, with an ARD of 5/26/22, section G0400 revealed documentation that the resident had no impairment in either the upper or lower extremities. This assessment failed to identify the presence of the contractures of the hips and knees.
On 6/17/22 at 12:25 PM, the MDS nurse (#53) reported she did not document the contractures because the resident doesn't move around much and so they did not interfere with the resident's daily function.
On 6/17/22 at 12:54 PM, the MDS nurse provided the notes for the 5/26/22 MDS. Review of these notes failed to reveal documentation of a rationale for coding no impairment for the resident who had contractures. Surveyor then reviewed the concern with the MDS nurse that the functional limitation in range of motion was not coded since there was a risk of injury related to the contractures.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Comprehensive Care Plan
(Tag F0656)
Could have caused harm · This affected 1 resident
A review of Resident #88's medical record on 6/9/22 at 10:23 AM revealed the resident had a hospitalization to rule out seizure and hypomagnesemia on 5/1/22-5/5/22. A review of the resident's discharg...
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A review of Resident #88's medical record on 6/9/22 at 10:23 AM revealed the resident had a hospitalization to rule out seizure and hypomagnesemia on 5/1/22-5/5/22. A review of the resident's discharge summary from the hospital, dated 5/5/22, indicated that Resident #88 had hypomagnesemia. Further review of Resident #88's medical records revealed that a nurse taught the resident about s/s (sign and symptom) of a low magnesium level on 5/9/22. However, a care plan was not updated regarding hypomagnesemia.
During an interview with the Assistant Director of Nursing (ADON) on 6/23/22 at 4:15 PM, she confirmed that, after a resident was discharged from the hospital, the facility staff needed to revise the care plan based on the resident's health status. The ADON agreed that the facility failed to update the care plan for Resident #88.
4) On 6/6/22 at 11:33 AM, an observation of Resident #33 revealed that the fingers on both hands were bent in a closed fist position and appeared to be contracted with no splint or device in either hand.
A contracture is a tightening of muscles that causes joints to become stiff preventing normal movement of the joint. ROM (Range of motion) refers to how far a person can move or stretch a body part, such as a joint or muscle. PROM (Passive ROM) means the person does not perform any movement themselves. AROM (Active ROM) means the person performs the movement of a joint entirely by themselves.
On 6/23/22 at 2:00 PM, a review of the Resident #33's medical record revealed that the resident resided in the facility since 2016, and had multiple diagnosis including, but not limited to, stroke, dementia, chronic pain syndrome and contracture of unspecified joint. The medical record documented that Resident #33 had severe cognitive impairment, and was totally dependent on staff for all ADLs (activities of daily living), including positioning. On 6/7/22, in a progress note, the PA (physician's assistant) indicated that Resident #33 was aphasic and in a chronic persistent vegetative state. The PA also documented Resident #33's upper and lower extremities were noted to have contractures.
Continued review of the resident's medical record failed to reveal documentation that Resident #33 was receiving or had received treatment or services that addressed the resident's limited range of motion and contractures. On 6/23/22 at 2:52 PM, when asked if Resident #33 had received treatment to prevent further decline of his/her contractures, the Assistant Director of Nurses (ADON), indicated he/she would look into it.
On 6/23/22 at 4:06 PM, the ADON provided the surveyor with a copy of an Occupational Therapy (OT) Discharge Summary which documented that Resident #33 was discharged from OT because the resident had achieved his/her maximum potential and was referred for the RNP (Restorative Nursing Program) to start on 7/23/21.
The OT's discharge recommendations included Resident #33 continue with UE (upper extremity) PROM and positioning with total assist of caregivers to prevent further loss of ROM and indicated that a Restorative ROM Program and a Restorative Splint and Brace Program had been established for the resident and staff had been trained. The OT documented a visual handout in the resident's record on details of recommended UB (upper body) PROM techniques that were provided for the restorative ROM program, and a visual handout on details of recommended UE (upper extremity) PROM techniques had been provided for the restorative splint/brace program,
Further review of Resident #33's medical record failed to reveal documentation to indicate that the recommended restorative ROM program and restorative splint and brace program had been implemented when the resident was discharged from therapy.
Review of Resident #33's care plans included 4 care plans that minimally addressed the Resident #33's actual contractures and limited ROM:
a) According to care plan documentation, Resident #33 had potential for impaired tissue integrity r/t immobility h/o pressure ulcer, incontinence, contractures, multiple joints, moisture, family's request for resident to remain in bed with the goal, Resident #33 will have intact skin, free of redness, blisters or discoloration by/through review date. The interventions had measures to prevent skin breakdown including side-to-side positioning and turning and positioning, however, there were no interventions addressed the resident's limited ROM and actual contractures.
b) A care plan, initiated on 3/8/16, Resident #33 has an ADL self-care performance deficit r/t (related to) multiple strokes, dementia, immobility, blindness, with the goal, the resident will accept routine care from staff, that had interventions which included contractures: the resident has contractures of all extremities. Provide frequent skin care to keep clean and prevent skin breakdown. There were no interventions that addressed the resident's limited ROM and actual contractures.
c) According to a care plan, Resident #33 has potential for pain r/t chronic pain syndrome, muscle spasms, contractures all extremities, GERD (gastroesophageal reflux disease) (heart burn), possible nausea, with the goals, Resident #33 will not have discomfort related to side effects of analgesia through the review date and the resident will show no s/s of pain/discomfort through the review date, that included an intervention, provide gentle active and passive ROM as tolerated with care.
The care plan intervention was not resident centered as the intervention did not identify the location of Resident #33's contractures, or the resident's joint or body part that was to receive the range of motion. There was no documentation in the medical record to indicate that the facility staff followed the care plan and the resident received ROM as tolerated with care. In addition, review of the medical record failed to reveal evidence that the resident would be able to perform active range of motion.
d) In an additional care plan, it was noted that Resident #33 has no unassisted physical mobility r/t multiple strokes, with the goal, the resident will remain free of complications related to immobility, including further contractures, thrombus (blood clot) formation, skin-breakdown, fall related injury through the next review date with the interventions, Hoyer lift at all times for transfers, Monitor/document/report PRN (as needed) any s/sx (signs/symptoms) of immobility; contractures forming or worsening, thrombus formation, skin-breakdown, fall related injury, PT, OT referrals as ordered, PRN, and provide gentle range of motion as tolerated with daily care.
The care plan was not comprehensive, with resident specific interventions to mitigate the potential complications of Resident #33's limited ROM and actual contractures. The care plan failed to identify the location of Resident #33's contractures or identify the resident's joint or body part that was to receive the range of motion. In addition, the medical record failed to reveal evidence that the facility staff followed the care plan. There was no documentation in the medical record to indicate that Resident #33 was provided gentle ROM with daily care.
No other care plans were found that addressed Resident #33's limited ROM and actual contractures, and no documentation was found to indicate that the recommended restorative ROM program or the restorative splint/brace program, as well as the recommended UB and UE PROM techniques had been added to the care plans.
The ADON was made aware of the concerns related to Resident #33's care plan on 6/23/22 at 4:25 PM.
5) On 6/9/22 at 9:00 AM, a review of complaint #MD00175512 was conducted. In the complaint, the complainant reported concerns related to the care that Resident #251 received while the resident resided in the facility. At that time, a review of Resident #251's medical record revealed that the resident was admitted to the facility in October 2021 with multiple diagnoses including, but not limited to, Hypertension, and had a history of Coronary (heart) artery disease, and had Coronary artery bypass grafting (surgery where a healthy blood vessel taken from another part of the body is used to make a new path for blood around a blocked artery leading to the heart).
On 6/9/22 at 9:40 AM, during a phone interview, the complainant reported that following Resident #251's discharge from the facility, the complainant requested a copy of the resident's medical records. The complainant stated he/she was concerned because Resident #251 had heart issues and the medical record showed that sometimes the resident's BP (blood pressure) would be high, and the facility staff would not recheck his/her BP again until the next morning. The complainant indicated this happened 4 or 5 times and the facility staff never called an ambulance or the family
Per the FDA (Food and Drug Administration) Normal blood pressure is 120/80 or lower. Blood pressure is considered high (stage 1) if it reads 130/80. Stage 2 high blood pressure is 140/90 or higher.
On 6/10/22 at 10:00 AM, a review of Resident #251's blood pressures recorded in his/her EMR (electronic medical record) was conducted. The EMR documented Resident #251's blood pressure was 180/88 on 12/4/21 at 7:40 PM, 180/80 on 12/9/22 at 7:56 PM, 160/94 on 1/2/22, 200/100 on 1/16/22, 186/76 on 1/18/22, 160/79 on 1/20/22 and 164/82 on 1/25/22 a 7:26 PM. Continuous review of the medical record failed to reveal documentation that the physician had been made notified when Resident #251 had abnormal blood pressures.
Review of Resident #251's care plans revealed a care plan the resident has coronary artery disease (CAD) r/t Atherosclerosis (thickening, hardening of the arteries), Hypertension (high blood pressure) with the intervention Monitor blood pressure. Notify physician of abnormal readings. The facility staff failed to follow the care plan by failing to notify the physician when Resident #251's blood pressure was abnormal.
The Director of Nurses was made aware of the above concern on 6/10/22 at 1:42 PM.
Based on medical record review and interviews, it was determined that the facility 1) failed to have an effective system in place to ensure that restorative nursing services were incorporated into resident care plans, 2) failed to develop and implement a comprehensive person-centered care plan for a resident with limited range of motion and contractures and a resident with hypomagnesemia, 3) and failed to follow the care plan. This was evident for 3 (#74, #28, #7) of 4 residents reviewed for a decline in activities of daily living, 1(#88) of 4 residents reviewed for hospitalization, 1 (#33) of 4 residents reviewed for position/mobility, and 1 (#251) of 4 residents reviewed for complaints. The findings include:
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.
1) On 6/9/22, review of Resident #74's medical record revealed that the resident had resided at the facility for several years. The resident's diagnosis included contractures of left and right hip and both knees. Review of the current care plan revealed the following interventions: NURSING REHAB/RESTORATIVE: LEROM [lower extremity range of motion] while in bed, passive of hip knee and ankle Rep [repetitions]: 10, Sets: 1. Upper extremity: while in bed, passive of wrist, elbow and shoulder. Rep: 10, sets: 2. Exercise program provided. This intervention had been initiated 10/1/18 and had a revision date of 6/20/19.
Further review of the medical record failed to reveal documentation to indicate that the restorative range of motion exercise program referenced in the care plan was currently being completed.
On 6/13/22 at 1:42 PM, the nursing supervisor (#34) reviewed the care plan interventions for Restorative listed above with the surveyor. The supervisor confirmed that the exercises indicated in the care plan were not occurring at present. She went on to report that they would have been done when the resident was in therapy in 2018 and should have been discontinued when the therapy was done.
Further review of the medical record revealed that, since 5/2/22, the resident's diagnosis included contractures of the hips and knees. A contracture is a tightening of muscles that causes joints to become stiff preventing normal movement of the joint.
Further review of the medical record and interview with the Rehab Director on 6/9/22 at 2:43 PM revealed that the resident had been discharged from OT on 5/26/22 with a plan to start a restorative nursing program. The Rehab Director reported that they had been working on identifying more optimal positions for the resident. The Rehab Director provided a Rehab Discharge Program - Occupational Therapy form, dated 5/26/22, that indicated it was for restorative care and addressed Upper Extremity ROM/Strengthening as well as positioning instructions.
Further review of the resident's care plan failed to reveal documentation to indicate that the May 2022 positioning instructions had been incorporated into the care plan.
On 6/15/22 at 2:18 PM, surveyor reviewed the concern with the Director of Nursing (DON) and Assistant Director of Nursing (ADON) that the care plan indicated that exercises should be conducted, but based on medical record review and staff interview, they were not occurring. Also, it was noted that since these exercises were put in place, the resident had participated in therapy again with new restorative recommendations, however, there was no update to the care plan to reflect the resident's current status and needs for ROM and positioning.
2) On 6/7/22, Resident #28 was observed to have contractures in both hands. The resident confirmed his/her hands had been like that since before admission to the facility.
A contracture is a tightening of muscles that causes joints to become stiff preventing normal movement of the joint. Contractures can be caused by inactivity.
On 6/14/22, review of the medical record revealed orders for occupational therapy (OT) starting in January 2022 that were discontinued on 2/4/22.
On 6/15/22 at 11:39 AM, the Rehab Director (#42) provided a copy of the 2/4/22 OT discharge summary and a Rehab Discharge Program - Occupational Therapy form.
Review of the OT Discharge Summary revealed that OT recommended a RNP (restorative nursing program) and that the program had been established.
Review of the Rehab Discharge Program - Occupational Therapy form revealed that an exercise program was attached and that 2-3 sets of 5-10 repetitions of Upper Extremity ROM/Strengthening exercises were recommended.
On 6/15/22 at 11:45 PM, the Rehab Director reported that they usually recommend that the exercises be completed 3-5 times a week and indicated they would be incorporated into the care plan. He proceeded to look up the current care plan and reported that he could not find these exercises in the care plan.
On 6/15/22, review of the current care plan revealed a plan addressing limited physical mobility which included an intervention to provide gentle ROM as tolerated with daily care, and to monitor for contractures forming or worsening. No documentation was found in the care plan regarding a restorative plan or the exercises recommended by OT.
3) On 6/7/22, review of Resident #7's medical record revealed that the resident had resided at the facility for more than 2 years and whose current diagnoses included, but were not limited to, dementia, lung disease, and kidney disease. Review of the physician orders revealed a 12/6/21 order to discontinue occupational therapy services and begin a restorative nursing program.
On 6/09/22 at 2:56 PM, the Rehab Director (#42) reported that therapy had recommended range of motion (ROM) and upper extremity exercises and that care giver training had occurred. The Rehab Director provided a copy of a Rehab Discharge Program Occupation Therapy form which revealed a start date of 12/31/21 for Restorative care.
Further review of the 12/31/21 Rehab Discharge Program Occupation Therapy form revealed an exercise program was attached and that 2 sets of 10 repetitions were being recommended. Review of the exercise program documentation revealed 4 different upper extremity exercises using 1-2 lbs weights.
Further review of the resident's care plan failed to reveal documentation to indicate the restorative nursing program, including the recommended exercises, had been added to the care plan.
On 6/13/22 at 1:46 PM surveyor asked nursing supervisor (#34) about an exercise program for Resident #7. After reviewing the resident's care plan in the electronic health record, the nursing supervisor reported that she did not see anything specific like a restorative program.
On 6/15/22 at 2:18 PM surveyor reviewed with the DON and the ADON that no documentation was found in the care plan regarding the restorative nursing program.
The concern regarding the failure to update the care plans regarding restorative nursing care was reviewed with the ADON and DON on 6/24/22 at 12:30 PM.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0657
(Tag F0657)
Could have caused harm · This affected 1 resident
Based on review of the medical record, it was determined the facility staff failed to ensure that the resident's plan of care was reviewed and revised by the interdisciplinary team after a quarterly r...
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Based on review of the medical record, it was determined the facility staff failed to ensure that the resident's plan of care was reviewed and revised by the interdisciplinary team after a quarterly review assessment. This was evident for 1 (#5) of 3 residents reviewed for skin assessments.
The findings include:
The MDS (Minimum Data Set) is a complete assessment of the resident which provides the facility with the information necessary to develop a plan of care, provide the appropriate care and services to the resident, and to modify the care plan based on the resident's status. 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.
Resident #5's medical record was reviewed on 10/26/22 at 11:00 AM. The record revealed that 2 Plans of Care were developed related to Resident #5's skin integrity. The first: Potential for impaired skin integrity was initiated 8/8/16 and included an updated focus: 6/22/22, scratch to left lower jawbone. It indicated that it was revised on 10/3/22 but did not reflect what the revision was on that date. The resident's goals were identified as (resident) will have intact skin free of redness, blisters, or discoloration by/through review date. and (Resident #5's) scratch to the left lower jawbone will show signs of improving/resolving without complications by the review date. The target date was 10/10/22. The second: plan of care had the focus: (resident) has an abrasion/scratch to left jaw bone. It was initiated 6/24/22. The resident's goal was: (Resident #5's) abrasion/scratch to left jaw bone will heal without complications by review date. The target date was 10/10/22.
Resident #5's record revealed a Quarterly MDS assessment with an assessment reference date of 9/8/22.
Review of the Care Plan Progress notes in Resident #5's record revealed that several care plan notes were written on 9/22/22 and 10/6/22 however, the notes failed to reveal that the facility staff evaluated resident #5's plans of care for skin integrity/scratch to left lower jaw after the most recent Quarterly MDS assessment.
Cross Reference F-684
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, review medical records and facility policy, and interview with staff, it was determined that the facility failed to ensure that each resident received necessary respiratory care ...
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Based on observation, review medical records and facility policy, and interview with staff, it was determined that the facility failed to ensure that each resident received necessary respiratory care and services. This was evidenced by the facility staff's failure to properly date and label oxygen tubing when changed for 2 (#78 and #26) of 6 residents reviewed for Respiratory Care, and failed to ensure that care was provided in accordance with facility policy and the resident's plan of care for 1(#26) of 6 residents reviewed for Respiratory Care. The findings include:
1) On 6/7/22 at 11:09 AM, the surveyor observed Resident #78 sitting in a wheelchair at a table in the dining room, socializing with other residents. An oxygen concentrator (a machine that concentrates oxygen from the air) was behind the resident. The resident was wearing a nasal cannula (oxygen tube with nose prongs) that was connected to the concentrator. The tubing was not date labeled to indicate when it was last changed. When asked, the resident was unable to recall when it was last changed.
Review of Resident #78's medical record revealed a physician's order, dated 5/8/22, for Oxygen Tubing and Water Bottle: Change oxygen tubing and humidification bottle twice monthly and PRN (as needed) Label with date. A pPlan of care was developed for Resident #78 for altered respiratory status/difficulty breathing. The interventions included, but were not limited to: Oxygen Tubing and Water Bottle: Change oxygen tubing and humidification bottle
twice monthly and PRN Label with date.
2) Resident #26 was observed on 6/7/22 at 12:46 PM lying in bed. An oxygen concentrator was at his/her bedside delivering oxygen through a nasal cannula. The nasal cannula was date labeled 5/3/22 11-7.
Review of Resident #26's medical record on 6/22/22 at 9:51 AM revealed an active physician order written 5/15/21 for: Oxygen Tubing and Water Bottle: Change oxygen tubing and humidification bottle monthly on the 15th of the month night shift. Label with date. The resident's TAR (Treatment Administration Record) for 6/22 included: Oxygen Tubing and Water Bottle: Change oxygen tubing and humidification bottle monthly on the 15th of the month night shift. Label with date. The TAR was signed off to indicate it was completed on 6/15/22.
Further review of Resident #26's medical record revealed a plan of care initiated 5/22/17 for altered respiratory status. The resident's goal was to maintain normal breathing pattern as evidenced by normal respirations, normal skin color and regular respiratory rate/pattern.The interventions included but were not limited to: Oxygen settings: continuous O2 (oxygen) via nasal cannula @ 5 LPM (liters per minute). Change tubing and water bottle on the 2nd and 15th of every month; label with date.
In addition to specifying that the oxygen tubing should be labeled when changed, the plan of care instructed that the tubing and humidification bottle should be changed twice a month, not once a month as indicated in the physician's order and TAR.
The surveyor requested the facility's oxygen policy and procedures and was provided with an Oxygen Use and Storage policy. Review of this policy on 6/22/22 at 10:57 AM revealed: Procedure: 6. b. Humidifier bottles will be disposed of and replaced when the bottle becomes empty and on the 2nd and 15th each month. The policy did not indicate a frequency for changing oxygen tubing.
An interview was conducted with the Director of Nursing (DON) and Assistant Director of Nursing (ADON) on 6/22/22 at 2:26 PM. They confirmed that the oxygen tubing and humidification bottles were changed twice a month. They provided and reviewed a policy for Oxygen and Nebulizer Tubing with the surveyor.
The policy stated: Oxygen and nebulizer tubing and water bottles will be changed routinely. Procedure:
1. Oxygen: a. Night shift charge nurse will change tubing on the 2nd and on the 15th of each month. b. All nurses are responsible for changing tubing as indicated when soiled. c. Tubing will be dated and initialed when changed. d. Night shift nurse will change the water bottles used for humidification on the 2nd and on the 15th of each month. and e. All nurses will replace humidification water bottles when empty or soiled.
Another observation was made of Resident #26 on 6/22/22 3:55 PM. The Resident was lying in bed and receiving oxygen by nasal cannula from the oxygen concentrator. No date label was on the oxygen tubing at that time.
According to the TAR, the tubing was changed on 6/15/22 however, the tubing had no date label.
The DON & ADON were made aware of these findings on 06/22/22 04:53 PM.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0711
(Tag F0711)
Could have caused harm · This affected 1 resident
Based on medical record review and interview, it was determined that the facility failed to ensure that physician's progress notes accurately reflected the medications that the resident was currently ...
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Based on medical record review and interview, it was determined that the facility failed to ensure that physician's progress notes accurately reflected the medications that the resident was currently receiving. This was found to be evident for 2 (#74 and #1) of 7 residents reviewed for unnecessary medications.
The findings include:
1a) On 6/9/22,a review of Resident #74's medical record revealed that the resident had resided at the facility for several years. The resident's diagnoses included, but were not limited to, non-alzhiemer's dementia; anxiety, depression and a psychotic disorder not related to schizophrenia. The resident had been receiving the antipsychotic medication Seroquel for more than one year.
On 6/13/22, review of the orders and the Medication Administration Record (MAR) for June 2022 revealed that the resident was receiving Seroquel 25 mg every morning and Seroquel 75 mg every evening at bedtime.
On 6/13/22 at 11:03 AM, review of the psychiatric nurse practitioner's (#44) note, dated 6/6/22, revealed a section for Current Medications. This section included documentation of the Seroquel 75 mg at bedtime but failed to include documentation of the Seroquel 25 mg being administered in the morning. The note also included Will attempt GDR [gradual dose reduction] of seroquel.
On 6/13/22, further review of the medical record failed to reveal documentation to indicate that a GDR had been ordered after the 6/6/22 psychiatric nurse practitioners visit. The current order for the morning dose of Seroquel was in effect since December 2020, and the evening dose since 4/25/22.
On 6/15/22 at 3:02 PM, surveyor reviewed the concern with the psychiatrist (#8) that the note, dated 6/6/22, failed to include the morning dose of the Seroquel and that the note indicated that a GDR was going to be attempted. The psychiatrist reported that the plan may have initally been to attempt a gradual dose reduction, but that was no longer the plan and a meeting was scheduled later that day. The psychiatrist went on to report that NP #44 was new and that the note may just be in error, but acknowledged that the current medication list should be accurate.
Further review of the psychiatric notes revealed that, on 4/25/22, there was a plan to GDR the Seroquel from 100 mg at bedtime to 75 mg. Corresponding orders reflect that the GDR was instituted on 4/25/22.
Review of the 5/3/22 psychiatric note, as completed by Psychiatrist #8, revealed that the resident was currently receiving 100 mg of Seroquel at bedtime. Further review of the 5/3/22 note indicated that the contents were nearly identical to the 4/25/22 note, which had included the plan to attempt a GDR of the Seroquel from 100mg at bedtime to 75 mg. No documentation was found in the 5/3/22 note to indicate that the GDR had been initiated more than a week prior to the 5/3/22 visit.
Review of the 5/14/22 psychiatric note, completed by Psychiatrist #8, again documented that the resident was receiving 100 mg of Seroquel at bedtime.
1b) Further review of the medical record revealed that Resident #74 had orders for the antidepressant escitalopram (Lexapro) starting in December 2020. This medication was discontinued on 3/17/2022. No documentation was found to indicate that the resident received the Lexapro after 3/17/22.
Further review of the medical record revealed a note completed by the Physician Assistant for a visit on 6/6/22. The note indicated the resident was seen for .scheduled review of [his/her] chronic conditions. The following was found in the Plan section of the note: Delusional Disorder/Anxiety -Continue Lexapro .
Further review of the psychiatric notes, dated 5/14/22, 5/3/22 and 4/25/22, revealed documentation that the resident was continuing to receive Lexapro 5 mg everyday.
On 6/24/22 at 12:30 PM, surveyor reviewed with the Director of Nursing (DON) and the Assistant Director of Nursing (ADON) the concern that the psychiatric notes did not accurately reflect the resident's current medications.
2) On 6/22/21, review of Resident #1's medical record revealed a diagnosis of diabetes. Current orders included sliding scale insulin based on blood sugar levels which were to be obtained 4 times a day. The resident also had orders for Januvia, a medication that helps lower blood sugar levels, that was being administered once daily.
Review of the primary care providers progress notes revealed the resident was seen by the physician assistant (PA #6) on 5/20/22. Review of the note for this visit revealed a plan to continue the Januvia and Continue insulin sliding scale with plan to discontinue in the near future adn [and] restart Glipizide 2.5 mg daily.
Glipizide is another medication used to lower a resident's blood sugar level. Glipizide and Januvia are different medications.
Further review of the medical record failed to reveal an order for Glipizide between 5/20/22 and the review date of 6/22/22.
Further review of the medical record revealed a note written by the primary care physician (PCP#41) for a visit on 5/25/22 which revealed the following: Continue Januvia 50 mg daily and recently started glipizide.
Review of the notes completed by PA #6 for visits conducted on 5/27/22 and 5/31/22 also revealed the Continue Januvia 50 mg daily and recently started glipizide statements.
Review of the notes completed by PCP #41 for a visit conducted on 6/1/22 also revealed the Continue Januvia 50 mg daily and recently started glipizide statement.
On 6/23/22 at 9:36 AM, PA #6 confirmed that she had seen Resident #1 the month before. Surveyor provided the 5/31 and 6/1/22 progress notes for the PA to review. The PA reported that she did not recall any discussion about Glipizide. She went on to report that when she writes a note, she starts with the old note and edits from there and if not actively looking at an issue, she may not make a change to the note. The PA confirmed that the notes should be accurate.
On 6/23/22 at 4:22 PM, surveyor reviewed with ADON the concern regarding primary care provider notes that indicated the resident was receiving a medication that had not been ordered or administered.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Staffing Information
(Tag F0732)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on surveyor observation and interview with facility staff, it was determined that the facility staff failed to post the re...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on surveyor observation and interview with facility staff, it was determined that the facility staff failed to post the required staffing information in a prominent place easily accessible to residents and visitors. This was evident for 1 (Canal Side Skylight) of 6 resident care areas observed during the survey.
The findings include:
The surveyor observed the C wing 3rd floor - Canal Side Skylight Unit on 6/6/22 at 10:49 AM. Access to the unit required travel via elevator or stairs that required entry of a code into a keypad to unlock. The unit consisted of 8 bedrooms, housing 11 residents. The surveyor was unable to find the unit staffing assignment posted in a prominent place accessible to residents and visitors. Further observation of several bedrooms on C wing 3rd floor including room [ROOM NUMBER], #304 and #310, confirmed that staffing information was not posted within the resident rooms.
On 6/6/22 at 11:03 AM, Staff #45 was asked how the C wing 3rd floor Unit was staffed. She indicated that 1 Geriatric Nursing Assistant (GNA) was assigned to the C wing 3rd floor, 1 GNA was assigned to C wing 2nd floor also known as Canal Side Heights, and a 3rd GNA was assigned as a float to assists with both floors and to cover for breaks. She also indicated that there was 1 nurse who covered both floors of the C wing.
During an observation of the C wing 2nd floor on 6/15/22 at 11:47 AM, the surveyor observed that the required staffing information for both floors of the C wing was posted outside of the nurses' station on the 2nd floor. This location was not readily accessible to the residents residing on the 3rd floor of C wing nor their visitors.
An immediate observation of the C wing 3rd floor on 6/15/22 at 11:53 AM revealed that the required staffing information was again not posted on the 3rd floor.
Staff #31 was present on the C wing 3rd floor and was asked during an interview at 11:55 AM, where the staffing assignment information was posted for the residents residing on C wing 3rd floor. She pointed to an empty clear plexiglass frame on the wall in the hallway across from room [ROOM NUMBER] and stated, I'm not sure, it's usually posted here.
On 6/15/22 at 1:44 PM, the Director of Nursing (DON) and Assistant Director of Nursing (ADON) were made aware of these findings.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0757
(Tag F0757)
Could have caused harm · This affected 1 resident
2) A medical record review on 6/10/22 at 10:56 AM for Resident #34 revealed a provider progress note, dated 6/10/22, that documented Resident #34 had a diagnosis of COPD (Chronic Obstructive Pulmonary...
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2) A medical record review on 6/10/22 at 10:56 AM for Resident #34 revealed a provider progress note, dated 6/10/22, that documented Resident #34 had a diagnosis of COPD (Chronic Obstructive Pulmonary Disease which is defined as a group of diseases that affect the person's ability to breath by causing airway blockages per the Centers for Disease Control) along with other chronic diseases. The provider documented that her plan for COPD management was to continue the bronchodilators and other orders as needed. Further review of the medical record revealed a Medication Administration Record (MAR) for 5/22 that documented Resident #34 had two orders for inhaled medications to treat COPD. The first order started on 6/23/21 for Combivent Respimat Aerosol Solution 20-100 MCG/ACT (Ipratropium and Albuterol) and the second order started on 3/8/22 for Advair HFA Aerosol 115-21 MCG/ACT (Fluticasone-Salmeterol). Both inhalers contain medication that helps the smooth muscles in the bronchial tubes to relax.
Further review of the medical record revealed that, on 5/6/22, the Consultant Pharmacist conducted a medication regimen review for Resident #34. A Note to Attending Physician/Prescriber was initiated and recommended that the Attending Physician Staff #41 discontinue one of the orders due to duplication of inhaled smooth relaxants. Also, the Consultant Pharmacist noted that the use of Albuterol and Salmeterol may increase potential cardiovascular side effects (increased heart rate, hypertension, and irregular heart rhythm). Under the section for Physician/Prescriber Response, the order was written to discontinue the Combivent. However, as of 6/10/22 Resident #34 had continued to receive both inhalers.
On 6/10/22 at 12:47 PM, during an interview with Licensed Practical Nurse (LPN) #19, she reported that when the Consultant Pharmacist completes the medication regimen review, the information was faxed directly to the Registered Nurse (RN) House Supervisors' office and the RN House Supervisor processes it and places the new order in the computer if needed. The form was then completed in the resident's paper medical record.
An interview with RN House Supervisor #35 on 6/15/22 at 9:54 AM revealed that Resident #34's Note to the Attending Physician/Prescriber form had been lost in the office and had not been processed. RN house Supervisor #35 confirmed that Resident #34 had continued to receive the Combivent after a physician order had been written to discontinued it on 5/6/22.
During a discussion with the DON and ADON on 6/10/22 at 2:34 PM, they were made aware of the concern.
Based on medical record review and interview, it was determined that the facility failed to ensure that the residents were free from unnecessary medications as evidenced by 1) failing to follow a physician's order to monitor a resident's blood sugar four times a day for a resident receiving insulin; and failure to follow the physician's order to hold the insulin injection when the blood sugar level was below 120 and 2) failing to discontinue a duplicate medication as ordered by the attending physician. This was found to be evident for 2 (#59 and #34) of 7 residents reviewed for unnecessary medications during the survey.
The findings include:
1) On 6/21/22, review of Resident #59's medical record revealed a diagnosis of diabetes and orders for insulin injections.
Further review of the medical record revealed an order, with a start date of 5/11/22, for Fingerstick Blood Sugar levels four times a day and to contact the provider if the level was less than 70 or greater than 400. Review of the Medication Administration Record (MAR) revealed that the Fingerstick Blood Sugar levels were being documented as being completed twice a day at 8:00 AM and 4:00 PM. Further review of the medical record failed to reveal documentation to indicate that the blood sugar levels were being obtained more than twice a day.
Further review of the medical record revealed an order, with a start date of 5/11/22, for 8 units of Novolin R to be administered twice daily but should be held (not administered) if the blood sugar levels were below 120.
Novolin R is a short-acting insulin that starts to work within 30 minutes after injection, peaks in 2 to 3 hours and keeps working for up to 8 hours.
Further review of the June 2022 MAR revealed documentation that:
On 6/1/22 at 8:00 AM, the resident's blood sugar was 74 and the insulin was administered.
On 6/6/22 at 4:00 PM, the resident's blood sugar was 102 and the insulin was administered.
On 6/10/22 at 8:00 AM, the resident's blood sugar was 94 and the insulin was administered.
On 6/14/22 at 8:00 AM, the resident's blood sugar was 83 and the insulin was administered.
On 6/22/2,2 surveyor reviewed the concern with the Director of Nursing (DON) and Assistant Director of Nursing (ADON) regarding the facility staff's failure to obtain the blood sugar levels four times a day as ordered by the provider and failure to hold the insulin on multiple occasions when the blood sugar was below the ordered parameter to hold. As of time of exit on 6/24/22 at 2:45 PM, no additional documentation was provided regarding these concerns.
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 medical record review and interview, it was determined that the facility failed to ensure the residents were free from unnecessary psychotropic medications as evidenced by 1) the administrati...
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Based on medical record review and interview, it was determined that the facility failed to ensure the residents were free from unnecessary psychotropic medications as evidenced by 1) the administration of as needed antianxiety medication in the absence of documentation of the need for or request of the medication. This was found to be evident for 1 (#1) of 7 residents reviewed for unnecessary medications.
The findings include:
On 6/22/22, review of Resident #1's medical record revealed diagnoses that included but not limited to depression and generalized anxiety disorder. The resident had an order, with a start date of 5/16/22, for Xanax every 8 hours as needed for anxiety for 14 days.
Xanax, also known as alprazolam, is an antianxiety medication.
Review of the May 2022 Medication Administration Record (MAR) revealed that Xanax was administered on 5/19, 5/24 and 5/30. Further review of the medical record failed to reveal documentation of behaviors or requests that would indicate the need to administer the as needed antianxiety medication.
Further review of the medical record revealed the resident was seen by the psychiatric nurse practitioner (#44) on 6/13/22. Review of the note for this visit revealed a plan to Start alprazolam 0.5 mg tablet by mouth TID [three times a day] x 14 day. The order was originally put in the medical record as a regularly scheduled dose to be given three times a day, but after the first dose was administered, the order was changed on 6/15/22 to be given as needed.
Review of the June 2022 MAR revealed that the as needed antianxiety medication was administered on 6/15 at 4:39 AM and again on 6/22 at 4:59 AM. Further review of the medical record failed to reveal documentation of behaviors or requests that would indicate the need to administer the as needed antianxiety medication.
On 6/22/22 at 4:55 PM, the Assistant Director of Nurisng (ADON) reported the expectation when an as needed antianxiety medication was administered was that staff would document the behaviors and any non-pharmalogical measures attempted prior to administration. Surveyor reviewed the concern that no documentation was found related to behaviors prior to the administration of several doses of as needed Xanax in May and June.
On 6/23/22 at 10:14 AM, Nurse Practitioner (NP) #44 confirmed that the Xanax order was suppose to be as needed, stating: should of put the prn [as needed] in it in reference to the plan found in the 6/13/22 note. Surveyor then reviewed the concern that the Xanax was being administered without documentation of behaviors to indicate the need for its use. NP #44 confirmed that she also needed to have notes to justify the use of the medication.
As of time of exit on 6/24/22 at 2:45 PM no additional documentation was provided regarding this concern.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0761
(Tag F0761)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, and facility policies review, it was determined that facility staff 1) failed to ensure d...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, and facility policies review, it was determined that facility staff 1) failed to ensure documentation of a multi-use medication's expiration date when opened, 2) failed to discard medication bottles and medical supplies when expired, and 3) failed to develop policy and procedures for multi-use medication containers and follow the directions. This was evident in 2 of 5 rehab nursing units observed during random observations made during the survey.
The findings include:
1) On [DATE] at 1:37 PM, the surveyor inspected a medication storage room on the [NAME] view 2nd-floor with Registered Nurse (RN) #34 attending. The surveyor observed that the Allergy relief medication bottle was opened with the handwritten date marked as 1/23. There was no expiration date marked on the bottle. The surveyor informed RN #34 of the finding. She stated that any opened multi-dose medication bottle would be located on the medication cart and opened bottle should not be placed in the medication storage room cabinet. She threw the Allergy relief medication away immediately.
An inspection of long-term care unit 2C's medication cart was performed on [DATE] at 1:45 PM. In the 4th drawer of the medication cart, there was an opened box of Inhaler (name: Anora Ellipta) without marking the opened date and expiration date. There were two opened lactulose bottles marked ¾ and 4/4, both bottles did not have opened date and expiration date. During an interview with Registered Nurse (RN) #35 on [DATE] at 1:50 PM, she stated that both lactulose bottles were in use: ¾ meant 3rd bottle of total 4 bottles and 4/4 meant 4th bottle of total 4 bottles. She said, A staff member might of opened the 4/4 marked bottle while ¾ marked bottle was still in use.
On [DATE] at 2:22 PM, an inspection was conducted at [NAME] View 1st floor of the medication storage room with RN #36 attending. An opened 32 oz container of Biofreeze professional gel (pain relief gel) was found on the countertop of the storage room. No documentation was found on the container to indicate when it was opened or when it would expire. RN #36 was informed, and she threw it away.
2) During the interview with RN #34 on [DATE] at 1:37 PM, she indicated that medication storage stock was managed by the central purchasing unit. An interview was conducted with Purchasing Coordinator (PC) #38 on [DATE] at 1:44 PM. PC #38 stated her responsibility is to stock and monitor expiration date for the medications, and she performed inventory regularly. An unopened Aspirin 325mg bottle expiration date 5/22 was found by the surveyor at the medication storage room of [NAME] View 2nd floor in a cabinet. PC #38 threw it away.
During an inspection at [NAME] View 1st floor on [DATE] at 2:22 PM, an expired foley catheter (expiration date [DATE]) was found in the medication storage room drawer. RN #36 was informed, and she destroyed it.
3) During the interview with RN #35 on [DATE] at 1:50 PM, she stated that all staff were supposed to mark the open date, and some staff circled the expired date and others did not. RN #35 said, circling expired date is just easy to recognize.
During an interview with Licensed Practical Nurse (LPN) #19 on [DATE] at 1:23 PM, she stated that she used a reference chart named 'medications with shortened expiration dates' for tracking expiration dates. The 'Medications with Shortened Expiration Dates' indicated product name, generic name, and stability, in-use, and room temperature.
On [DATE] at 1:37 PM, an interview was conducted with RN #34. She stated that she wrote the opened date and circled the expired date.
On [DATE] at 12:20 PM, the facility's policy and procedure for 'Medication- Multi-Use Containers' was submitted by the Director of Nursing (DON). The submitted policy and procedure listed certain discarding times; 6 months after opening for ophthalmic drops, multi-dose vials, 30 days after opening for bacteriostatic water / normal saline for injections, and within 24 hours for sterile water for irrigation, sterile water for injection, and sterile normal saline for injection. However, there was no documentation related to the pill bottle maintenance guide. The DON was informed that each staff had a different method to track expiration dates and asked about the policy and procedures regarding this issue. She said, This is the only policy regarding multi-dose medication. I don't know about other medications not listed here.
The DON and the Assistant Director of Nursing (ADON) were aware of the above concerns on [DATE] at 12:40 PM.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0775
(Tag F0775)
Could have caused harm · This affected 1 resident
Based on medical record review and interview, it was determined that the facility failed to have an effective system in place to ensure lab results of COVID tests were kept in the resident's medical r...
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Based on medical record review and interview, it was determined that the facility failed to have an effective system in place to ensure lab results of COVID tests were kept in the resident's medical record. This was found to be evident for 3 (#74, #1 and #59) of 3 residents whose COVID testing results were reviewed during the survey.
The findings include:
1) On 6/9/22, review of Resident #74's medical record revealed the resident resided at the facility for several years. Review of the Medication Administration Record for June revealed documenation to indicate that staff had obtained a Nasopharyngeal Swab for COVID testing on 6/1, 6/9 and 6/16/22. The most recent COVID test results found in the electronic health record were from October 2021.
On 6/21/22, a review of Resident #74's paper chart failed to reveal documentation of COVID test results.
2) On 6/22/22, review of Resident #1's medical record revealed documenation to indicate staff had obtained a Nasopharyngeal Swab for COVID testing on 6/1, 6/9 and 6/16/22. Further review of the medical record failed to reveal documentation of the results of these three COVID tests.
3) On 6/22/22, review of Resident #59's medical record revealed documenation to indicate that staff had obtained a Nasopharyngeal Swab for COVID testing on 6/1, 6/9 and 6/16/22. Further review of the medical record failed to reveal documentation of the results of these three COVID tests.
On 6/22/22 at 4:55 PM, surveyor reviewed the concern with the ADON that the COVID results for Residents #74, #1 and #59 could not be found in the medical record. The ADON reported the results were in Simple Report, (a separate computer application/ program for the purpose of compilation of residents' COVID results) and confirmed that the Simple Report was not part of the resident's medical record.
Review of the statement of deficiencies for a Focused Infection Control survey conducted in December 2020 revealed a deficiency for failure to have laboratory reports in the medical record when a resident was tested for COVID-19.
(Cross reference to F867)
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected 1 resident
Based on surveyor observation and interview with the resident and staff, it was determined the facility failed to establish and maintain an infection prevention and control program designed to 1) ensu...
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Based on surveyor observation and interview with the resident and staff, it was determined the facility failed to establish and maintain an infection prevention and control program designed to 1) ensure staff were performing hand hygiene between changing gloves, and 2) provide a safe and sanitary environment as evidenced by staff failure to store a resident's toothbrush in a sanitary manner. This was evident for 1 (Registered Nurse, RN #33) of 3 staff observed for medication administration during the survey and 1 (Registered Nurse, RN #33) of 3 staff observed for medication administration during the survey and this was evident for 1 (#18) of 61 resident's reviewed during the survey. The findings include:
1) On 6/10/22 at 9:56 AM, an observation was made for RN #33's wound care for Resident #200. RN #33 prepared her materials on the bedside table for the dressing, set up, performed hand hygiene, put on clean gloves, removed the old dressing, and removed the gloves. Without performing hand hygiene, she put on a new pair of gloves, proceeded to clean the wound, and apply the treatment and new dressing, and removed the gloves. Right after the dressing was completed, RN #33 was interviewed by the surveyor. RN #33 explained the whole procedure for dressing change without mentioning hand hygiene between removing contaminated gloves and applying clean gloves.
An interview was conducted with the Assistant Director of Nursing (ADON) on 6/23/22 at 3:45 PM. The ADON was asked about the dressing change procedure. She stated that all staff should wash their hand between changing gloves.
The ADON was made aware of the above concerns.
2) An observation was made of Resident #18's bathroom on 6/16/22 at 3:18 PM. On the counter to the left of the sink was a gray emesis basin. The basin contained an opaque watery liquid approximately ½ inch deep. The liquid had soiled water and toothpaste residue along the sides of the basin. A blue battery powered spinning toothbrush was lying in the liquid within the emesis basin.
Resident #18 was lying in his/her bed and was interviewed immediately after the surveyor's observation. When asked when he/she last brushed his/her teeth the resident responded, this morning.
The Director of Nursing and Assistant Director of Nursing were made aware of the above concerns and observed the storage of Resident #18's toothbrush on 6/16/22 at 3:27 PM.
Review of Resident #18's medical record on 6/23/22 at 12:42 PM revealed that the resident's diagnoses included, but were not limited to: Kidney transplant, pancreas transplant, disorder involving the immune mechanism, legal blindness. Resident #18's Quarterly MDS with an assessment reference date of 2/28/22 section G Functional Status J. Personal hygiene was coded to reflect that Resident #18 required Extensive assistance of 1 person to maintain personal hygiene including combing hair, brushing teeth, washing/drying face, and hands.
A plan of care was developed for Resident #18 for: Risk for impaired immunity/risk for infection related to kidney, pancreas transplant with immunosuppressant therapy, decreased mobility. Resident #18's goal was that he/she would not display any complications related to immune deficiency. The interventions staff were to implement to assist the resident in reaching his/her goal included but were not limited to: The resident is at risk for contracting infections due to impaired immune status. Keep the environment clean and people with infection away.
The facility's failure to establish and maintain standard infection control practices placed Resident #18 at a higher risk for infection.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0883
(Tag F0883)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, policy and procedure review, and staff interviews, it was determined that the facility staff 1) ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, policy and procedure review, and staff interviews, it was determined that the facility staff 1) failed to document that the residents and/or their Responsible Parties (RPs) were provided education on Influenza and Pneumococcal vaccines before requesting consent, 2) failed to develop the policies and procedures to ensure that residents or RPs receives education regarding the benefits and potential side effects of Influenza and pneumococcal immunizations. This was evident for 5 (#21, #22, #57, #59, and #71) of 5 residents reviewed for Immunization during the survey. The findings include:
Pneumococcal vaccine help prevents pneumococcal disease, which is any illness caused by streptococcus pneumonia bacteria. The Centers for Disease Control and Prevention (CDC) recommends a pneumococcal vaccine for age [AGE] years or older and adults 19 through 64 with certain medical conditions or risk factors. (Centers for Disease Control and Prevention- vaccines and preventable disease)
Flu is a contagious disease that spreads around the United States annually, usually between October and May. Anyone can get the Flu, but it is more dangerous for some people. Infants and young children, people 65 years and older, pregnant people, and people with certain health conditions or a weakened immune system are at the greatest risk of flu complications. Influenza (Flu) vaccines can prevent influenza. (Centers for Disease Control and Prevention- vaccines and preventable disease)
1) On 6/16/22 at 3:50 PM, a medical record review was conducted for Resident #59. The resident's RP refused the Flu vaccine and the Pneumococcal vaccine. A facility's consent form, dated 9/27/21, was filed in the resident's paper chart. However, no other documentation was found in the record that the resident received education regarding the benefits or risks of receiving the Flu and Pneumococcal vaccine.
2) A review of the medical record for Resident #21 was conducted on 6/16/22 at 4:20 PM. A consent form was filed in the resident's paper chart that was marked as refused Flu and Pneumococcal vaccine dated 6/02/21. However, there was no supportive documentation regarding the resident receiving education regarding the risks or benefits of receiving the vaccines.
3) A medical record review of Resident #57 was conducted on 6/17/22 at 7:20 AM. A consent form was filed in the resident's paper chart marked as consented Flu and Pneumococcal vaccine dated 11/17/20. The resident received the Flu vaccine on 9/23/21 and the Pneumococcal vaccine on 5/16/22. However, there was no supportive documentation regarding the resident's education regarding the risks or benefits of receiving the vaccines.
4) A record review for Resident #71 revealed that a consent form was filed in the resident's paper chart marked as refused Flu and consented Pneumococcal vaccine dated 4/26/21. However, there was no supportive documentation regarding the resident's education regarding the risks or benefits of receiving the Flu vaccine
5)A medical record review of Resident #22 on 6/17/22 at 09:50 AM revealed the resident's RP consented to the Flu and Pneumococcal vaccines on 9/11/19. The resident received the Pneumococcal vaccine on 10/31/19 and the Flu vaccine on 9/23/21. However, education was not documented on the resident's paper or electronic chart.
During an interview with the Director of Nursing (DON) and Assistant Director of Nursing (ADON) on 6/17/22 at 11:50 AM, the DON explained that the facility assessed a new resident's vaccination eligibility upon admission. If the resident is a candidate for the vaccine, a consent form will be signed by the resident self or RPs, and the signed consent will be filed in the resident's paper chart. Also, the DON stated the facility did not separately document providing education to residents. This surveyor informed the DON and the ADON that the form did not include education regarding the benefits and potential side effects of the Flu and Pneumococcal vaccine.
On 6/17/22 at 2:15 PM, the DON submitted a copy of policies and procedures for Resident Pneumococcal vaccination and Resident Influenza Vaccination. The vaccination policies and procedures did not indicate that each resident or RPs receive education regarding the immunization's benefits and potential side effects.
On 6/23/22 at 2:30 PM, surveyor reviewed with the DON and ADON the concern regarding the failure to include the provision of education about the vaccines in the policy and procedures.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Room Equipment
(Tag F0908)
Could have caused harm · This affected 1 resident
Based on observation and interview, it was determined that the facility failed to ensure that the walk in freezer was functioning in a manner that prevented ice build up, which included ice frozen to ...
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Based on observation and interview, it was determined that the facility failed to ensure that the walk in freezer was functioning in a manner that prevented ice build up, which included ice frozen to the floor; and failed to ensure unit refrigerators were maintained in a manner to keep items at safe temperatures. This was found to be evident for the one walk in freezer in the kitchen; and one of the six unit refrigerators used for storing food items.
The findings include:
1) On 6/6/22 at 10:00 AM, during a tour of the kitchen with the executive chef, (#43) the walk in freezer was observed to have small frozen mounds observed on the ceiling in front of the compressor, and an approximately 1.5 inch in diameter mound of ice was stuck to the floor where staff would walk.
On 6/16/22 at 11:30 AM, observation of the walk in freezer again revealed ice build up on the ceiling in front of the compressor, similar to the observation on 6/6/22. The food service director (FSD #25) indicated that she was aware of the surveyor's observation on 6/6/22. She reported she had not yet received a final report from maintenance, and as far as she knew, they were still working on the issue.
6/23/22 at 11:40 AM, the FSD reported she had not gotten a final report about the walk in freezer and indicated that the maintenance director would have more information.
On 6/23/22 at 12:10 PM, maintenance director (#59) reported there was no problem with the walk in freezer; that it always had an ice build up and that was why we have the magnets. He went on to report that they have magnets on the ceiling in front of the compressor where the ice forms so that they can remove the magnets and clean off the ice. The maintenance director was unable to recall the last time a maintenance company had serviced the walk-in freezer. Surveyor requested documentation of the most recent maintenance company service call for the walk-in freezer.
On 6/23/22 at 12:33 PM, the FSD confirmed that there currently was ice on the ceiling of the walk in freezer. Surveyor reviewed the concern that if working properly, there should not be ice build up in the walk in freezer.
On 6/23/22 at 2:20 PM, the maintenance director reported the service company had not been to the facility in the past five years. He indicated they assessed the walk in freezer today and are going to put in a bigger drain.
On 6/23/22 at 2:55 PM, the FSD confirmed the service company was here today and they informed her will be addressing the issue of the ice build up.
2) On 6/23/22 at 1:31 PM, the [NAME] View Heights refrigerator thermometer read 48 degrees; water was observed on the floor of fridge where multiple items were located including cartons of milk and Ensure. The medical records manager (#63), who reported she was also a GNA (geriatric nursing assistant), confirmed the temperature reading and indicated she would follow up.
On 6/23/22, at approximately 2:35 PM, the food service director (FSD #25) reported that the fridge on Heights unit had been out of service earlier this month. At approximately 2:55 PM, the FSD provided documentation of Refrigerator Temperature Log for the Heights. This log indicated that the refrigerator was out of service June 1st through June 13 and did not include temperature documentation for those dates. Further review of this form revealed two temperatures had been documented for 6/23 of 38 degrees in the morning, and 37 degrees in the evening. Temperatures had also been documented for the Mornings of 6/24 and 6/25 but had been scratched out.
On 6/24/22, the maintenance director provided a copy of a Maintenance Work Order, dated 6/13/22, which indicated the Heights Freezer very loud, please check, and that the freezer was defrosted on 6/13/22.
On 6/24/22 at 9:05 AM, the maintenance director reported, in regard to the Heights refrigerator being out of service earlier in the month, that they had defrosted the [NAME] View (heights) fridge and turned it back on and it was working for a day so they put it back in service. He also reported that, since yesterdays observation, they had a repair company look at the refrigerator and parts are being replaced.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0578
(Tag F0578)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2) On [DATE] at 9:10 AM, a review of Resident #71's medical record revealed a clinician's progress note, dated [DATE], that docu...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2) On [DATE] at 9:10 AM, a review of Resident #71's medical record revealed a clinician's progress note, dated [DATE], that documented Resident #71 had been admitted to the facility with dementia. An Assessment of Decision-Making Capacity was completed on [DATE] by the attending physician. This document read that it was an initial assessment and concluded that Resident #71 was incapable of making decisions due his/her acute paranoia and has tangential thought process. However, further review of the medical record revealed that the facility failed to have a second physician certify that Resident #71 had been incapable of decision-making.
A review of the paper medical record for Resident #71 on [DATE] at 9:10 AM, revealed an Advanced Directive signed and dated [DATE], by Resident #71. This document read that Resident #71 designated three individuals to make decisions for him/her and the transfer of decision-making was to become operative when Resident #71 had been determined to be incapable of making decisions by two physicians.
Further review of the paper medical record revealed a MOLST form which indicated that the order for No CPR Option B was the result of a discussion with a family member, even though Resident #71 had not been deemed incapable by two physicians. (According to the Health Care Decision Act and person is capable until deemed incapable by two physicians.)
3) During the initial tour on [DATE], Resident #83 was observed talking to the ceiling and when surveyor attempted to engage Resident #83 in conversation, he/she stated that the ceiling and walls were coming down on him/her.
A medical record review on [DATE] at 10:31 AM revealed a Minimum Data Set (MDS) with an Assessment Reference Date of [DATE], and there was documentation in section C that Resident #83 had scored a 12 out 15 on the Brief Interview for Mental Status (BIMS - a standardized test to measure a resident's level of cognition.) This indicated moderate cognitive impairment however, physician notes, dated [DATE], had not indicated a diagnosis for this cognitive impairment.
Further review revealed an Advanced Directive which had been signed by Resident #83 on [DATE] designating a person to make health care decisions for the resident. The Advanced Directive had not specified when it became operative, so according to the Health Care Decision Act, this Advanced Directive if not specified it would become operative when Resident #83 had been deemed incapable by two physicians.
A review of Resident #83's paper medical record on [DATE] at 9:36 AM revealed a MOLST form, dated [DATE], that documented the surrogate decision-maker had made the decision for life-sustaining treatment for Resident #83. Further review revealed an Assessment of Decision-Making Capacity signed by the attending physician on [DATE] which read that it was an initial assessment and stated that the resident [#83] was hard of hearing and possessed some capacity for focal questions. The attending physician further documented that the capacity was variable and fluid and deemed the resident incapable. However, further review of the medical record revealed the facility failed to have a second physician to determine the resident's capacity to make decision therefore the Advanced Directives had not been effect.
On [DATE] at 2:16 PM, surveyors reviewed with the Director of Nursing (DON) and the Associate Administrator the concerns regarding the MOLST being completed by surrogate decision makers when the residents had not been deemed incapable. The DON and Associate Administrator were unable to provide the facility's process for deeming a resident incapable and stated that they would report back to the surveyors.
During a subsequent interview on [DATE] at 10:13 AM with the DON and the Assistant Director of Nursing (ADON) present, the DON reported that, after talking with the Medical Director, it was determined that the facility had failed to obtain a second physician certification to determine capacity for a resident. The Medical Director was not available to be interviewed. The ADON confirmed that they were aware that 2 physicians were needed to certify a resident incapable of making healthcare decisions and that the facility had not obtained 2 certifications.
An interview with Physician #60 on [DATE] at 2:26 PM revealed that, unless otherwise noted on an Advanced Directive, the order went into effect on the day that 2 physicians had certified a resident to be incapable of making decisions.
4) Resident #70's medical record was reviewed on [DATE] at 9:57 AM. The resident's diagnoses included Dementia, Cerebrovascular disease, and Traumatic Subdural Hemorrhage.
The resident's EMR (Electronic Medical Record) revealed a MOLST order, written [DATE] at 3:44 PM. It indicated to attempt CPR and noted that this order was made as a result of a discussion with, and the informed consent of the patient.
The paper record revealed a MOLST form dated [DATE] that included No CPR, Option B, Palliative and Supportive Care. This order indicated that it was made as a result of a discussion with, and the informed consent of the patient's health care agent as named in the patient's advance directive.
Resident #70's written Advance Directive revealed that the resident directed that the appointment of a Health Care Agent shall take effect when and if two physicians, one of whom is my attending physician, certify that I am disabled because I lack sufficient understanding or capacity to make or communicate decisions with respect to my own health care. Resident #70's Living Will directed: My agents authority becomes operative when my attending physician and a second physician determine that I am incapable of making an informed decision regarding my health care.
Further review of the EMR revealed one Assessment of Decision-Making Capacity, dated [DATE], which indicated that it was an admission assessment. It did not indicate that it was either the 1st or 2nd assessment required to activate a Health Care POA/Agent. The only other information provided was: Pt. has been deemed not to have medical decision-making capacity.
The EMR revealed another Assessment of Decision-Making Capacity, dated [DATE]. It indicated that it was a second assessment required to activate a Health Care POA/Agent or appoint a Surrogate Decision Maker. However, it was completed almost 1 month after the MOLST was completed on [DATE].
Neither of the physician's certifications of decision-making capacity indicated that they were made within 2 hours of the physician's examination of the resident.
The facility failed to follow Resident #70's advance directive by failing to ensure that 2 valid physicians' certificates of incapacity were completed prior to allowing the designee to make an informed decision to change Resident #70's MOLST order.
5) Resident #35's medical record was reviewed on [DATE] at 9:42 AM. The resident's diagnoses included Vascular Dementia with behavioral disturbance and Unspecified Sequelae of Cerebral Infarction.
The EMR (Electronic Medical Record) revealed a MOLST, dated [DATE], that indicated No CPR, Option B Palliative and Supportive Care. This order indicated that it was made as a result of a discussion with, and the informed consent of the patient's health care agent as named in the patient's advance directive.
The resident's paper record revealed a MOLST form, dated [DATE], that included No CPR, Option B, Palliative and Supportive Care. This order also indicated that it was made as a result of a discussion with, and the informed consent of the patient's health care agent as named in the patient's advance directive.
Further review of the resident's medical record failed to reveal that Resident #35 had formulated an Advance Directive such as a living will or Durable Power of Attorney appointing a health care decision maker.
On [DATE] at approximately 10:55 AM, Staff #2 (a Social Work Associate) provided the surveyor with a progress note written [DATE] by Staff #5, a Physician Assistant. The note indicated that she and Staff #2 spoke with Resident #35 to complete a verbal advanced directive in which the resident stated that if he/she were unable to make decisions for his/herself, he/she would want his/her grandson to make them on his/her behalf, both medical and financial. MOLST form to be discussed with grandson.
The note did not specify the scope of the grandson's authority over health care decisions or if the resident placed any limitations on the agent's authority. The oral advance directive was not signed by the witness.
Further review of the record revealed one Physician's Certification of Competency and/or Dependent Status. It revealed documentation that, in the attending physician's opinion, Resident #35 was not competent to understand his/her medical condition and to make informed decisions. It was signed by the attending physician and dated [DATE]. It did not indicate if this certification was made within 2 hours of the physician examination of the resident. The record failed to reveal that a second physician examined and certified that Resident #35 was incapable of making informed decisions regarding his/her health care.
The facility failed to ensure that the resident's oral advance directive followed the Health Care Decision Act requirements and failed to ensure that 2 physicians' certificates of incapacity to make health care decisions were in place before allowing a health care agent to make health care decisions for Resident #35.
6) Resident #78's medical record was reviewed on [DATE] at 10:05 AM. The resident's diagnoses included Unspecified Dementia without behavioral disturbance.
The resident's paper record revealed a MOLST form, dated [DATE], that included No CPR, Option B, Palliative and Supportive Care and indicated that it was made as a result of a discussion with, and the informed consent of the patient and patient's surrogate as per the authority granted by the Health Care Decisions Act.
Further review of the resident's record on [DATE] at 9:37 AM failed to reveal that Resident #78 had formulated an Advance Directive such as a living will or Durable Power of Attorney appointing a health care decision maker.
The EMR revealed a progress note for a date of service of [DATE] by Staff #6 a Physician Assistant. The note indicated: Forms discussed or completed: Verbal Advanced Directive. Details of discussion: In setting that patient is unable to make decisions for him/herself, he/she would like his/her daughter (name) to act as his/her healthcare proxy. Listed as participants in face-to-face discussion were the provider, staff #6 and a witness Staff #65 an LPN. The note did not specify the scope of the agent's authority over health care decisions or if the resident placed any limitations on the agent's authority. The verbal advance directive was not signed by the witness.
Further review of the EMR revealed 1 Assessment of Decision-Making Capacity Effective Date: [DATE] which indicated that it was an initial admission assessment. It did not indicate that it was either the 1st or 2nd assessment required to activate a Health Care POA/Agent. The only other information it provided was: Pt. has been deemed not to have medical decision-making capacity. It did not indicate if this certification was made within 2 hours of the physician examination of the resident. The record failed to reveal that a second physician examined and certified that Resident #78 was incapable of making informed decisions regarding his/her health care.
The facility failed to ensure that Resident #78's verbal advance directive followed the Health Care Decision Act requirements and failed to ensure 2 physicians' certificates of incapacity to make health care decisions were in place before allowing a health care agent to make health care decisions for Resident #78.
7) Resident #26's medical record was reviewed on [DATE] at 9:04 AM. The resident's diagnoses included Vascular Dementia with behavioral disturbance.
The resident's EMR revealed a MOLST form dated [DATE]. It indicated that the orders were entered as a result of a discussion with and the informed consent of: the patient's surrogate per the authority granted by the Health Care Decisions Act; beside the line was a handwritten entry: (son and daughter).
The resident's paper record revealed a MOLST form, dated [DATE], that included No CPR, Option B, Palliative and Supportive Care. This order also indicated that it was made as a result of a discussion with, and the informed consent of the patient and patient's surrogate as per the authority granted by the Health Care Decisions Act, it also indicated son/daughter.
Further review of the record revealed a progress note, written [DATE], by Staff #41 the attending physician. The note indicated A verbal oral advance directive was attempted today in the presence of the pt, this provider and charge nurse (first name only) at 11:15 am. When questioned about who he/she be making medical decision for him/her, he/she stated he/she would like his/her son and daughter (First names) both to make medical decisions for him/her. Will contact family for further MOLST review. The scope of the agent's authority was not identified nor was the oral advance directive signed by the witness.
Further review of the record revealed that Resident #26 had a written Advance Directive in place, dated [DATE], naming his/her daughter as primary agent and son as first back up agent if the primary agent could not be contacted. A third agent was also identified in the event that the second back up agent could not be contacted.
Resident #26 specified that the agent's power would go into effect whenever I am not able to make informed decisions about my health care, either because the doctor in charge of my care (attending physician) decides that I have lost this ability temporarily, or my attending physician and a consulting doctor agree that I have lost this ability permanently.
The record also revealed one Physicians Certification of Competency and/or Dependent Status form, dated [DATE], and this form indicated that the resident was examined on that date and that it was the practitioner's opinion that he/she was not competent to understand his/her medical condition and to make informed decisions.
The record review failed to reveal a 2nd physician's certification to indicate that Resident #26 was incapable of making medical decisions.
In an interview on [DATE] at 12:05 PM, Staff #2 a Social Work Associate was asked to explain a verbal advance directive. She explained the physician gets with us, either a social worker or a nurse on the floor. If the resident is deemed incapable of making medical decisions but is able to name someone to be their decision makers, they go in with a witness and ask the resident who they want to make decisions. She was asked why a written Advance Directive would not be done. She stated if the person is deemed unable to make medical decisions, we don't do the written Advance Directive, we do the verbal when asked why there would be a difference, she responded that if the resident couldn't make medical decisions for themselves but were able to say they want their daughter to sign the paperwork then we go in and ask with a witness and get a verbal Advance Directive. When asked, she indicated that the facility did not have a policy on verbal advance directives.
On [DATE] at approximately 1:50 PM, the Director of Nursing (DON) reported that physician #41, who is the medical director, does an assessment upon admission regarding the resident's capability to make medical decisions. The DON was unable to verbalize the process for obtaining a second certification of incapacity but indicated she would ask.
In an interview on [DATE] at 12:15 PM the Director of Nursing was asked if she was familiar with the process of obtaining a verbal/oral advance directive. She indicated that she thought it would be best for the surveyor to go over it with the providers. She and the Assistant Director of Nursing were made aware of the surveyor's concerns related to Advance Directives and Certificates of Incapacity.
An interview was conducted on [DATE] at 1:37 PM with Staff #5 and Staff #6 both PAs (Physicians Assistants). When asked why paper advance directives wouldn't be done instead of verbal, they indicated that Social Services hands them out, they could not answer why they were not completed. They indicated that when a resident is admitted to the facility, they attempt to complete a MOLST within 24 hours of admission. That they are not able to determine someone's capacity. The physician would usually come in within 48 hours. They indicated that the resident is considered capable of making informed medical decision upon arrival unless there is documentation from the hospital indicating that they are not. They indicated that they gauge a resident's ability to complete the MOLST while talking to them. When asked if they review the resident's certifications of capacity to determine the resident's capacity prior to updating a MOLST, Staff #5 indicated No.
(Cross Reference F842)
Based on medical record review and interview, it was determined that the facility staff failed to ensure that 2 physicians' certificates of incapacity were obtained, and Advance Directives were completed as per the Health Care Decisions Act prior to allowing resident representatives to make informed health care decisions on the resident's behalf. This was evident for 7 (#97, #71, #83, #70, #35, #78 and #26) of 26 residents reviewed for advance directives during the survey.
The findings include:
Maryland Medical Orders for Life-Sustaining Treatment (MOLST) is a form which includes medical orders for emergency medical services or other medical personnel regarding CPR (cardiopulmonary resuscitation) and other life sustaining treatment options.
According to the Health Care Decisions Act:
5-602
(d) (1) Any competent individual may make an oral advance directive to authorize the providing, withholding, or withdrawing of any life-sustaining procedure or to appoint an agent to make health care decisions for the individual.
(2) An oral advance directive shall have the same effect as a written or electronic advance directive if made in the presence of the attending physician, physician assistant, or nurse practitioner and one witness and if the substance of the oral advance directive is documented as part of the individual's medical record. The documentation shall be dated and signed by the attending physician, physician assistant, or nurse practitioner and the witness.
(e) (1) Unless otherwise provided in the document, an advance directive shall become effective when the declarant's attending physician and a second physician certify in writing that the patient is incapable of making an informed decision.
According to Centers for Medicaid and Medicare, the definition for Advance directive is a written instruction, such as a living will or durable power of attorney for health care, recognized under State law (whether statutory or as recognized by the courts of the State), relating to the provision of health care when the individual is incapacitated.
1) On [DATE], review of Resident #97's medical record revealed that the resident was admitted to the facility in 2020 with diagnoses that included dementia. Review of the resident's paper chart revealed a MOLST form, dated [DATE], that included a No CPR, Option B, Palliative and Supportive Care order.
Further review of the [DATE] MOLST revealed that the order had been made as a result of a discussion with and the informed consent of the patient's health care agent as named in the patient's Advance Directive. Review of the resident's Advance Directive revealed the appointment of a Health Care Agent to make decisions about my health care if I can't decide for myself anymore. No certifications of incapacity to make health care decisions were found in either the electronic health record or the paper medical record.
Further review of the electronic health record revealed another active MOLST, dated [DATE], which revealed an order to Attempt CPR. This MOLST revealed the order had been made as a result of a discussion with and the informed consent of the patient's health care agent as named in the patient's advance directive.
On [DATE] at approximately 1:50 PM, the Director of Nursing (DON) reported that physician #41, who is the medical director, does an assessment upon admission regarding the resident's capability to make medical decisions. The DON was unable to verbalize the process for obtaining a second certification of incapacity but indicated she would ask.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0688
(Tag F0688)
Could have caused harm · This affected multiple residents
3) On 6/6/22 at 11:33 AM, an observation of Resident #33 revealed that the resident's fingers on both hands were bent in a closed fist position and appeared to be contracted with no splint or device i...
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3) On 6/6/22 at 11:33 AM, an observation of Resident #33 revealed that the resident's fingers on both hands were bent in a closed fist position and appeared to be contracted with no splint or device in either hand.
A contracture is a condition of shortening and hardening of muscles, tendons or other tissue which often leads to deformity and rigidity of joints. ROM (Range of motion) refers to how far a person can move or stretch a body part, such as a joint or muscle. PROM (Passive ROM) means the person does not perform any movement themselves. AROM (Active ROM) means the person performs the movement of a joint entirely by themselves.
On 6/23/22 at 2:00 PM, a review of the Resident #33's medical record revealed that the resident resided in the facility since 2016. Resident #33 had multiple diagnoses including, but not limited to, stroke, dementia, chronic pain syndrome and contracture of unspecified joint. The medical record revealed documentation that Resident #33 had severe cognitive impairment, was totally dependent on staff for all ADLs (activities of daily living), including positioning. On 6/7/22, in a progress note, the PA (physician's assistant) indicated that Resident #33 was aphasic and in a chronic persistent vegetative state with contractures in the resident's upper and lower extremities.
Continued review of the resident's medical record failed to reveal documentation that Resident #33 was receiving or had received treatment or services that addressed the resident's limited range of motion and contractures.
On 6/23/22 at 2:52 PM, when asked if Resident #33 had received treatment to prevent further decline of his/her contractures, the Assistant Director of Nurses (ADON), indicated that he/she would look into it. On 6/23/22 at 4:06 PM, the ADON provided the surveyor with a copy of an Occupational Therapy (OT) Discharge Summary with dates of service 6/29/21 to 7/22/21, which documented the Resident #33 was discharged from OT because the resident had achieved his/her maximum potential and was referred for the RNP (Restorative Nursing Program) to start on 7/23/21. The OT's recommended Resident #33 continue with UE (upper extremity) PROM and positioning with total assist of caregivers to prevent further loss of ROM and indicated a Restorative Range of Motion Program and Restorative Splint and Brace Program had been established for Resident #33 and staff had been trained. The OT documented a visual handout on details of recommended upper body PROM techniques was provided for the ROM program, for the splint/brace program, a visual handout on details of recommended upper body PROM techniques had been provided.
Further review of Resident #33's medical record failed to reveal documentation to indicate that the restorative ROM program and restorative splint and brace program had been implemented as recommended when the resident was discharged from therapy. Review of June 2022 GNA (geriatric nursing assistant) task documentation for ADL care that was provided to Resident #33 found no documentation to indicate the Resident received passive range of motion.
At that time, during an interview, the ADON stated that he/she spoke with the therapist who told her that Resident #33 was seen by therapy in 2021 and, when the resident was discharged , therapy made recommendations for splints and ROM. The ADON stated that the recommendations had not been implemented and indicated that, when a resident was discharged from therapy with recommendations for restorative care, he/she would expect to see a physician's order for the recommendation.
Review of Resident #33's quarterly MDS (Minimum data set) with an ARD (assessment reference date) of 3/26/22, Section G. Functional status, revealed documentation that Resident #33 was totally dependent on staff for all ADLs (activities of daily living), including positioning. The MDS failed to accurately capture Resident #33's functional limitation in Range of Motion. Section G0400. Functional Limitation in Range of Motion, Code for limitation: A. upper extremity (shoulder, elbow, wrist, hand) was coded 0, no impairment, and B. Lower extremity (hip, knee, ankle, foot) was coded 0, no impairment, which was inaccurate.
Review of Resident #33's care plans included 4 care plans that minimally addressed the Resident #33's actual contractures and limited ROM:
a) In a care plan initiated in 2016, for the Resident's potential for impaired tissue integrity r/t immobility, h/o pressure ulcer, incontinence, contractures: multiple joints, moisture, family's request for resident to remain in bed, the goal was Resident #33 will have intact skin, free of redness, blisters or discoloration by/through review date. The interventions had measures to prevent skin breakdown such as side-to-side positioning and turning and positioning, however, there were no interventions that addressed the resident's limited ROM and actual contractures.
b) In a care plan, initiated on 3/8/16, Resident #33 has an ADL self-care performance deficit r/t (related to) multiple strokes, dementia, immobility, blindness, with the goal, the resident will accept routine care from staff, that had interventions which included contractures: the resident has contractures of all extremities. Provide frequent skin care to keep clean and prevent skin breakdown. There were no interventions that addressed the resident's limited ROM and actual contractures.
c) In another care plan, Resident #33 has potential for pain r/t chronic pain syndrome, muscle spasms, contractures all extremities, GERD (gastroesophageal reflux disease) (heart burn), possible nausea, with the goals, Resident #33 will not have discomfort related to side effects of analgesia through the review date and the resident will show no s/s of pain/discomfort through the review date, that included an intervention, provide gentle active and passive ROM as tolerated with care. The care plan intervention was not resident centered as the intervention did not identify the location of Resident #33's contractures, or the resident's joint or body part that was to receive the range of motion. There was no documentation in the medical record to indicate the facility staff followed the care plan and the resident received ROM as tolerated with care. In addition, review of the medical record failed to reveal evidence that the resident would be able able to perform active range of motion.
d) In another care plan that stated Resident #33 has no unassisted physical mobility r/t multiple strokes, with the goal, the resident will remain free of complications related to immobility, including further contractures, thrombus (blood clot) formation, skin-breakdown, fall related injury through the next review date, that interventions, Hoyer lift at all times for transfers, Monitor/document/report PRN (as needed) any s/sx (signs/symptoms) of immobility; contractures forming or worsening, thrombus formation, skin-breakdown, fall related injury, PT, OT referrals as ordered, PRN, and provide gentle range of motion as tolerated with daily care. The care plan was not comprehensive, with resident specific interventions to mitigate the potential complications of Resident #33's limited ROM and actual contractures. The care plan failed to identify the location of Resident #33's contractures or identify the resident's joint or body part that was to receive the range of motion. In addition, the medical record failed to reveal evidence that the facility staff followed the care plan. There was no documentation in the medical record to indicate that Resident #33 was provided gentle ROM with daily care.
No other care plans were found in the record that addressed Resident #33's limited ROM and actual contractures and no documentation was found in the care plans to indicate that the restorative nursing program and the splint/brace program along with the PROM techniques which were recommended by therapy on 7/23/21 had been added to the care plan.
On 6/23/22 at 4:25 PM, the above concerns were discussed with the ADON.
Based on medical record review and interviews, it was determined that the facility failed to have an effective system in place to ensure that restorative nursing services were incorporated into residents' care plans and provided by staff as recommended upon discharge from therapy. This was found to be evident for 3 (#28, #7, #33) of 6 residents reviewed for decline in activities of daily living and positioning.
The findings include:
1) On 6/7/22, Resident #28 was observed to have contractures in both hands. The resident confirmed that his/her hands had been like that since before admission to the facility.
A contracture is a tightening of muscles that causes joints to become stiff, preventing normal movement of the joint. Contractures can be caused by inactivity.
On 6/14/22, review of the medical record revealed orders for occupational therapy (OT) starting in January 2022. The OT orders were discontinued on 2/4/22.
On 6/15/22, review of the 3/17/22 Minimum Data Set assessment revealed the resident had function range of motion impairment on both sides of the body in both upper and lower extremities. Review of the current care plan revealed a plan addressing limited physical mobility which included an intervention to provide gentle ROM as tolerated with daily care, and to monitor for contractures forming or worsening.
On 6/15/22 at 11:39, the Rehab Director (#42) provided a copy of the 2/4/22 OT discharge summary and a Rehab Discharge Program - Occupational Therapy form. An exercise program was attached and that 2-3 sets of 5-10 repititions of Upper Extremity ROM/Strengthening exercises were recommended. The form also included documentation of caregiver training for at least two staff. The Rehab Director reported that they usually recommend that the exercises are completed 3-5 times a week and indicated they would be incorporated into the care plan. He proceeded to look up the current care plan and reported he could not find these exercises in the care plan.
On 6/15/22 at 1:10 PM, during an interview with the resident's GNA (#39) she stated that she/he assisted with ROM, but denied knowledge of any specific instructions for this resident.
On 6/15/22 at 2:18 PM, surveyor reveiwed the concern with the Director of Nursing (DON) and the Assistant Director of Nursing (ADON) that Resident #28 had a restorative plan upon discharge from therapy but no documentation was found to indicate that the plan was implemented.
2) On 6/7/22, review of Resident #7's medical record revealed that the resident had resided at the facility for more than 2 years and whose current diagnoss included but were not limited to dementia, lung disease, and kidney disease. Review of the physician's orders revealed a 12/6/21 order to discontinue occupational therapy services and begin restorative nursing program.
On 6/09/22 at 2:56 PM, the Rehab Director (#42) reported that therapy had recommended range of motion (ROM) and upper extremeity exercises and said that care giver training had occurred. The Rehab Director provided a copy of a Rehab Discharge Program Occupation Therapy form with a start date of 12/31/21 for Restorative care.
Further review of the 12/31/21 Rehab Discharge Program Occupation Therapy form revealed that an exercise program was attached and that 2 sets of 10 repetitions were being recommended. Review of the exercise program documentation revealed 4 different upper extremity exercises using 1-2 lbs weights. The Rehab Discharge Program Occupation Therapy form included documentation that at least 3 staff care givers had received training, including return demonstration, of the restorative program prior to the start date of 12/31/21.
Further review of the medical record failed to reveal documentation regarding a restorative nursing program for the resident or the implementation of the exercises included in the Rehab Discharge Program.
On 6/13/22 at 1:46 PM, surveyor asked nursing supervisor (#34) about an exercise program for Resident #7. After reviewing the resident's care plan in the electronic health record, the nursing suprervisor reported that she did not see anything specific like a restorative program.
On 6/15/22 at 1:10 PM, interveiw with GNA (#39), who was assigned to care for the resident at this time, revealed that she had been working on the unit since April. The GNA reported that ROM exercises were completed with the resident for both upper and lower extremities (arms and legs) but confirmed they were the basic ROM that was completed with everyone. When asked about a restorative nursing program, GNA #39 indicated she was not aware of one for this resident.
On 6/15/22 at 2:18 PM, when asked about the restorative nursing program at the facility, the ADON reported: there was not one in place, that they needed one, and knew they needed one. Surveyor reviewed the concern regarding Resident #7 having an order for a restorative nursing program that included exercises but no documentation was found that the plan had been implemented and that interviews with staff also failed to reveal knowledge of an exercise program.
At the time of exit on 6/24/22 at 2:45 PM, no additional documentation was provided to indicate that the restorative nursing program had been implemented for this resident.
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** A3) A review of Resident #71's paper medical record on [DATE] at 9:10 AM, revealed a MOLST, dated [DATE], that documented No CPR...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** A3) A review of Resident #71's paper medical record on [DATE] at 9:10 AM, revealed a MOLST, dated [DATE], that documented No CPR Option B.
A review of Resident #71's electronic medical record (EMR) revealed under the Misc tab that a MOLST, dated [DATE], had been uploaded and was not voided, therefore, it was still active.
On [DATE] at 1:48 PM, an interview with the DON and Associate Administrator revealed that the facility had identified an issue with the MOLST forms and had implemented a process to have the MOLST in the resident's paper medical record and, once a MOLST was voided, then it could be sent to the Medical Records Department to be uploaded in the electronic medical record. However, they had not checked the MOLST that had been previously uploaded in the electronic medical record to ensure that they had been properly voided.
On [DATE] at 10:02 AM the Assistant Director of Nursing reported that they had found a MOLST dated [DATE] on the paper medical record that had been voided on [DATE]. The ADON provided a copy of the voided MOLST.
The DON and ADON were made aware of the concern on [DATE] at 10:23 AM.
A4) A review of Resident #26's medical record, on [DATE] at 9:04 AM, revealed that a MOLST form, dated [DATE], was in the resident's paper record and scanned in his/her Electronic Medical Record (EMR). A scanned copy of a prior MOLST form, dated [DATE], was also found in Resident #26's EMR. The name of the file of the scanned document was MOLST VOID [DATE] pdf. Review of the scanned document revealed that the facility staff failed to void the older scanned MOLST document as per the MOLST instructions.
In an interview on [DATE] at 10:26 AM with Licensed Practical Nurse (LPN) Staff #1, she was asked where she would look to determine a resident's CPR status, she indicated she would check the paper record for MOLST status stating, we always go by the MOLST in the paper record.
A5) Resident #35's medical record was reviewed on [DATE] at 9:42 AM. His/her paper record contained a MOLST form, dated [DATE]. Review of the EMR revealed a scanned document titled: MOLST VOID 10-8-19.pdf. The document was opened and revealed a prior MOLST form, dated [DATE]. The facility staff failed to ensure that this MOLST form was voided as per the MOLST instructions.
A6) Resident #70's medical record was reviewed on [DATE] at 9:56 AM. A MOLST form dated [DATE] was filed in the resident's paper record indicating No CPR Option B. Review of the resident's EMR revealed a scanned document file named MOLST [DATE].pdf. The scanned document indicated Attempt CPR. The scanned MOLST in the EMR was not voided as per the MOLST instructions.
The Director of Nursing and Assistant Director of Nursing were made aware of these findings on [DATE] at 2:10 PM.
A6) A review of Resident #71's paper medical record on [DATE] at 9:10 AM revealed a MOLST, dated [DATE], that documented No CPR Option B.
A review of Resident #71's electronic medical record (EMR) revealed under the Misc tab that a MOLST, dated [DATE], had been uploaded and was not voided, therefore, it was still active.
On [DATE] at 1:48 PM, an interview with the DON and Associate Administrator revealed that the facility had identified an issue with the MOLST forms and had implemented a process to have the MOLST on the resident's paper medical record and once a MOLST was voided then it could be sent to the Medical Records Department to be uploaded in the electronic medical record. However, they had checked the MOLST that had been previously uploaded in the electronic medical record to ensure that it had been properly voided.
On [DATE] at 10:02 AM, the Assistant Director of Nursing reported that they had found a MOLST, dated [DATE], on the paper medical record that had been voided on [DATE]. The ADON provided a copy of the voided MOLST.
The DON and ADON were made aware of the concern on [DATE] at 10:23 AM.
(Cross Reference F578)
B) Documented completion of treatment interventions that were not provided:
B1) Resident #35 was observed on [DATE] at 2:31 PM with a piece of white elastic mesh stockinette,4-5 inches long, that covered a dressing on the resident's left forearm, approximately midway between his/her wrist and elbow, otherwise his/her arms were bare.
Resident #35's medical record was reviewed on [DATE] at 9:59 AM. The record included a physician's order that was written on [DATE], for arm protectors to bilateral (both) arms at all times. May remove for bathing. Please document if resident declines application. The reason for the order was indicated as For fragile skin.
The record failed to reveal documentation as to why the resident was not wearing his/her arm protectors on [DATE] when observed by the surveyor.
The 6/22 Treatment Administration Record (TAR) included the order for arm protectors with spaces labeled Day Eve and Night for the nurse to sign off that they completed this order each shift.
Additional observations of Resident #35 were made by the surveyor on [DATE] at 2:32 PM, and [DATE] at 11:47 AM. During each of these observations, Resident #35 was lying in bed, arms bare except for the elastic mesh stockinette on his/her left forearm.
Further review of the 6/2022 TAR on [DATE] at 12:32 PM revealed that the order for arm protectors was signed off every shift from [DATE] - [DATE] including day shift on [DATE], [DATE] and [DATE] when the surveyor observed the resident without the arm protectors in place. No documentation was found in the record to indicate that the arm protectors were not applied on those days.
During an interview on [DATE] at 1:28 PM, Staff #56 reviewed and confirmed that she signed off Resident #35's arm protectors for day shift. She then observed Resident #35 with the surveyor and confirmed that the resident was not wearing arm protectors. When asked who was responsible for putting the arm protectors on Resident #35, she stated technically if I'm signing them off, I should be putting them on; but usually the girls will put them on. When asked how she verifies that they are on the resident she stated, it would be by sight.
The Director of Nursing and Assistant Director of Nursing were made aware of these findings on [DATE] at 1:44 PM.
(Cross reference F 684)
C) Failed to document resident behaviors as per the physician's order:
C1) Resident #201's medical record was reviewed on [DATE] at 9:08 AM. The record revealed that resident #201's diagnoses included, but were not limited to, unspecified dementia with behavioral disturbance and delusional disorder. A Plan of Care was developed for: Resident #201 is physically aggressive/combative with staff at times (hitting, kicking, pushing, throwing items) related to dementia, poor impulse control. The Residents goals included but were not limited to: Will demonstrate effective coping skills and will not harm self or others. The interventions that staff were to implement to assist the resident with this problem included, but were not limited to: Monitor/Document observed behavior and attempted interventions in behavior note; Monitor/document/report PRN (as needed) any signs/symptoms of resident posing danger to self and others; When the resident becomes agitated: Intervene before agitation escalates; Guide away from source of distress; Engage calmly in conversation; If response is aggressive, staff to walk calmly away and approach later.
A Physicians order was written with a start date [DATE] for BEHAVIORS - MONITOR FOR THE FOLLOWING: ITCHING, PICKING AT SKIN, RESTLESSNESS (AGITATION), HITTING, INCREASE IN COMPLAINTS, BITING, KICKING, SPITTING, CUSSING, RACIAL SLURS, ELOPEMENT, STEALING, DELUSIONS, HALLUCINATIONS, PSYCHOSIS, AGRESSION, REFUSING CARE, etc. Document: 'N' if monitored and none of the above observed. 'Y' if monitored and any of the above was observed, select chart code 'Other/ See Nurses Notes' and progress note findings. Every shift
Review of the GNA Point of Care (POC) behavior documentation revealed that the GNAs identified that Resident #201 displayed 1 or more behaviors 11 times on 10 out of 31 days in the month of 7/2021 including wandering, abusive language, threatening behavior, pushing, grabbing, yelling/screaming, kicking/hitting, pinching/scratching/spitting and threatening behavior.
Review of Resident #201's Medication Administration Record (MAR) revealed that the nurse documented that the resident had no behaviors on the 10 days as identified by the GNAs POC documentation.
Resident #201's MAR revealed that the only times the nurse documented that the resident had problematic behaviors throughout the month of 7/2021 was on the evening shifts of [DATE] and [DATE]. The corresponding nursing progress note documented agitated on [DATE] and refused meds on [DATE]. The MAR revealed that the nurses failed to identify and document when the resident was displaying problematic behaviors as identified by the GNA's.
The facility staff failed to maintain complete and accurately documented medical records by failing to identify and document observed behaviors on the MAR and observed behaviors and attempted interventions in a behavior note as per the physician's order and Resident #201's Plan of Care. The Director of Nursing and Assistant Director of Nursing were made aware of these findings on [DATE] at 2:10 PM.
Based on medical record review, observation, and interview, it was determined that the facility failed to maintain complete and accurately documented medical records for each resident as evidenced by:
A) Failing to have an effective system in place to ensure that both paper and electronic versions of the MOLST forms were voided when a new MOLST was established for 6 (#97, #7, #71, #26, #35, and #70) of 13 residents reviewed for advance directives. B) Falsely documenting completion of treatment interventions that were not actually provided for 1 (#35) of 13 residents reviewed for abuse. C) Failing to document resident behaviors as per the physician order for 1 (#201) of 13 residents reviewed for abuse.
The findings include:
A) Maryland Medical Orders for Life-Sustaining Treatment (MOLST) is a form which includes medical orders for emergency medical services or other medical personnel regarding CPR (cardiopulmonary resuscitation) and other life sustaining treatment options.
Once a MOLST order form is completed and signed, a new form should be completed and signed whenever there are any changes to any of the orders. To void the MOLST order form, a physician or nurse practitioner shall draw a diagonal line through the sheet, write VOID in large letters across the page and sign and date below the line. The voided order form should be kept in the patient's medical record.
A1) On [DATE], a review of Resident #97's medical record revealed that the resident was admitted to the facility in 2020 with diagnoses that included dementia. Review of the resident's paper chart revealed a MOLST form, dated [DATE], that included a No CPR, Option B, Palliative and Supportive Care order.
Further review of the electronic health record revealed another active MOLST, dated [DATE], which revealed an order to Attempt CPR. The [DATE] MOLST was found in the miscellaneous section of the electronic health record and had been entered on [DATE] and was labeled Molst 7-19-2020.
On [DATE] at 1:48 PM, the Director of Nursing (DON) reported that, when the MOLST orders changed, the old MOLST was taken out, voided, and put under miscellaneous in the hard chart. She went on to report that the voided MOLST is scanned into the electronic health record when the chart is thinned. The surveyor reviewed the concern with the DON and the Associate Administrator that Resident #97's electronic version of the [DATE] MOLST failed to reveal documentation to indicate it had been voided.
On [DATE], the facility provided a copy of the [DATE] MOLST that was documented as having been voided on [DATE].
A2) On [DATE], review of Resident #7's electronic health record revealed a MOLST, dated [DATE], that included orders for No CPR Option A-2.
Option A-2 of the MOLST includes prior to arrest, administer all medications needed to stabilize the patient. If cardiac and/or pulmonary arrest occurs, do not attempt resuscitation (No CPR). Do Not Intubate: Comprehensive efforts may include limited ventilatory support by CPAP or BIPAP, but do not intubate.
No documentation was found in the electronic health record to indicate the [DATE] MOLST had been voided.
On [DATE], review of the paper chart revealed a MOLST, dated [DATE], that included orders for No CPR, Option B, Palliative and Supportive Care.
Option B includes prior to arrest, provide passive oxygen for comfort and control any external bleeding. Prior to arrest, provide medications for pain relief as needed, but no other medications. Do not intubate or use CPAP or BiPAP. If cardiac and/or pulmonary arrest occurs, do not attempt to resuscitation (No CPR). Allow death to occur naturally.
On [DATE] at 9:40 AM, review of copies provided by the facility revealed a copy of the [DATE] MOLST which included documentation of VOID on [DATE].
On [DATE] at 10:02 AM, the ADON reported that the voided [DATE] MOLST was found on the paper chart. The DON and ADON then viewed, with surveyor, that the description in the electronic health record of the [DATE] MOLST states MOLST.pdf and when opened revealed an active (not voided) version of the [DATE] MOLST.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
QAPI Program
(Tag F0867)
Could have caused harm · This affected multiple residents
Based on observations, review of facility records, and resident and staff interview, it was determined that the facility failed to implement an effective Quality Assessment and Assurance (QAA) based o...
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Based on observations, review of facility records, and resident and staff interview, it was determined that the facility failed to implement an effective Quality Assessment and Assurance (QAA) based on repeat deficiencies related to 1) resident abuse, 2) abuse policies and procedures, 3) timely reporting of allegations of abuse to the state agency, 4) conducting a thorough investigation of allegations of abuse, 5) physician notification for a resident's change in condition, 6) notice of bed hold policy, 7) respiratory care services, 8) residents unnecessary medications, 9) improper storage of medications, 10) inaccurate/incomplete medical records, and 11) posting of nursing staff for all units. This was evident for 1 recertification survey reviewed and 1 complaint survey reviewed. The failure to assess and correct identified deficient practices has the potential to affect all residents in the facility.
The findings include:
1) On 6/23/22 at 4:15 PM, a review of a complaint survey that was conducted 9/23/20, 9/24/20 - 10/2/20, and 10/5/20 - 10/8/20, revealed that 4 complaints and 7 facility reported incidents had been reviewed. During the survey, deficiencies were cited for the 1) failure to keep residents free of abuse, 2) failure to develop and implement abuse policies and procedures, 3) failure to report allegations of abuse in a timely manner, and 4) failure to conduct a thorough investigation of allegations of abuse.
During this survey, 13 residents were reviewed for allegation of abuse and the same deficient practices were found. In addition, it was found that the facility failed to revised the Resident Abuse Reporting Policy and Procedure dated 5/2017, as indicated on their plan of correction for a compliance date of 12/1/2020. (Cross Reference F600, F607, F609, and F610)
On 6/23/22 at 4:00 PM, a review of the recertification survey that was conducted on 10/12/18, 10/15/18 - 10/19/18, revealed that following deficiencies were cited, 1) physician notification for a resident's change in condition, 2) notice of bed hold policy had not been given at time of transfer, 3) respiratory care services, 4) resident with unnecessary medications, 5) improper storage of medications, 6) inaccurate/incomplete medical records, and 7) posting of nursing staff for all units.
During this survey the survey team found similar deficient practices as the previous recertification survey. (Cross Reference F580, F625, F695, F757, F761, and F842)
A review of the Quality Assurance (QA) plan on 6/23/22 at 3:05 PM revealed that the facility failed to provide a procedure for QA processes.
An interview with the QA Committee leader, QA Nurse Staff #67 revealed they put action plans in place based on review of trending concerns and conversation with staff and Administration. The action plans were reviewed for effectiveness then additional interventions were put into place if quality had not been improved.
The concerns regarding the abuse allegations, staff reporting of the allegations, and lack of a thorough investigation was discussed with the Administrator and Associate Administrator on 6/16/22 at 4:01 PM.
These concerns were reported to the Director of Nursing and Assistant Director of Nursing on 6/23/22 at 10:23 AM.
2) During observation of the C wing 3rd floor (Canal Side Skylight) Unit on 6/6/22 at 10:49 AM and 6/15/22 at 11:53 AM, the surveyor observed that the facility failed to post required staffing information in a prominent location readily available to residents and visitors. This was confirmed in an interview with Staff #31 on 6/15/22 at 11:55 AM.
On 6/17/22 at 2:58 PM, the surveyor reviewed the results of the facility's last recertification survey. The review revealed that the facility was cited for the same deficient practice involving the same nursing unit during the last recertification survey. The facility's quality assessment and performance improvement committee developed a plan to correct the deficient practice by 12/12/18. However, the plan of action failed to correct the deficient practice and the same deficient practice was again identified during the current survey. The Director of Nursing and Assistant Director of Nursing were made aware of these findings on 6/23/22 at 2:10 PM. (Cross reference F732)
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0887
(Tag F0887)
Could have caused harm · This affected multiple residents
Based on medical record review and staff interview, it was determined the facility failed to document that education was provided regarding the benefits, risks, and potential side effects of receiving...
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Based on medical record review and staff interview, it was determined the facility failed to document that education was provided regarding the benefits, risks, and potential side effects of receiving the COVID-19 vaccine to residents and staff. This was evident for 2 (#21 and #71) of 5 residents and 4 (#28, #35, #46, and #47) of 4 facility staff members reviewed for COVID-19 vaccinations during the survey.
The findings include:
On 6/16/22 at 4:20 PM, a medical record review was conducted for Resident #21. A consent form was found in the resident's paper chart marked as refused COVID-19 vaccine, dated 6/02/21. However, no documentation was found for evidence of education provided under the resident's paper chart or electronic medical record.
A medical record review of Resident #71 was conducted on 6/17/22 at 8:00 AM. The resident signed a COVID -19 Vaccination Declination form on 10/13/21. However, there was no supportive documentation regarding the resident's education regarding the risks or benefits of receiving the vaccine.
During an interview with the Director of Nursing (DON) and Assistant Director of Nursing (ADON) on 6/17/22 at 11:50 AM, they reported the facility did not separately document providing education to residents.
A review of COVID-19 vaccination records for 4 facility staff members was conducted on 6/17/22 at 1:10 PM. Staff #28 was an unvaccinated direct resident care person. On 6/21/22 at 10:15 AM, the DON submitted a COVID-19 Vaccination Religious Exemption Form for Staff #28 that was signed on 11/16/21. However, no supportive documentation was found to support that Staff #28 had received education about the COVID-19 vaccine. Staff #35 was a direct resident care provider who was completely vaccinated without a booster dose. The DON submitted staff #35's COVID-19 vaccination record on 6/21/22 at 10:15 AM. However, there was no documentation that Staff #35 received education regarding the COVID-19 vaccine. Staff #46 was an unvaccinated direct resident care provider . On 6/21/22 at 10:15 AM, the DON submitted a Medical Exemption for Staff #46, which was signed on 1/28/22. However, there was no evidence that Staff #46 received education for the COVID-19 vaccine. Staff #47 was a direct resident care provider who was completely vaccinated without a booster dose. The DON submitted a copy of Staff #47's vaccination records. However, there was no other documentation to support that she/he received COVID-19 vaccine education.
An interview was conducted with the Director of Nursing (DON) and a Registered Nurse (RN) # 40 on 6/22/22 at 12:03 PM. RN #40 had previously held the infection control preventionist role from March 2020 to September 2021. She brought training materials (printed presentation slides) for May 2021 COVID-19 -related training and an attending list that failed to include documentation of the date, the subject, or the title of the training. RN #40 also stated the facility offered each manufacturer's COVID-19 vaccination fact sheet while they held staff training. The submitted training material had 80 staff signatures, including 33 unvaccinated staff for attendance. The DON stated there was 191 staff, including 76 unvaccinated staff, when the training was held. However, the review of training material revealed that it did not include the education regarding COVID-19 vaccination benefits, risks, and potential side effects.
The DON and ADON were made aware above issue on 6/23/22 at 2:30 PM.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Abuse Prevention Policies
(Tag F0607)
Could have caused harm · This affected most or all residents
Based on record review and staff interview, it was determined that the facility failed to develop and implement abuse policies and procedures. This was evident during the survey and has the potential ...
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Based on record review and staff interview, it was determined that the facility failed to develop and implement abuse policies and procedures. This was evident during the survey and has the potential to affect all residents.
The findings include:
On 6/16/22 at 12:24 PM, the Associate Administrator provided a copy of the Resident Abuse Reporting Policy and Procedure and reported that this was the version that was active. It was noted as Corporate Policy - Abuse 5-2017 in the bottom right corner of the policy. A review of the policy and procedure revealed that, on page 2, under Reporting Procedure: Maryland law requires employees to report all alleged violations involving resident neglect, or abuse, including injuries of unknown origin, and misappropriation of property. The first bullet stated to report immediately or within 2 hours of forming the suspicion and the second bullet included documentation to report suspected abuse to the Administrator, or to the immediate supervisor who must then report to the Administrator. On page 3 of the document, it was noted that the Administrator would then fill out a self-report form and submit to the State Agency within 24 hours of receiving the report.
On 6/16/22 at 1:00 PM, a review of the plan of correction for the complaint survey for 10/8/20 in which this deficiency was cited, revealed that the facility reported that, by 12/1/20, the abuse policy and procedure was to be updated by the Administrator. However, the same Resident Abuse Reporting Policy and Procedure dated 5/2017 was still in effect.
Review of 5 (MD00161874, MD00169491, MD00174072, MD00177642, and MD00177857) self-reported incidents involving abuse, that were dated after the compliance date of 12/1/20, were reviewed during the course of the survey, 2 (MD00179320 and MD00180313) self-reported incidents that occurred during the survey revealed several concerns.
4 of the 7 self-reported incidents reviewed were substantiated for abuse.
5 of 7 self-reported incidents of abuse had not been reported to the State Agency within the 2-hour required time frame.
4 of the 7 self-reported incidents reviewed revealed the facility had failed to conduct a thorough investigation.
In addition, review of the Grievance process, on 6/15/22 at approximately 3:00 PM, revealed that Resident #71 had sent an email to a facility staff member with an allegation of abuse regarding Geriatric Nursing Assistant (GNA) #46 dated 5/5/22. The Social Services Associate (SSA) #21 failed to report the allegation to the Administrator or Designee until 5/6/22. The email read, .What I am actually writing about is an aide I want to report. Her name is [GNA #46], she is rude, rough, and let's you know she doesn't care. Last night I woke & my sheet, pad, and brief were wet.she [GNA #46] roughly changed my brief She threw the wet top sheet over me until I insisted a dry new one. The rest of the night was laying in & smelling like urine .
An interview on 6/16/22 at 3:14 PM with the ADON revealed she had interviewed Resident #71 regarding what he/she meant by rough and determined that GNA #46 had been impatient and rude and had not hurt Resident #71 and therefore, had not reported the allegation to the State Agency. However, the ADON failed to address the part of the allegation regarding GNA #46's failure to change Resident #71's bed when it was wet with urine.
During an interview on 6/16/22 at 4:01 PM, it was revealed that the Administrator was the Abuse Coordinator. He reported that, with the changes in the Director of Nursing and Assistant Director of Nursing positions, that the facility had provided on-the-job training for abuse investigation and reporting. The concerns with the self-reported incidents involving abuse had been reviewed with the Administrator and he was made aware of the concerns with staff not reporting within required time frames and not conducting a thorough investigation of the incidents. He reported that he understood the concerns. In addition, the concern that these were repeat deficiencies that had been cited during a complaint survey dated 10/8/20. The Administrator verbalized understanding that the plan of correction had not been fully implemented.
The Administrator was subsequently interviewed on 6/17/22 at 1:50 PM and revealed that he was ok with staff waiting 2 hours to report allegations of abuse to him as stated in the abuse policy. In addition, he reported that the section that stated, the Administrator would report the allegations within 24 hours was inaccurate. When asked about the plan of correction for the complaint survey dated 10/8/20, in which he stated as part of the plan of correction the 5/2017 abuse policy and procedure would be revised by 12/1/20, he reported that the revisions had not been completed. The Administrator reported that he does review the final investigation report for abuse.
In addition, the email that Resident #71 had sent on 5/5/22, with an allegation of abuse was reviewed with the Administrator and Associate Administrator. It was apparent that the Administrator and Associate Administrator had not been aware of the email.
(Cross Reference F600, F609, and F610)
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Pharmacy Services
(Tag F0755)
Could have caused harm · This affected most or all residents
Based on a review of medical records, policies, and other pertinent documentation, observations, and interviews, it was determined that the facility failed 1) to ensure that staff completed the contro...
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Based on a review of medical records, policies, and other pertinent documentation, observations, and interviews, it was determined that the facility failed 1) to ensure that staff completed the controlled drug count at the change of shift as evidenced by missing/inaccurate documentation by nursing staff that the count had been completed prior to the end of the shift, and 2) to ensure that nursing staff routinely signed that the count was correct at the change of shifts. This was evident for 6 (Rehab units 1 & 2, long-term care units A, B, and C) out of 6 medication carts reviewed for the controlled drug count verification sheet.The findings include:
A controlled drug means a drug or other substance that is tightly controlled by the government because it may be abused or cause addiction. The control applies to the way the substance is made, used, handled, stored, and distributed. Controlled substances include opioids, stimulants, depressants, hallucinogens, and anabolic steroids. (National Institutes of Health)
Controlled Drug Count Verification is the shift count sheet for narcotics to maintain controlled drug security. The form has a series of columns that include: date (MM/DD/YY), time (AM, PM), correct drug count (YES, NO), balance verified by the nurse coming on duty (one signature only), balanced verified by the nurse going off duty (one signature only), and comments/documentation. There should be one row of documentation for each change of shift that includes the signatures of the off-going and on-coming nurse. These signatures indicate that the count was completed.
1) Observation of the Controlled Drug Count Verification sheet for Unit B on 6/7/22 at 2:00 PM revealed the day nurse had already signed on the row indicating that the end-of-shift count had been conducted. The ADON confirmed the observation and the concern that the nurse had already signed for the end of the shift.
1a) A controlled drug count verification sheet for Rehab unit-2 was reviewed on 6/8/22 at 1:10 PM. The review of the sheet revealed that, on 5/24/22 at 7 AM, the coming on duty nurse's signature was not recorded, and on 5/24/22 at 2 PM, the going off-duty nurse's signature was not recorded.
1b) A controlled drug count verification sheet for Rehab unit-1 was reviewed on 6/8/22 at 1:23 PM. The review revealed that, on 5/24/22 at night shift, the going off duty nurse's signature was not recorded, and on 5/31/22 at 10 PM, the coming on duty nurse did not sign. On 6/1/22 at 2 PM, the coming on duty signature was missing, and on 6/1/22 at 10 PM, the going off duty signature was missing. Also, on 6/1/22 at 7 AM, an entire column was not filled; correct drug count, coming on duty, and going off duty were not recorded.
On 6/24/22 at 10:54 AM, a review of the facility's policy and procedure named Medication- Narcotics revealed, Narcotics must be counted at the beginning and end of every shift by the Charge Nurse ending the shift and the Charge Nurse beginning the shift., and Both nurses must date and sign the count log for each narcotic.
1c) A controlled drug count verification sheet for long-term care unit B-1 was reviewed on 6/8/22 at 1:38 PM. The record review revealed that:
- 5/23/22 at 3 PM going off duty nurse had not signed
- 5/24/22 at 7 AM coming of duty nurse had not signed
- 5/24/22 at 3 PM correct drug count (yea, no) was not recorded
- 5/27/22 at 7 AM and 3 PM correct drug count were not recorded
- 5/29/22 at 11:00 going off duty nurse had not signed
- 5/31/22 at 7 AM correct drug count was not recorded and coming on duty nurse had not signed
- 5/31/22 at 3 PM going off duty nurse had not signed
- 6/2/22 at 11 PM correct drug count was not recorded and coming on duty nurse had not signed
1d) A controlled drug count verification sheet for long-term care unit A was reviewed on 6/8/22 at 1:50 PM. The record review revealed:
- 5/17/22 at 2 PM going off duty nurse's signature was not recorded
- 5/17/22 at 10 PM coming of duty nurse's signature was not recorded
- 5/22/22 at 7 AM whole column was not filled: correct drug count, coming on duty nurse signature, and going off duty nurse signature was not recorded
- 5/22/22 at 9 AM correct drug count and going off duty nurse were not recorded
- 5/31/22 at 10 PM coming on-duty nurse had not signed
- 5/31/22 at 11 PM going off duty nurse had not signed
- 6/5/22 at 2 PM correct drug count was not recorded
-6/7/22 at 7 AM coming on-duty nurse had not signed.
1e) A controlled drug count verification sheet for long-term care unit C was reviewed on 6/8/22 at 2:00 PM. The record review revealed:
- 5/7/22 at 7 PM whole column was not filled; no data on correct drug count, coming on duty, and going off duty
- 5/7/22 at 11 PM going off duty nurse had not signed
- 5/12/22 at 11 AM coming on duty nurse had not signed
- There was no column for the 5/12/22 evening shift and night shift.
- 5/13/22 at 7 AM going off duty nurse had not signed
- 5/13/22 at 7 PM going off duty nurse had not signed
- 5/24/22 at 7AM correct drug count and coming on duty nurse were not recorded
- 5/24/22 at 3PM going off duty nurse had not singed
- 5/22/22 at 7 AM correct drug count and coming on duty nurse were not recorded
- 5/25/22 at 3 PM correct drug count and going off duty nurse were not recorded
- 5/25/22 at 11 PM correct drug count was not recorded
- 5/27/22 at 11 PM going off duty nurse was not recorded
There were no columns completed for 5/11/22 evening shift, 5/12/22 night shift, 5/14/22 evening shift, 5/15/22 evening shift, 5/16/22 night shift, 5/19/22 evening shift, 5/22/22 evening shift, 5/26/22 evening shift, 5/28/22 evening shift, 5/29/22 evening shift, 6/1/22 evening shift, 6/4/22 night shift, 6/2/22 evening shift, 6/4/22 night shift, 6/5/22 evening shift, 6/6/22 evening shift, and 6/7/22 night shift.
An interview was conducted with the Director of Nursing (DON) on 6/8/22 at 2:21 PM. She stated that the count sheet should be signed by coming on staff (count) and going off staff (verified). She also explained that if a staff member worked 16 hours, they needed to fill out each shift section. For example, a staff working 7 AM - 11 PM must fill out the column 7 AM, 3 PM, and 11 PM.
The DON was aware of the count sheet issue during the interview on 6/8/22 at 2:21 PM.
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, interview and review of relevant documentation, it was determined that the facility failed to ensure that food was stored in accordance with professional standards for food safet...
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Based on observation, interview and review of relevant documentation, it was determined that the facility failed to ensure that food was stored in accordance with professional standards for food safety as evidenced by the facility's failure to 1) have a cleaning schedule for the ice machine; 2) seal and label open containers of food; and 3) ensure that elevated temperatures in the nursing unit food refrigerators were reported to maintenance. This has the potential to affect all residents. The findings include:
On 6/6/22 at 10:00 AM, the following observations were made during a tour of the kitchen with the Executive Chef Staff #43:
-Observation of the ice machine revealed scattered small black dots covering 3/4 of the ceiling of the ice machine. The executive chef was unable to locate a cleaning schedule for the ice machine and was unable to report when it was last cleaned.
- In refrigerator #4, an opened bag containing hotdogs was observed unsealed. Three containers wrapped in foil were not labeled or dated. The executive chef identified these as cheese and removed them from the refrigerator.
2a) On 6/23/22 at 1:46 PM, observation of the Unit C up refrigerator revealed a temperature log that was kept at the refrigerator. Review of this log revealed documentation of 48 degrees on 6/12, 13 and 14. There was a notation on 6/13 that the temperature control was adjusted. The temperature was recorded as 44 degrees on 6/15/22.
Further review of the Unit C up Food Storage Refrigerator Temps log sheet revealed the following documentation: Fridge - Maintain at 36 - 41 degrees and a notation at the bottom **MAINTENANCE TO BE CONTACTED IF TEMP IS OUT OF RANGE**. The log sheet included columns to record the Fridge temp, Freezer temp, the initials of the person recording the reading and a comments section.
Further review of the June 2022 Unit C up temperature log failed to reveal documentation to indicate that maintenance had been notified regarding the elevated temperatures recorded on June 12 through 15.
b) On 6/23/22 at 2:05 PM, a review of the Unit B's Food Storage Refrigerator Temps log sheet for June 2022 revealed temperatures above 41 degrees on June 2, 3, 4, 7, 8, 9, 10, 11, 12, 13, 14, 16, 17, and 19. Six of these fourteen dates had the temperature recorded as 48 degrees, five of the fourteen were recorded as 46 degrees. On 6/14, there was a notation in the comments column adjusted temp. No documentation was found on this log to indicate that maintenance had been notified about the elevated temperatures. The Assistant Administrator was made aware of the documented elevated refrigerator levels on 6/23/22 at 2:05 PM.
On 6/23/22 at approximately 2:35 PM, the food service director (FSD#25), after review of the elevated temperature found on the Unit B and Unit C up refrigerator temperature logs, reported that she was not previously aware of these temperatures. She went on to report that the dietary staff had temperature logs for these refrigerator.
On 6/23/22 at approximately 2:55 PM, the FSD provided temperature logs, with name of dietary contractor at the top of the log, for Unit B and Unit C up. These logs included columns to record the temperature in the morning and the evening and an If Out of Compliance, Record Action Taken.
Review of the June 2022 Unit B log, completed by dietary staff, failed to reveal documentation for temperatures June 6 - 10 or for June 13 - 17, or for June 21, 22 or 23, the Food Service Director reported that her staff have to ask nursing staff to unlock the Unit B refrigerator in order to obtain the temperature. The maximum temperature recorded by the dietary staff was 40 degrees.
Further review of the dietary department temperature logs for the Unit C up refrigerator revealed temperatures were documented in the morning and evening daily. The maximum temperature recorded on the dietary documentation was 39 degrees.
On 6/23/22 at 4:22 PM, surveyor reviewed the concern with Assistant Director of Nursing regarding the failure of nursing staff to notify maintenance when refrigerator temperatures were elevated.
As of time of exit on 6/24/22 at 2:45 PM, no additional documentation was provided to indicate that the elevated temperatures of the Unit C up and the Unit B food refrigerators were reported to maintenance when originally documented.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Administration
(Tag F0835)
Could have caused harm · This affected most or all residents
Based on observation, resident and staff interview and medical record review, it was determined that the facility administration failed to provide effective oversight activities for the facility to en...
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Based on observation, resident and staff interview and medical record review, it was determined that the facility administration failed to provide effective oversight activities for the facility to ensure that the facility had the resources and that those resources were used effectively in order to meet the health and safety needs of each resident and failed to identify and correct inappropriate care processes/standards, as evidenced by 1) failing to revise and update the facility's Resident Abuse Reporting Policy and Procedure, 2) failing to ensure that facility staff protected residents from abuse and neglect, 3) failing to ensure the facility reported investigations to the State Agency within the required time frame, 4) failing to ensure that all allegations of abuse were thoroughly investigated so that the necessary actions could be taken to prevent further abuse. The Administration's failure to ensure that processes were in place that could identify and correct deficient practices in care that had the potential to adversely affect the health and safety of all the residents in the facility.
The findings include:
On 6/23/22 at 4:15 PM, a review of a complaint survey that was conducted 9/23/20, 9/24/20 - 10/2/20, and 10/5/20 - 10/8/20, revealed that 4 complaints and 7 facility reported incidents had been reviewed. During the survey deficiencies were cited for the 1) failure to keep residents free of abuse, 2) failure to develop and implement abuse policies and procedures, 3) failure to report allegations of abuse in a timely manner, and 4) failure to conduct a thorough investigation of allegations of abuse.
1) The facility submitted a plan of correction that was to place the facility back in compliance by 12/1/20. The plan specified that the abuse policies and procedures were to be updated and implemented to adequately prevent, investigate, and correct any future occurrences of abuse, neglect, and exploitation; additional in-servicing for department heads regarding abuse; re-education for all staff on dementia and abuse, and these activities were to be monitored by the Quality Assurance Committee quarterly.
On 6/16/22 at 12:24 PM, the Associate Administrator provided a copy of the Resident Abuse Reporting Policy and Procedure and reported that this was the version that was active. It was noted as Corporate Policy - Abuse 5-2017 in the bottom right corner of the policy. A review of the policy and procedure revealed that, on page 2 under Reporting Procedure,: Maryland law requires employees to report all alleged violations involving resident neglect, or abuse, including injuries of unknown origin, and misappropriation of property. The first bullet stated to report immediately, or within 2 hours of forming the suspicion, and the second bullet had documentation for staff to report to the Administrator, or to their immediate supervisor who must report to the Administrator. On page 3 of the document, it was noted that the Administrator will fill out a self-report form and submit to the State Agency within 24 hours of receiving the report.
An interview with the Administrator on 6/17/22 at 1:50 PM, revealed that he had not updated the Resident Abuse Reporting Policy and Procedure dated 5/2017, as stated in the Plan of Correction. He reported they had a new Director of Nursing and a new Assistant Director of Nursing who had received on-the-job training for abuse reporting and investigation. The Administrator reported that he was the Abuse Coordinator and reviewed the final reports for facility reported incidents and resident grievance forms. (Cross Reference F607)
2) During this survey 11 (#74, #201, #71, #28, #63, #150, #61, #509, #35, and #83) residents were reviewed for allegations of abuse after the date of compliance of 12/2/22. The review revealed that 1 allegation of abuse was substantiated.
On 6/13/22 at 3:38 PM, a review of the facility's investigation file for the self-report MD00174072 revealed that, on 11/7/21 at 2:09 PM, Resident #61 had reported to another employee that Geriatric Nursing Assistant (GNA) #68 had made comments to him/her about GNA #68's daughters eating everything on their plates while shoving the spoon in Resident #68's mouth. In addition, GNA #68 had called Resident #61 a liar and these comments had upset him/her. Resident #61 was found to have no injuries. GNA #68 was suspended pending the investigation. The self-report was sent to the State Agency on 11/8/21 at 1:55 PM. Witness statements had been collected from staff and residents and the facility substantiated Resident #61's allegation of abuse, terminated GNA #68, and reported the abuse to the certification board. (Cross Reference F600)
3) During this survey, it was determined that reports regarding allegations of abuse for 4 (#28, #71, #61, and #35) of the 11 residents reviewed for abuse had not been sent to the State Agency within the required 2-hour time frame.
3a) On 6/14/22, review of the facility reported incident MD00177857 revealed that Resident #28 reported to a nurse on 5/28/22, that on 5/26/22, GNA #13 stated you have a big butt. The report had not been sent to the State Agency until 5/31/22. Further review of this incident revealed that the Assistant Director of Nursing (ADON) had been made aware of this allegation of abuse via email from Geriatric Nursing Assistant (GNA) #55 on 5/27/22, but failed to report the allegation of abuse at that time.
3b) On 6/15/22 at approximately 3:00 PM, a review of the email that Resident #71 had sent to SSA (Social Services Assistant) #21 on 5/5/22 at 12:00 PM revealed that Resident #71 alleged that GNA #46 had been rough while providing incontinence care and had left Resident #71 in a bed with urine-soaked pad and sheets. Further review revealed that SSA #21 had failed to immediately report the concern to the Administrator, but had forwarded the email on 5/6/22 at 2:03 PM to the Social Services Director, Director of Nursing, Assistant Director of Nursing, and Registered Nurse #40. Review of the Concern Form completed by the ADON on 5/6/22 revealed she determined Resident #71 had meant GNA #46 was impatient and rude with him/her during care. However, the ADON failed to address the concern with GNA #46 failing to provide care and services needed by allowing Resident #71 to lay in urine-soaked bed linens and failed to report the allegation of abuse to the state agency.
3c) On 6/13/22 at 3:38 PM, a review of the Facility's Investigation file for the self-report MD00174072 revealed that the facility's self-report form that documented the facility was made aware on 11/7/22 at 2:09 PM of an allegation of abuse from Resident #61 who reported Geriatric Nursing Assistant (GNA) #68 had made comments to Resident #61 about the fact that her daughters eat all the food on their plates, calling Resident #61 a liar, and while feeding Resident #61 was shoving the spoon in his/her mouth. However, the facility failed to report the allegation of abuse to the state agency until 11/8/21 at 1:55 PM almost 24 hours after the allegation was made.
3d) Complaint #MD00161874 was reviewed on 6/9/22 at 10:47 AM. The complaint was received by the State Agency from Adult Protective Services (APS). The complaint indicated that APS received an allegation from an anonymous caller that Resident #35 was fine when visited on 12/24/20 and observed with bruising on the face and neck on 12/27/20, and that the resident said that he/she was punched in the face in the middle of the night by a big black lady.
The Director of Nursing was asked to provide documentation regarding any incidents related to Resident #35 from December of 2020. Documentation was provided to the surveyor and reviewed on 6/10/22 at 8:00 AM.
The facility's documentation included an email communication, dated 1/4/21 at 2:52 PM, between Social Work Associate (SSA) Staff #2, Previous Director of Nursing (DON) Staff #7, and the former Assistant Director of Nursing (ADON) Staff #54. Staff #2 indicated in the email that she received a call from the Ombudsman regarding an APS referral she received. The email included The referral stated that this person visited the resident on December 24th and he/she was fine and came again on December 27th and the resident was badly bruised and had swelling. When asked what happened the resident stated, A big black lady came in and punched me in the face The email response from Staff #7 on 1/4/22 at 3:40 PM included I guess we should have reported this .at least we have an investigation on file and when he/she was interviewed originally, he/she didn't say this. On 1/4/21 at 4:05 PM, Staff #7 sent another reply in which he stated, Actually in looking at it we have a good note regarding his/her behaviors and that the bruise was self-inflicted so nothing to report. Staff #67 did an investigation just to be on the safe side, but it looks like everything is order. However, the facility failed to report the allegation of abuse to the State Agency. (Cross Reference F609)
4) It was determined that the facility failed to conduct a thorough investigation for 4 (#28, #35, #63, and #83) of 11 residents that had allegations of abuse reported.
4a) On 6/14/22, a review of the facility investigation documentation for the reported incident MD00177857 revealed the resident reported to a nurse on 5/28/22 that on 5/26/22 GNA #13 stated you have a big butt. There was a typed statement, dated 5/31/22, which indicated it was a verbal statement from GNA #13 obtained via telephone by [name #14]. Further review of the investigation documentation failed to reveal documentation to indicate interviews were conducted with any other staff or residents.
On 6/14/22, review of the Corporate Abuse Policy Investigation and Reporting [provided during the survey, but failed to include a revision date] revealed:
Role of the Investigator:
1. The individual conducting the investigation will, as a minimum:
g. Interview staff members (on all shifts) who have had contact with the resident during the period of the alleged incident
i. Interview other residents to whom the accused employee provides care or services
4b) A complaint #MD00161874 was reviewed on 6/9/22 at 10:47 AM. The complaint was received by the State Agency from Adult Protective Services (APS). The complaint indicated that APS received an allegation from an anonymous caller that Resident #35 was fine when visited on 12/24/20 and observed with bruising on the face and neck on 12/27/20, and the resident said that he/she was punched in the face in the middle of the night by a big black lady.
On 6/10/22 at 8:00 AM, further review of this incident revealed email documentation which indicated that the facility was made aware of the allegation of abuse from the Ombudsman but failed to report it to the State Agency. In addition, the facility had failed to conduct a thorough investigation of the allegation of abuse.
4c) Review of the facility's investigation file for the self-reported incident #MD00180313 on 6/14/22 at 10:04 AM revealed a self-report that documented Resident #63 had reported to the facility that GNA #9 had thrown his/her newspapers away when Resident #63 had asked her not to. Further review of the investigation file revealed that the facility staff had interviewed the resident and taken a statement from GNA #9 and had not interviewed other residents who had received care from GNA #9 or any other staff who may have witnessed the incident. According to the education form GNA #9 was educated regarding resident rights and allowed to continue to work with vulnerable residents. (Cross Reference F610)
An interview with the Administrator on 6/16/22 at 4:01 PM revealed that he was the Abuse Coordinator. When asked about the education of staff regarding abuse, he reported that he provides abuse training during orientation and that GNA #55 provides the training annually. The Administrator reported that the Director of Nursing and Assistant Director of Nursing received on the job training for conducting a thorough investigation on allegations of abuse. In regards to the the abuse allegation that had not been reported in the time frame required and had not been investigated thoroughly, he agreed that the facility had some more work to do regarding training staff about abuse reporting and investigating.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0886
(Tag F0886)
Could have caused harm · This affected most or all residents
Based on record review and interview, it was determined that the facility failed to have an effective system in place to ensure staff who were not up to date with COVID immunizations, including unvacc...
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Based on record review and interview, it was determined that the facility failed to have an effective system in place to ensure staff who were not up to date with COVID immunizations, including unvaccinated staff, were tested according to state and federal guidelines. This was found to be evident for 19 out of 22 staff (Geriatric Nurse Aide #9, #18, #24, #27, #31, #39, #46, #47, #48, #49, #50, #51, #55, Licensed Practical Nurse #1, #19, #32, Registered Nurse #34, #35, and Social Worker #21) not up to date staff reviewed for COVID-19 testing during the survey This deficient practice has the potential to affect all residents, staff, and visitors in the facility.
The finding includes:
COVID-19 Vaccine up-to-date means a person has received all recommended COVID-19 vaccines, including any booster dose(s) when eligible. (Center of Disease Control: CDC)
The CDC has developed COVID-19 Community Levels to help communities decide what prevention steps to take based on the latest local COVID-19 data. Levels are determined each week for each county in the U.S. A county's risk level can be low, medium, or high based on a combination of three metrics: the number of new local COVID-19 cases; the number of new local COVID-19 hospital admissions; and the proportion of local hospital beds occupied by patients with COVID. Level of COVID-19 Community Transmission Minimum Testing Frequency of Staff who are not up-to-date:
- Low (blue): Not recommended
- Moderate (yellow): Once a week
- Substantial (orange): Twice a week
- High (red): Twice a week
During an entrance conference with the Director of Nursing (DON) and the Assistant Director of Nursing (ADON) on 6/6/22 at 8:30 AM, they were asked about COVID -19 Staff Vaccination Status. The DON submitted the COVID-19 staff vaccination status form on 6/6/22 at 11:32 AM. The DON stated that the facility currently had 189 staff, including 93 who completed the COVID-19 Vaccine (without booster), 57 who were up-to-date with COVID-19 Vaccine, and 39 unvaccinated staff.
The line listing is one type of epidemiologic database and is organized like a spreadsheet with rows and columns. Typically, each row is called a record or observation and represents one person or case of disease. (Center for Disease Control and Prevention)
On 6/17/22 at 2:10 PM, a review of the line listing for the COVID-19 outbreak revealed that 5 residents and 4 staff tested positive for COVID -19 on 4/25/22, 1 resident and 1 staff tested positive for COVID-19 on 4/27/22, and 1 staff tested positive on 4/30/22. All the residents who tested positive for COVID-19 resided in the same unit, and 5 of the 6 staff who tested positive (LPN#4, #29, GNA #48, #62, and CMA #28) had worked in the same unit where the COVID 19 positive residents had resided.
On 6/17/22 at 2:20 PM, a review of the facility's weekly staff testing logs revealed that CMA (Certified Medicine Aide) #28, LPN (Licensed Practical Nurse) # 29, and GNA (Geriatric Nursing Assistant) #48 tested positive for COVID-19 who worked in the same unit that COVID-19 positive residents resided the week of 4/25/22 and had not done the weekly test on the week of 4/17/22, which was a week prior to the start of the COVID-19 outbreak.
On 6/22/22 at 09:50 AM, a review of the facility's policy COVID-19 Mitigation; C0VID Testing plan indicated that the minimum testing frequency of staff who was not up-to-date based on level of community transmission: Low-not recommended, moderate -once a week, substantial -twice a week, and high- twice a week.
Further review of the facility's documentation for county positive rate revealed:
- On 4/15/22: moderate transmission rate, all staff continues to test weekly regardless of vaccine status.
- On 4/21/22: out of outbreak on 4/21/22, staff will be required to test only if not up to date on covid -19 vaccine. Moderate transmission rate.
- On 4/25/22: all staff, regardless of vaccination status, will test once a week, effective immediately.
Also, a review of the facility's policy COVID-19 Vaccine Exemptions & Accommodations indicated, All unvaccinated employees are required to submit to twice-weekly testing (or more frequently if indicated by Federal, State, or Local law or guidelines or WRV) regardless of the community transmission rate. All results must be entered into the testing database, SimpleReport.
On 6/22/22 at 10:50 AM, a review of the COVID-19 Staff Vaccination Status submitted by the Director of Nursing (DON) on 6/6/22 revealed that CMA #28 was unvaccinated. On 6/22/22 at 2:30 PM, a review of the unit assignment sheet from 4/19/22 to 4/24/22 revealed that Staff #28 worked in a unit where the outbreak was identified on 4/19/22, 4/20/22, and 4/21/22. However, the review of the SimpleReport (submitted by the Infection Control Preventionist (ICP) on 6/22/22 at 11:28 AM) revealed documentation that CMA #28's last COVID-19 test at the facility was on 4/6/22. During an interview with the Assistant Director of Nursing (ADON) on 6/23/22 at 10:16 AM, she stated that Staff #28 tested for COVID -19 positive on 4/27/22 at-home test and reported to the facility. The DON confirmed that CMA #28 did not do the COVID-19 test weekly.
Per the COVID-19 Staff Vaccination Status submitted by the DON on 6/6/22, it was confirmed that LPN #29 was unvaccinated. On 6/22/22 at 2:30 PM, a review of the unit assignment sheet showed that LPN #29 worked in the unit where the COVID-19 outbreak was identified on 4/21/22. However, LPN #29's last negative COVID-19 test was on 3/10/22, prior to testing positive on 4/25/22. During the interview with the ADON on 6/23/22 at 10:16 AM, she confirmed that LPN #29 did not have other documents to support her weekly COVID-19 test.
A review of the COVID-19 Staff Vaccination Status revealed that GNA #48 was not up-to-date for the COVID-19 vaccine. A review of the unit assignment sheet on 6/22/22 at 2:30 PM revealed that GNA #48 worked the unit where the COVID outbreak occurred on 4/23/22 and 4/24/22. However, GNA #48's last SimpleReport for COVID-19 test was on 4/1/22, prior to testing positive on 4/25/22. During the interview with the ADON on 6/23/22 at 10:16 AM, she confirmed that the facility did not have GNA #48's weekly COVID-19 test result. The ADON confirmed that, on 4/25/22, they tested positive for COVID-19 in a test that was done by herself at home and then reported to the facility.
On 6/22/22 at 09:40 AM, the Infection Control Preventionist (ICP) was asked to provide the facility staff's COVID-19 test results from 4/25/22 to current. At 11:28 AM on 6/22/22, the ICP brought a copy of SimpleReport. The ICP explained all the COVID-19 test results should upload to SimpleReport.
The surveyor randomly selected 20 staff who were not up-to-date: 10 completed vaccine staff (without booster shot) and 10 unvaccinated staff, and reviewed the selected staff's COVID-19 test records on 6/22/22 at 10:20 AM.
According to the facility's documentation for the County Transmission level (submitted by the DON on 6/22/22), the COVID-19 Community level of the week 5/1/22 was moderate (moderate level required COVID-19 test once a week for not up-to-date staff). A review of the SimpleReport on 6/22/22 at 11:50 AM revealed that 14 of 20, not up-to-date staff were not listed on it for the week of 5/1.
The COVID-19 County Transmission Level of week 5/8/22 was moderate, and 9 of 20, not up-to-date vaccination staff did not have a COVID-19 test record on the SimpleReport for the week of 5/8/22.
Week of 5/15/22's COVID-19 County Transmission Level was high per the facility documentation (data extracted from CDC COVID Tracker). Per the CDC guidelines (Ref: QSO-20-38-NH), the facility should test all staff who are not up-to-date twice a week. However, the SimpleReport did not show that 17 of 20 not up-to-date vaccinated staff tested twice a week to meet CDC's requirement.
The COVID-19 County Transmission Level of week 5/22/22 and week 5/29/22 were high. Per SimpleReport recording, 16 of 20, not up-to-date vaccinated staff did not test for COVID-19 twice a week on the week of 5/22/22. And 12 of 20 not up-to-date staff were not tested twice a week on the week of 5/29/22.
The County Transmission Level of COVID-19 on week 6/5/22 was high. However, a review of SimpleReport revealed that 13 of 20, not up-to-date staff, had no documentation of having had a COVID test for a week of 6/5/22.
The week of 6/12/22's County Transmission Level of COVID-19 was high. The facility provided SimpleReport did not include a COVID-19 test twice a week for 12 of 20, not up-to-date vaccinated staff.
During an interview with the DON on 6/23/22 at 10:16 AM, she was asked if the facility had any staff who refused COVID-19 testing. She said, Not that I know of. As of the time of exit, no additional documentation was provided regarding testing refusal.
On 6/23/22 at 11:50 AM, surveyor reviewed with the DON and ADON the concern regarding the failure to include testing staff who are not up-to-date on the COVID-19 Vaccine, including unvaccinated staff.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0888
(Tag F0888)
Could have caused harm · This affected most or all residents
Based on interviews with facility staff, a review of the facility's policies and procedures, and a review of the facility's testing documentation, it was determined that the facility failed to impleme...
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Based on interviews with facility staff, a review of the facility's policies and procedures, and a review of the facility's testing documentation, it was determined that the facility failed to implement their policies and procedures for testing staff who were granted an exception for COVID-19 vaccinations. This deficient practice has the potential to affect all residents, staff, and visitors in the facility.
The finding includes:
On 6/22/22 at 09:40 AM, the facility's policy and procedure titled Vaccine Exemptions & Accommodations was reviewed. It stated, All unvaccinated employees are required to submit to twice-weekly testing (or more frequently if indicated by Federal, State, or Local law or guidelines or WRV) regardless of the community transmission rate. All results must be entered into the testing database, SimpleReport., and all unvaccinated staff are required to wear an N95 while in the facility unless eating or drinking during break times.
The surveyor randomly selected 10 unvaccinated staff on 6/22/22 at 10:20 AM and reviewed their COVID-19 testing record from 5/1/22 to 6/18/22 (for 7 weeks). A review of the SimpleReport data revealed that the following unvaccinated staff; GNA (Geriatric Nurse Assistant) #18, GNA #27, GNA #31, GNA #46, GNA #49, GNA #50, GNA #51, GNA #55, and LPN (Licensed Practical Nurse) #1 had missed at least one or more tests per week during the 7-week window.
- LPN #1 tested twice a week for three weeks and once a week for four weeks
- GNA #18 did test twice a week for three weeks, tested on ce a week for three weeks, and no test was done for a week
- GNA #27 tested on ce a week for five weeks and did not test for two weeks
- GNA #31 did test twice a week for three weeks, tested on ce a week for two weeks, and no test was done for two weeks
- GNA #46 had tested twice a week for one week, tested on e time a week for three weeks, and no test was done for three weeks
- GNA #49 had only one test for a seven week window
- GNA #50 tested twice a week for one week, tested on ce a week for four weeks, and not tested for two weeks
- GNA #51 tested on ce a week for two weeks, and no record for testing for five weeks
- GNA #55 had twice a week test for two weeks, tested on ce a week for four weeks, and no test was done for a week.
On 6/22/22 at 11:48 AM, during an interview with the ICP, she stated that the facility had been conducting COVID-19 tests twice a week for unvaccinated staff. The ICP was asked how the staff's COVID-19 testing was tracked. The ICP said, I recently started to audit the COVID testing log. I randomly selected 10 staff for auditing. I made the DON and the ADON aware that the staff hads not been testing twice a week as they are supposed to. I have been sending them the compliance updates for testing on May 15th. However, as of the time of exit, no other documentation was submitted by the ICP to support that the facility tracked unvaccinated staff's COVID-19 testing.
From 11:20 AM to 1:00 PM on 6/23/22, the surveyor observed each unit to monitor unvaccinated staff's use of N95 masks as indicated in the facility policy. There was 6 unvaccinated staff working in the entire building on the 6/23/22 day shift. 5 (GNA #27, CMA #28, LPN #29, LPN #30, and GNA #31) of 6 staff were not wearing N95 mask.
On 6/23/22 at 3:10 PM, the surveyor reviewed with the DON and the ADON the concerns regarding the failure to implement the COVID-19 policy and procedure for testing staff who were granted an exception for COVID-19 vaccinations.
MINOR
(B)
Minor Issue - procedural, no safety impact
Deficiency F0625
(Tag F0625)
Minor procedural issue · This affected multiple residents
Based on medical record review and staff interview, it was determined that the facility 1) failed to notify the resident and/or resident's Representative Party (RPs) in writing of the bed hold policy ...
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Based on medical record review and staff interview, it was determined that the facility 1) failed to notify the resident and/or resident's Representative Party (RPs) in writing of the bed hold policy upon transfer of a resident to an acute care facility (Resident #88, 78 and 102) and 2) and failed to ensure that the policy included the required information. This was evident for 4 (Resident #7, #78, #88, and #102) of 4 residents reviewed for transfers out of the facility. The findings include:
1a) A review of Resident #88's electronic and paper medical record on 6/09/22 at 10:23 AM revealed that the resident had a change in condition on 5/01/22. The physician was notified and ordered the resident to be transferred to the hospital for evaluation related to decreasing O2 saturation and altered mental status. Further review of Resident #88's medical record documentation revealed that the responsible party was called, however, there was no written documentation that the responsible party and/or resident was given a copy of the bed hold policy.
An interview was conducted with the Director of Nursing (DON) on 6/14/22 at 3:02 PM. She stated that the facility initiated a transfer packet with a transfer out report sheet and a notice of resident transfer or discharge at the end of May 2022. She also said, before we started to use the form, I'm not sure how the staff documented the bed hold policy. The DON was asked to provide the facility policy and procedure for the bed hold policy. She submitted the Bed Hold Policy and Notice of Transfer on 6/15/22.
1b) A review of Resident #78's electronic and paper medical records on 6/16/22 at 1:12 PM revealed that the resident was transferred to the hospital on 4/20/22 for evaluation of altered mental status. Resident #78's medical record documentation revealed that the responsible party was called, however, there was no written documentation that the responsible party and/or resident was given a copy of the bed hold policy.
1c) A closed record review of Resident #102's electronic and paper medical records on 6/23/22 at 3:30 PM revealed that the resident transferred to the hospital on 4/9/22 due to shortness of breath. However, there was no written documentation that the responsible party and/or resident was given a copy of the bed hold policy.
2) A review of Resident #7's electronic and paper medical records on 6/16/22 at 9:49 AM revealed the resident was transferred to the hospital on 5/14/22 for evaluation related to weakness on both hands and lethargy. A copy of the Notice of Resident Transfer or Discharge form was filed on Resident #7's paper chart with the RP's signature and date; however, the form did not include how long a facility will hold the bed, how to reserve bed payments would be made, and the conditions upon which the resident would return to the facility.
On 6/16/22 at 11:00 AM, a review of the facility's policy Bed Hold Policy and the Notice of Transfer which were submitted by the DON on 6/15/22 was conducted. The policy showed, The facility must notify the patient (if capable and alert) or the resident representative in writing within 24 hours. This is to include notice of transfer and bed hold policy. There was no other detail was written in the policy.
During an interview with the DON on 6/17/22 at 8:20 AM, she was made aware by the surveyor of the incomplete transfer packet.
During an interview with the DON and ADON on 6/23/22 at 2:10 PM, they were made aware of incomplete bed hold policy concerns by the surveyor. No additional documentation was provided at the time of the survey exit regarding the bed hold policy concerns.
MINOR
(C)
Minor Issue - procedural, no safety impact
Transfer Notice
(Tag F0623)
Minor procedural issue · This affected most or all residents
Based on a review of medical records and other pertinent documentation and interviews, it was determined that the facility failed to ensure that the written transfer notice included all the required i...
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Based on a review of medical records and other pertinent documentation and interviews, it was determined that the facility failed to ensure that the written transfer notice included all the required information including the right to appeal. This was found to be evident for 3 (#78, #88, and #102) out of the 4 residents reviewed for hospitalization during the survey. The findings include:
1) A review of Resident #88's electronic and paper medical record on 6/09/22 at 10:23 AM revealed that the resident had a change in condition on 5/01/22. The resident's medical record revealed documentation that the resident was sent to a hospital for evaluation and treatment, and the Responsible Party (RP) was called. However, there was no written documentation related to the resident transfer or discharge notice.
2) A review of Resident #78's electronic and paper medical records on 6/16/22 at 1:12 PM revealed that the resident was transferred to the hospital on 4/20/22 for evaluation of altered mental status. A nurse's note, dated 4/22/22, showed that the resident's RP was notified regarding the transfer to the hospital. However, there was no written notification on the resident's medical records.
3) A closed record review of Resident #102's electronic and paper medical records on 6/23/22 at 3:30 PM revealed that the resident transferred to the hospital on 4/9/22 due to shortness of breath. However, there was no written documentation regarding the transfer notice.
On 6/9/22 at 10:23 AM, an interview was conducted with Licensed Practical Nurse (LPN) #32. She explained that the facility staff should prepare a filled-out Notice of Resident Transfer or Discharge form, a copy of the bed hold policy, and a copy of the MOLST (Medical Order for Life-Sustaining Treatment) form for the transfer.
On 6/14/22 at 3:02 PM, an interview with the Director of Nursing (DON) was conducted. She stated that the facility recently recognized they did not have a system for documenting notice of resident transfer or discharge, so they created a transfer packet in May 2022. She said, since we started the form in May 2022, before the time, we did not have any documentation to support written transfer notice provided to residents. The transfer packet was reviewed with the DON during the interview. However, the packet did not include all the required information including the right to appeal.
The concern was addressed with the DON at 3:10 PM on 6/14/22.
Oct 2018
29 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Notification of Changes
(Tag F0580)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the medical record and interview with the resident and staff, it was determined that the facility failed to n...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the medical record and interview with the resident and staff, it was determined that the facility failed to notify the Physician and Dietician when a resident had a significant weight loss. This was evident for 1 (#97) of 11 residents reviewed for Nutrition.
The findings include:
During an interview, on 10/16/18 at 9:20 AM, Resident #97 indicated that he/she had lost a few pounds since his/her last weight. A review of the resident's medical record on 10/17/18 revealed that Resident #97's weight was recorded on his/her weight record as 122.2 lbs. (pounds) on 8/3/18. He/She was hospitalized [DATE], returned to the facility on 9/6/18 with a readmission weight on 9/8/18 of 111 lbs. this reflected a 11.2 lb., or 9.17% weight decrease from 1 month prior. Further review of the record failed to reveal that the Physician or Dietician had been notified when Resident #97 was assessed to have had the significant weight loss. On 10/18/18 at 8:26 AM, Staff #1 (the Director of Nursing) was made aware of the above findings and confirmed that neither the dietician nor the physician had been notified of the resident's significant weight loss. During a telephone interview on 10/18/18 at 12:14 PM Staff #9 (the Dietician) indicated that he/she was not notified of Resident #97's significant weight loss. Cross reference F - 692.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0582
(Tag F0582)
Could have caused harm · This affected 1 resident
Based on review of Medicare beneficiaries who were discharged from skilled therapy and nursing services and interview with staff it was determined that the facility staff failed to provide 1 (#268) of...
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Based on review of Medicare beneficiaries who were discharged from skilled therapy and nursing services and interview with staff it was determined that the facility staff failed to provide 1 (#268) of 3 Medicare beneficiaries reviewed with a written notice of Medicare Provider Non-Coverage.
The findings include:
The SNFABN (Skilled Nursing Facility Advanced Beneficiary Notice of Non-coverage) provides information to residents/beneficiaries that services may no longer be covered by Medicare and addresses the resident's liability for payment should they wish to continue receiving the skilled services. The NOMNC (Notice of Medicare Non-coverage) informs the beneficiary of his or her right to file appeal of the decision and right to an expedited review of Medicare non-coverage of services.
On 10/19/18 at 2:00 PM, a review of the SNF Beneficiary Protection Notification Review worksheet completed by the facility indicated that Resident #268 was discharged from skilled services on 5/2/18 with benefit days remaining. The worksheet indicated that a SNFABN form and NOMNC form had not been provided to the resident/representative because the original discharge was 4/30/18, family requested 5/4/18 when ALF (Assisted Living Facility) had a room available for transfer.
On 10/19/18 at 2:56 PM, during an interview, Staff #19 confirmed that Resident #268 had not been issued the required SNFABN notice and NOMNC letter.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0583
(Tag F0583)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2) 10/15/18 at 12:12 PM, during an observation of Resident #78 in the Canal Side Terrace-B Sunroom, the Surveyor observed a ther...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2) 10/15/18 at 12:12 PM, during an observation of Resident #78 in the Canal Side Terrace-B Sunroom, the Surveyor observed a therapy staff person come in and conduct an interview with the Resident #78. At the time of the interview, Resident #78 was sitting at a table near the window and there were multiple residents in the room in the area near the resident. There were two residents observed sitting in wheel chairs and to the right of the resident, there was a table with 3 residents. The facility staff must respect a resident's right to personal privacy.
The Director of Nurses was made aware of these findings on 10/18/18 at 3:32 PM.
Based on observation, it was determined that facility staff 1) failed to protect a resident's medical record from public view and 2) failed to take steps to provide a resident privacy during an interview. This was evident for 1 of 3 medication carts observed during the survey and for 1 (#78) of 8 residents in Canal Side Terrace-B observed for the initial pool process of the survey.
The findings include:
Observation was made, on 10/19/18 at 1:59 PM, of an unattended medication cart which was sitting outside of room [ROOM NUMBER]. There was a laptop computer sitting on top of the medication cart that was open. The screen displayed Resident #366's medication administration record (MAR) which displayed what medications Resident #366 was prescribed. Also sitting on the side of the medication cart was an opened Controlled Substance Tracking Form which displayed the names of 6 residents. Staff #18 walked up to the medication cart at 2:01 PM and completed a task. The surveyor walked away from the medication cart and then proceeded to walk back up to the unattended medication cart at 2:03 PM. The computer screen displayed the desktop with various applications. The computer screen was not locked.
Staff #2 was advised on 10/19/18 at 2:30 PM.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0624
(Tag F0624)
Could have caused harm · This affected 1 resident
Based on medical record review and staff interview it was determined that he facility failed to orient, prepare and document a resident's preparation for a transfer to the hospital. This was evident f...
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Based on medical record review and staff interview it was determined that he facility failed to orient, prepare and document a resident's preparation for a transfer to the hospital. This was evident for 2 (#16, #78) of 10 residents reviewed for hospitalization.
The findings include:
1) On 10/12/18 at 2:30 PM, a review of Resident #16's medical record revealed documentation that, on 5/14/18, the Resident #16 was transferred to the emergency room for an acute change in condition related to hematuria (blood in urine) and vomiting blood. Review of Resident #16's medical record did not reveal any documentation that the resident had received an explanation as to why he/she was going to the emergency room and the potential response of the resident's understanding.
2) On 10/15/18 at 3:20 PM, a review of Resident #78's medical record documented that on 9/29/18, Resident #78 was transferred to the hospital emergency room for evaluation of shortness of breath and an increased heart rate. Review of the resident's medical record did not reveal any documentation that the resident had received an explanation as to why he/she was going to the emergency room and the potential response of the resident's understanding.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Assessment Accuracy
(Tag F0641)
Could have caused harm · This affected 1 resident
Based on observation, medical record review and staff interview, it was determined the facility staff failed to ensure Minimum Data Set (MDS) assessments were accurately coded. This was evident for 1 ...
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Based on observation, medical record review and staff interview, it was determined the facility staff failed to ensure Minimum Data Set (MDS) assessments were accurately coded. This was evident for 1 (#72) of 4 residents reviewed for dental.
The findings include:
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.
On 10/15/18 at 11:47 AM, an observation of Resident #72 revealed that the resident was edentulous (did not have any natural teeth). On 10/18/18, review of Resident #72's medical record revealed that on 9/8/18 in a Nursing Admission/readmission Assessment, the nurse documented the resident did not have his/her own teeth.
Review of Resident #72's admission assessment MDS with an assessment reference date (ARD) of 9/17/18, 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.
On 10/18/18 at 12:00 PM, during an interview, Staff #6 confirmed the MDS inaccuracy.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0661
(Tag F0661)
Could have caused harm · This affected 1 resident
Based on medical record review and staff interview, it was determined the facility failed to have a discharge summary written and available to go with a resident to another facility upon discharge. Th...
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Based on medical record review and staff interview, it was determined the facility failed to have a discharge summary written and available to go with a resident to another facility upon discharge. This was evident for 1 (#43) of 3 residents reviewed for discharge.
The findings include:
Review of Resident #43's medical record on 10/17/18 documented that, on 10/5/18, resident discharged today to another facility. {name} arrived at 3:00 PM to take resident and belongings to new facility. The noted ended, d/c (discharge) packet sent with EMTs.
Further review of the medical record revealed the physician's discharge summary that was in the medical record was dated 10/14/18 which was 9 days after Resident #43's discharge. Discussed with the Director of Nursing (DON) on 10/18/18 at 10:50 AM. The DON stated, the discharge summary should have gone with the resident.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0679
(Tag F0679)
Could have caused harm · This affected 1 resident
Based on observations, medical record review and staff interview, it was determined the facility failed to implement an ongoing resident centered activities program designed to meet the interests and ...
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Based on observations, medical record review and staff interview, it was determined the facility failed to implement an ongoing resident centered activities program designed to meet the interests and support the physical, mental and psychosocial well-being of each resident. This was evident for 1 (#8) of 1 residents reviewed for activities.
The findings include:
On 10/15/18 through 10/19/18 of the survey, daily, intermittent observations of Resident #8 were made at various times of the day. Resident #8 was never observed in an activity or having a 1:1 (one on one) activity with facility staff. On each observation, Resident #8 was observed in the resident's room, in bed or in a wheel chair located in the hall outside of the resident's room.
On 10/19/18, review of Resident #8's medical record revealed that the resident was cognitively impaired and dependent on the facility staff for activities of daily living. On 10/19/18 at 11:02, during an interview, when asked if Resident #8 participated in activities, Staff #11 (Life Enrichment Assistant Director), stated that the resident's activity participation was up and down, that the resident loved music, loved sitting outdoors in the sun, during the summer and was encouraged to attend activites. Staff #11 stated that Resident #8 was provided 1:1 visits, which included spiritual support and reading him/her the mail and each unit had a 1:1 schedule that was followed. Staff #11 stated he/she would provide the surveyor with documentation of Resident #8's participation in activities and the resident's 1:1 visits.
On 10/19/18 at 1:14 PM, Staff #4 (Life Enrichment Director) and Staff #11 provided the surveyor with 3 Activity Participation notes for Resident #8. 1) On 2/7/18 at 11:04 AM, the Director of Life Enrichment documented that the Resident #8 had not attended any group programs since the last review and declined invitations to group programs and continued to receive 1:1 visits from Life Enrichment Staff. 2) On 5/17/18 at 3:40 PM, the Assistant Director of Life Enrichment documented that Resident #8 had attended 3 group programs over the last 3 months, declined invitations frequently, required strong encouragement to attend and received 1:1 visits from Life Enrichment Staff. 3) On 7/25/18 at 3:09 PM, the Assistant Director of Life Enrichment documented that Resident #8 enjoyed bingo, musical performances, front porch visits, pet visits and sundae Sunday; the resident frequently declined invitations, required encouragement to attend and was provided 1:1 visits by the Life Enrichment Staff. No other documentation was provided to the surveyor to confirm that Resident #8 was encouraged to participate in activities, attended activities, or of 1:1 visits.
Staff #4 and Staff #11 confirmed that there was no documentation that Resident #8 received 1:1 visits.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0698
(Tag F0698)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation and staff interview, it was determined the facility failed to ensure that a resident...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation and staff interview, it was determined the facility failed to ensure that a resident who received dialysis services 1) had fluids monitored, 2) had the fistula site monitored and 3) had a resident centered care plan for dialysis. This was evident for 1 (#103) of 3 residents reviewed for discharge.
The findings include:
Review of the medical record for Resident #103 on 10/17/18 revealed the resident was initially admitted to the facility on [DATE]. A social service note, written on 9/11/18 at 10:01 AM, stated, goes to dialysis 3x a week, family transports. The 9/17/18 physician's progress note documented that the resident had end stage renal disease (ESRD), on HD (hemodialysis) and had multiple comorbidities. The resident was sent out to the hospital on [DATE] and re-admitted to the facility on [DATE].
Review of October 2018 physician's orders for Resident #103 revealed that the resident was monitored for intake and output every shift prior to being sent to the hospital on [DATE], however was not monitored since return to the facility on [DATE]. A second order palpate the thrill and auscultate the bruit to AV fistula in left arm was done every shift prior to hospitalization on 10/7/18, however, had not been done since return to the facility on [DATE].
On 10/17/18 at 2:05 PM, the nurse, Staff #5, was asked if the resident was on a fluid restriction. Staff #5 stated, I don't know but he/she should be because of dialysis. The surveyor and Staff #5 walked into Resident #103's room and there was a full cup, 480 ml., of water in a cup on the resident's over the bed tray table. Staff #5 walked out of the room into the hallway and asked four staff members in the hall, which included 2 Geriatric Nursing Assistants (GNA), 1 Certified Medicine Aide (CMA) and 1 LPN (Licensed Practical Nurse) if the resident was on a fluid restriction. The 4 staff members stared at Staff #5 and Staff #5 stated to the surveyor, well that was a deer in the headlights look if I ever saw one.
The surveyor asked Staff #5 if there was a care plan for dialysis. Staff #5 looked in the medical record and confirmed there was no care plan for dialysis.
Staff #10 was asked on 10/19/18 at 11:20 AM, if Staff #10 checked the resident's fistula site, palpated the thrill and auscultated the bruit. Staff #10 stated, I do not check the site except to put the gel on the site before he/she goes to dialysis. He/she is new to us on this floor. He was on the rehab unit. He is over here temporarily.
On 10/19/18 at 1:25 PM, the Director of Nursing (DON) stated, I would expect that the site would be checked each shift. The DON was advised of the above and stated, we rarely get dialysis patients.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0710
(Tag F0710)
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 and interview with the resident and staff, it was determined that the facility failed to e...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on Review of the medical record and interview with the resident and staff, it was determined that the facility failed to ensure that a physician, physician assistant, nurse practitioner or clinical nurse specialist supervised the immediate care and needs for a resident with significant weight loss. This was evident for 1 (#97) of 11 residents reviewed for Nutrition.
The findings include:
During an interview, on 10/16/18 at 9:20 AM, Resident #97 indicated that he/she had lost about 4 pounds since his/her last weight and added that he/she received Redi care supplements with meals. Review of the residents record on 10/17/18 at 10:28 AM revealed a physician's order for Renal diet, regular texture with thin liquid consistency. There was no physicians order for nutritional supplements. The residents weight record revealed that he/she weighed 122.2 lbs. (pounds) on 8/3/18. The resident was hospitalized from [DATE] - 9/6/18 and upon return from the hospital his/her weight on 9/8/18 was 111 lbs. reflecting a 9.17% (11.2 lb.) weight loss in 1 month. A 5% loss in 1 month or 10% loss in 6 months is considered significant. The record failed to reveal that the facility staff notified the physician or the dietician when the resident was assessed to have the significant weight loss. A review of the residents' care record revealed that the resident had received a Readi Care shake at 12:00 PM and 5:00 PM from 10/1/18 - 10/18/18 and at 7:00 AM on 10/18/18 and Magic cup 12:00 PM and 5:00 PM starting 10/14/18 at 5:00 PM, although there was no current physicians order for either. Progress notes reveal that Resident #97 was seen by a primary care practitioner on 9/7/18, 9/10/18, 9/11/18 and 9/17/18 with no mention of the resident's weight loss in the progress note. The progress note dated 9/21/18 indicated Weight stable.
On 10/18/18 at 8:26 AM, Staff #1 confirmed that neither the Dietician nor the Physician had addressed Resident #97's weight loss. Staff #1 later confirmed that there were no current orders in the residents record for the supplements, that an order for the Readi Care shake was not rewritten upon Resident #97's readmission, however, it was carried over on his/her care record and that somehow the Magic Cup order was added to the care record as well, but no actual physicians order had been written for the Magic Cup. Cross reference F-692.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0805
(Tag F0805)
Could have caused harm · This affected 1 resident
Based on observations and staff interview, it was determined that facility failed to provide the correct consistency of a diet as prescribed by a physician. This was identified for 1 (#29) of 11 resid...
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Based on observations and staff interview, it was determined that facility failed to provide the correct consistency of a diet as prescribed by a physician. This was identified for 1 (#29) of 11 residents reviewed for nutrition and during 2 of 2 meal time observations.
The findings include.
On 10/17/18, Observations of the lunch time meal service in the Canal Side Heights dining room revealed that resident #29 was served Salisbury steak that was chopped. The resident's tray/meal ticket indicated both chopped meats and ground meat. A speech language pathologist (Staff #25) was in the dinning room at the time working/observing another resident. Upon interview of the speech language pathologist (SLP), she confirmed that Resident #29 was to receive ground meat and Resident #29 did not receive the correct texture of meat. The SLP acknowledged working with Resident #29 and due to swallowing difficulties and subsequently, the resident's diet was changed to a ground meat consistency. Review of Resident #29's medical record later in the day revealed a change to the prescribed diet on 10/15/18. The order in the electronic record read Regular diet mechanical soft texture ground consistency.
A second lunch time meal observation on the Canal Side Height was conducted on 10/18/18. Resident #29 was observed at 1:00 PM with chopped meat and not ground meat on the plate. On the day of the observation,Resident #29 was assisted with feeding by a Geriatric Nursing Assistant (GNA) (Staff #15). When asked, Staff #15 confirmed that he/she was not feeding the resident #29 ground meat. The Director of Culinary Services (Staff #22) was notified of Resident #29 receiving the incorrect meat consistency on 10/18/18.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Resident Rights
(Tag F0550)
Could have caused harm · This affected multiple residents
Based on observation and resident interview, it was determined the facility failed to treat residents in a dignified manner as evidenced by 1) failing to serve all residents at the same table at the s...
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Based on observation and resident interview, it was determined the facility failed to treat residents in a dignified manner as evidenced by 1) failing to serve all residents at the same table at the same time during dining observations, and 2) failing to cover a urinary drainage bag. The observations were noted during 2 of 2 lunch time dining in the Canal Heights dining room.
The findings include.
1) A lunch time dining observation was made on 10/17/18 at 12:35 PM in the Canal Side Heights dining room. Residents #40 and #15 were sitting next to each other at a table in the dining room. At 12:41 PM, resident #40 was served her/his meal tray. Resident #40 indicated/stated that she/he would like to eat at the same time as her/his table mate. Staff were observed serving other tables. Resident #15 was served her/his tray at 12:49 PM. At another table of 8 residents, 5 residents were observed to be eating by 12:45 PM, with three residents waiting. One (resident #33) of the three residents was served her/his lunch tray at 12:56 PM. The next resident #29 was served her/his lunch tray at 1:00 PM. The last resident (#113) at the table of 8 was served her/his tray at 1:02 PM. This was 17 minutes after over half the residents at the same table were eating.
A second observation was conducted on 10/18/18 in the same Canal Side Height's dining room, beginning at 12:48 PM. At the beginning of the observations, 2 residents, at a table of 4 residents, were already eating from their lunch tray. A third resident was served a tray at 12:50 PM. The fourth resident (#13) seated at the table with the others, received her/his tray at 1:10 PM. This was 22 minutes after two of the residents were observed to be eating. At another table of 4 residents, 1 resident was observed to be eating at 12:48 PM. The third resident at the table was served her/his tray at 1:04 PM and the fourth resident was served her/his tray at 1:10 PM.
Failing to provide meals to all residents at a table at the same time does not promote an environment that maintains or enhances each resident's dignity.
2) Resident #49 was observed sitting in his/her wheelchair in a dining room during the lunch-time meal on 10/18/18 at 12:50 PM. An exposed urinary catheter bag was observed lying on the floor underneath the wheel-chair and not covered. (A urinary catheter is used as a conduit to drain urine from the bladder into an attached bag or container.)
The facility staff failed to promote Resident #49's dignity by failing cover the resident's urinary drainage bag while in a public area of the facility.
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) The facility failed to develop a comprehensive care plan that included contact precautions as an intervention for Resident #1...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4) The facility failed to develop a comprehensive care plan that included contact precautions as an intervention for Resident #102's communicable, antibiotic-resistant infection.
Isolation precautions, which include contact precautions, are categories of additional equipment that aid in protecting residents and staff members from certain infectious processes that a resident's illnesses may cause. Contact precautions include the addition of a gown and face shield to the gloves and hand hygiene that staff members use when interacting with the resident. Methicillin-Resistant Staphylococcus Aureus (MRSA) is an antibiotic-resistant organism that can infect a patient via several different vectors. Depending on how much exposure visitors and staff members may have to a MRSA infection, contact precautions may be initiated to prevent transfer of the organism from person to person.
Resident #102's medical record was reviewed on 10/17/2018 at 9:30 AM. During the review, it was found that the resident was most recently admitted with a diagnosis of MRSA of the Left knee. Licensed Practical Nurse (LPN) #29 was interviewed on 10/16/2018 at 11:40 AM who stated that s/he was the charge nurse for Resident #102's unit at the time. LPN #29 also stated that Resident #102 was on contact precautions.
Further review of Resident #102's medical record demonstrated that no intervention of contact precautions was a part of the resident's care plan. These concerns were reviewed with the director of nursing during the course of the survey.
5) On 10/15/18 at 11:47 AM, Resident #72 was observed to not have any teeth. On 10/17/18, a review of GNA (geriatric nursing assistant) documentation for the past 30 days indicated that Resident #72 had upper dentures that were used intermittently and the resident was on a mechanically altered diet. Continued review of Resident #72's medical record revealed that the resident had multiple diagnosis and was receiving Hospice Services.
Review of Resident #72 care plans failed to reveal a resident centered plan of care to address the resident's special nutritional needs related to the resident's multiple diagnosis and dental status. The Director of Nurses was informed of the above findings on 10/17/18 at 1:43 PM
6) On 10/15/18 a review of Resident #78's medical record revealed the resident was admitted to the facility at the end of August 2018 following a surgical repair of a right hip fracture. On 8/30/18, in a Nutritional Assessment Note, the dietician documented that Resident #78's past medical history included, but was not limited to: cerebrovascular accident (stroke), seizure disorder, hypertension, hiatal hernia (a condition in which part of the stomach pushes up through the diaphragm muscle), GERD (heart burn) and gallstones. The dietician further documented that the resident reported that food feels like it get stuck in the resident's throat at times r/t hiatal hernia and that the resident is on medications with nutritional implications.
Review of Resident #78's care plans failed to reveal a nutrition care plan to address Resident #78's special nutritional needs.
7) On 10/12/18 at 2:14 PM, an observation Resident #16 revealed the resident's urinary catheter drainage bag (bag connected to a tube which drains urine from the bladder) was uncovered and hanging on the side of the resident's bed that was visible from the room's entrance door. On 10/15/18 at 11:15 AM, an observation of Resident #16 revealed the resident's urinary catheter drainage bag was uncovered and lying on the floor on the on the side of the resident's bed that was visible from the room's entrance door. On 10/18/18 at 12:30 PM, 2 surveyors made an observation of Resident #16's urinary drainage bag. The bag was uncovered and lying on the floor on the side of the resident's bed that was visible from the room's entrance door. At that time, Staff #7 was informed of these findings and confirmed the findings.
A review of Resident #16's care plans revealed a care plan The resident has a Foley catheter that had a Catheter intervention that included Position catheter bag and tubing below the level of the bladder and away from entrance room door. The facility staff failed to follow the care plan by failing to position Resident #16's catheter bag and tubing away from the entrance room door.
Based on medical record review and interview with facility staff, it was determined that the facility failed to develop comprehensive and implement comprehensive, resident-centered care plans to meet the residents medical, nursing, mental and psychosocial needs. This was evident for 7 (#97, #63, #103, #102, #72, #78, #16) of 38 residents reviewed during the investigation phase of the survey.
The findings include:
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.
1) Resident#97's medical record was reviewed on 10/16/18 at 2:38 PM. The resident had been hospitalized from [DATE] - 9/6/18 and returned with a Cholecystostomy tube (a temporary tube inserted through the abdominal wall to drain the gall bladder) in his/her abdomen. No plan of care was developed to direct the resident's care and treatment related to the drainage tube. The resident had plan of care for Chronic Pain with the goal: The resident will verbalize adequate relief of pain or ability to cope with incompletely relieved pain through the review date. The resident had another plan of care for psychosocial wellbeing problem (actual or potential) related to Recent Admission, Disease Process: MS (Multiple Sclerosis. The goal was: Resident will have no indications of psychosocial wellbeing problem by/through review date. The plans were not person centered and did not clearly identify what staff were to measure to evaluate the residents progress or lack of progress toward reaching his/her stated goals.
2) Resident #63's record was reviewed on10/17/18 at 11:21 AM. A nutritional assessment dated [DATE] indicated Significant Change Category: Extreme risk of malnutrition. A Nutrition/Dietary progress note dated 9/20/18 indicated that the care conference team met with the family of Resident #63 that day, discussed food preferences and reviewed meal intake and supplement regimen. Further review of the record failed to reveal that a nutrition plan of care had been developed to address Resident #63's unique nutrition needs. During an interview on 10/18/18 at 2:00 PM Staff #1 was made aware of these findings and was asked about the facility's process for creating a care plan. She indicated that when new issues arise the nurses initiate the care plan and the MDS (minimum data set) nurse reviews to make sure that everything is included.
3) Review of the medical record for Resident #103 on 10/17/18 revealed the resident was admitted to the facility on [DATE] with diagnoses of CHF (congestive heart failure) along with hypertension, MI (myocardial infarction - heart attack), COPD and renal failure requiring dialysis 3 times per week. The nursing admission summary dated [DATE] at 00:20 stated, oxygen saturation 92% on 2L. The note continued, States SOB (short of breath) on exertion. Resident gets dialysis on M-W-F. Has an AV fistula in the left upper arm with a good thrill and bruit.
Review of care plans developed and implemented for Resident #103 failed to produce resident centered care plans for Resident #103's respiratory status related to oxygen, dialysis and nutrition related to monitoring for fluid overload and special nutritional needs related to dialysis.
Cross Reference F695 and F698
Reviewed with the Director of Nursing on 10/19/18 at 1:25 PM.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0657
(Tag F0657)
Could have caused harm · This affected multiple residents
6) On 10/16/18, review of Resident #73's physician orders revealed a 4/14/17 order for Oxygen continuous via NC (nasal cannula) at 3 LPM (liters per minute) every shift.
A review of Resident #73's ca...
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6) On 10/16/18, review of Resident #73's physician orders revealed a 4/14/17 order for Oxygen continuous via NC (nasal cannula) at 3 LPM (liters per minute) every shift.
A review of Resident #73's care plans revealed a care plan The resident has altered respiratory status r/t (related to) COPD (chronic obstructive pulmonary disease), sleep apnea (sleep disorder in which breathing repeatedly stops and starts) that included the intervention Oxygen settings: 02 (oxygen) via nasal cannula @ 2 L (liters)/minute. The intervention was initiated and revised on 4/5/17. The facility failed to revise the Resident #73's plan of care to reflect the resident's current Oxygen administration rate.
Continued review of Resident #73's care plans revealed a care plan The resident has potential fluid deficit r/t diurectic use that included the intervention TED (Thrombo-Embolic Deterrent) (blood clot preventer) stockings that was initiated on 4/3/17. Review of Resident #73's physician orders failed to reveal an order for TED stockings.
7) Review of Resident #16's care plans had the care plan The resident has altered cardiovascular status that included the intervention TED hose on in am, off pm which was initiated on 9/22/14. Review of Resident #16's October 2018 GNA (geriatric nursing assistant) documentation revealed the GNA documented TED hose were applied to Resident #16 on 5 of 18 days. Review of Resident #16's physician orders failed to reveal an order for Resident #16 to wear TED hose. On 10/17/18 at 2:20 PM, during an interview, Staff #5 confirmed that Resident #16 did not have a physician order for TED hose. The care plan was not updated to reflect that Resident #16 no longer had a physician order for TED hose.
Continued review of Resident #16's care plans revealed a care plan The resident has a Foley catheter (tube inserted into the bladder to drain urine) that had a Catheter intervention that included The resident has a 16 Fr (French) Foley catheter; change Foley and bag every four weeks which was last revised on 11/8/16. Review of Resident #16's physician orders revealed a 5/21/18 order Change Foley catheter only if malfunction occurs as needed. The care plan was not updated to reflect the physician order to change the Foley only when needed.
5) Resident #100's record was reviewed on 10/16/18 at 10:46 AM and revealed the resident experience a 9.26% (significant weight loss) in one month. His/Her weight dropped from 106.2 pounds on 9/1/18 to 97.2 pounds on 10/1/18. The resident had a plan of care for significant weight loss with decreased PO (oral) intake which may be related to dementia and anxiety. The resident's goal was: Intake of meals will be 50-75% and 50-75% of supplements. Weight will be stable within 5% of 105 pounds or will gain 1-3 pounds per month. Resident #100's weight of 97.2 pounds reflected 7.43% below the resident's goal of 105 pounds and the resident did not gain 1-3 pounds per month, therefore the resident did not reach his/her goal. The plan indicated Revision on 10/18/18 by (Staff #6) but did not reflect that it had been reviewed after a significant weight loss or that the interventions had been evaluated for revision.
4) Review of the discharge care plan for Resident #43 revealed the goal the resident will (specify) verbalize/communicate an understanding of the discharge plan and describe the desired outcome by the review date. The care plan was initiated on 7/20/18 and revised on 8/24/18. Review of the medical record revealed a physician's certification of competency and/or dependent status which documented on 7/20/18 that the resident was not competent to understand his/her medical condition and to make informed decisions. The resident had a BIMS (brief interview of mental status) of 4 on a 1 to 15 scale which indicated severe cognitive impairment. The care plan was not updated to reflect the goal as Resident #43 would not be able to understand the discharge plan.
Based on observation, record review and interview with facility staff it was determined that facility staff failed to revise resident plans of care to reflect residents' current status. This was evident but not limited to 7 (#60, #34, #41, #43, #100, #16, #73) of 38 residents residents reviewed during the investigative phase of the survey.
The findings include:
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.
1) Review of Resident #60's medical record revealed a care plan The resident uses antidepressant medication Remeron r/t (related to) depression. The goal was The resident will be free from discomfort or adverse reactions related to antidepressant therapy through the review date. The care plan was initiated on 6/26/18. Documentation for this plan of care revealed that the goal was revised on 9/25/18 as the target date for the goal was changed to 12/20/18. Interview of the MDS assessment coordinator (staff #6) revealed that she had simply changed the goal date. Staff #6 was informed that the resident was not receiving any antidepressant medication. Review of the discontinued orders and the medication administration record for June 2018 revealed that resident #60 only received the antidepressant medication Remeron for 3 days (June 4 to June 6, 2018). This plan of care did not reflect the resident's current problems. Documentation in progress notes revealed that a quarterly care plan meeting was held on 9/20/18. As of 10/18/18, there was not any documentation related to quarterly evaluations for all of resident #60's care plans.
2) Resident #34 was admitted to the facility in October of 2017. Review of resident #34's medical record on 10/17/18 revealed that resident #34's cognition is severely impaired. A care plan was initiated on 10/9/17 stating; The resident wishes to return home with family but will need LTC (long term care). The goal is written as The resident will communicate an understanding of the discharge plan and describe the desired outcome by the review date. Interventions for the plan of care, dated 10/9/17, stated encourage the resident to discuss feelings and concerns with impending discharge, Evaluate the resident's motivation to return to the community and make arrangements with required community resources to support independence post-discharge. Review of care plan evaluation notes did not reveal any evaluations related to the stated goals and the stated interventions. The goal date was simply revised on 10/10/18 to a new date of 10/25/18, without any revisions to interventions.
3)Resident #41 was admitted to the facility in November of 2017. One of the care plans that was developed on admission indicated: Resident has psychosocial well-being problems related to LTC (long term care) from ALF (assisted living facility). The goal to this identified was The resident will demonstrate adjustment to nursing home placement by next review. The documentation in the medical record did not address evaluations related to this specific care plan. A social service's note of 8/14/18 stated; MDS assessment completed for 08-10-18. Staff interview preferred. Resident is anxious and continues to be combative at times with care. Continue with goals and approaches. A second note, written by social service on the same date (8/14/18) stated Resident continues to be appropriate for LTC continue with goals and approaches. The interventions to meet the goal has not changed since the initiation of the plan of care dated 11/24/17. The MDS (minimal data set) assessment coordinator (staff #6 simply changes the quarterly target date.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0676
(Tag F0676)
Could have caused harm · This affected multiple residents
2) Review of the medical record for Resident #30 on 10/19/18 revealed an order that was written on 10/5/18 that stated d/c PT (discontinue physical therapy) begin RNP (restorative nursing program). Re...
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2) Review of the medical record for Resident #30 on 10/19/18 revealed an order that was written on 10/5/18 that stated d/c PT (discontinue physical therapy) begin RNP (restorative nursing program). Resident #30 had diagnoses of presence of unspecified artificial hip joint, fracture of unspecified part of neck of left femur, difficulty walking, multiple fractures of ribs, wedge compression fracture of T5-T6 vertebra and dementia.
Review of Resident #30's care plan resident has limited physicial mobility r/t dementia, impaired balance/gait, weakness with the goal resident will remain free of complications related to immobility, including contractures, thrombus formation, skin breakdown, fall related injury through the next review date, that was revised on 10/19/18, had the intervention provide gentle range of motion (ROM) as tolerated with daily care. The nursing rehab/restorative intervention stated, ACTIVE ROM Program: Upper extremity, while seated of fingers, wrist, elbow, shoulder. Repetitions of 10, Sets 2. Encourage daily ROM. Lower extremity active while in bed of hip, knee, ankle. Rep:10, sets:1 which was initiated on 5/9/17 and revised on 10/11/18. A second intervention NURSING REHAB/RESTORATIVE: Walking Program: CGA (Certified Geriatric Assistant) to min assist with
FWW 20 feet on average in room and corridor. Patient is crouched when walking. Please encourage ambulation to bathroom.
Further review of Resident #30's medical record revealed a Rehab Discharge Program Physical Therapy form with a start date of 10/6/18 which had Restorative checked off and had directions for lower extremity range of motion/strengthening while seated, Active to hip, knee, ankle with 10 repetitions, 1 set. There were signatures of the 4 GNAs (Geriatric Nursing Assistants) that were trained how to do the range of motion from the physical therapist.
On 10/19/18 at 10:30 AM, Staff #15 (a GNA) stated, we are short staffed and when we only have 3 people we can't get everything done and that includes walking. The acuity level on the second floor is higher. Staff #14, a GNA that signed the form that he/she was trained by the physical therapist stated, I don't actively do that. I thought it meant for him/her to put his/her legs in his/her pants. I do not actively do ROM. Staff #7, the resident's nurse, stated on 10/19/18 at 10:30 AM that he/she was not aware of the restorative nursing order.
On 10/19/18 at 11:05 AM, the Director of Nursing stated that they did not have an active restorative program as they did not have the staff to get that program working with dedicated restorative aids.
Based on resident family and staff interview and medical record review, it was determined the facility failed to provide the necessary care and follow-up to ensure that residents received the appropriate treatment and services to maintain, and/or improve ambulatory status. This was evident but not limited for 2 (#9, #30) of 2 residents reviewed for restorative.
The findings include:
1) Interview of resident #9's daughter, on 10/12/18 at 3 PM, revealed a concern that resident #9 was to be walked daily. Resident #9's daughter indicated that there was not enough staff to assure her loved one was routinely walked. Review of resident #9's care plans revealed care planning for limited physical mobility r/t weakness, history of left distal femur fracture, pain related to chronic left leg cellulitis, impaired vision and hearing. The goal for this plan of care was The resident will maintain current level of mobility (able to walk with a walker and one assist) through next review. This plan of care was initiated on 6/23/16. One intervention was written as Ambulation the resident requires standby/limited assist by staff to walk dated 10/26/18. An intervention revised on 8/7/18, indicated; Nursing rehab/restorative: Walking program CGA (certified geriatric assistant) with gait belt in place and using front wheeled walker up to 40ft in room and corridor. Precautions: wheelchair to follow. The goal has not been changed as the resident requires the assist of two to be provide with this walking program. Other nursing rehab/restorative interventions list 40 reps of upper extremity active and passive ROM to fingers, wrist, elbows, and shoulders. On 10/19/18, review of the documentation by the geriatric assistances revealed that the resident was last walked on 10/11/18 for 5 minutes. On 10/10/18, the staff documented 5 minutes of walking. On 10/4/18, staff on day shift charted that resident #9 had refused. Documentation revealed that the resident was not walked between 10/10/18 and 9/29/18. The staff documented on all three shifts. All the times resident was not walked, staff documented not applicable.
Interview of the director of nursing, on 10/19/2018 at 9:05 AM, revealed that the facility does not have an active restorative program as the facility does not have dedicated restorative aids to maintain a more consistent restorative program.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0692
(Tag F0692)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on Review of the medical record and interview with the resident and staff, it was determined that the facility failed to e...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on Review of the medical record and interview with the resident and staff, it was determined that the facility failed to ensure that a resident maintained acceptable parameters of nutritional status. This was evident for 1 (#97) of 11 residents reviewed for Nutrition.
The findings include:
During an interview, on 10/16/18 at 9:20 AM, Resident #97 indicated that he/she had lost about 4 pounds since his/her last weight and added that he/she gets Redi care supplements with meals. Review of the residents record, on 10/17/18 at 10:28 AM, revealed a physician's order for Renal diet, regular texture with thin liquid consistency. There was no physicians order for nutritional supplements. The residents weight record revealed that he/she weighed 122.2 lbs. (pounds) on 8/3/18. The resident was hospitalized from [DATE] - 9/6/18 and upon return from the hospital, his/her weight on 9/8/18 was 111 lbs. reflecting a 9.17% (11.2 lb.) weight loss in 1 month. A 5% loss in 1 month or 10% loss in 6 months is considered significant.
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. Resident #97 had a nutrition care plan for potential nutritional problems with the goal: resident will maintain adequate nutritional status as evidenced by maintaining weight within 5% of 128# and will tolerate textures without adverse effect through next review. The interventions included but were not limited to: Provide supplements as ordered and RD (Registered Dietician) to evaluate and make diet change recommendations PRN (as needed). The residents' weight of 111 lbs. was 13.28% less than his/her goal weight of 128 lbs., however, the record failed to reveal that the facility staff notified the physician or the dietician that the resident was assessed to have a significant weight loss, that an admission nutrition assessment was performed when the resident was readmitted from the hospital, that the RD evaluated and made diet change recommendations when Resident #97 had a significant weight loss as per the plan of care, or that the resident's plan of care had been reviewed and revised when the resident had a significant weight loss. A review of the residents' care record revealed that the resident had received a Readi Care shake at 12:00 PM and 5:00 PM from 10/1/18 - 10/18/18 and at 7:00 AM on 10/18/18 and Magic cup 12:00 PM and 5:00 PM starting 10/14/18 at 5:00 PM, although there was no current physicians order for either. Progress notes reveal that Resident #97 was seen by a primary care practitioner on 9/7/18, 9/10/18, 9/11/18 and 9/17/18 with no mention of the resident's weight loss in the note. The progress note, dated 9/21/18, indicated Weight stable.
On 10/18/18 at 8:26 AM, Staff #1 confirmed that neither the Dietician nor the Physician had addressed Resident #97's weight loss. A telephone interview was conducted with Staff #9, the Dietician on 10/18/18 at 12:14 PM. She indicated that she did not complete a readmission assessment for Resident #97, and that nursing staff did not notify her of the resident's weight loss. She indicated that she discovered the resident's weight loss when she pulled up the resident's weights for her quarterly review, saw the resident on 10/11/18 and ordered the Magic Cup supplements at that time. The surveyor inquired as to how she updated the nutrition care plan. Staff #9 indicated that she was told she could initiate a care plan for nutrition if she felt one was necessary for Resident #97, who came to the facility temporarily, that care plans were already in place and that nursing would initiate and adjust them as per the dieticians' recommendations. Staff #1 was made aware of the above findings on 10/18/18 at 2:00 PM. Staff #1 confirmed that there were no current orders in the residents record for the supplements, that an order for the Readi Care shake was not rewritten upon Resident #97's readmission, however, it was carried over on his/her care record. She indicated that somehow the Magic Cup order was added to the care record as well, but no actual physician's order had been written for the Magic Cup.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Respiratory Care
(Tag F0695)
Could have caused harm · This affected multiple residents
2) On 10/15/18 at 12:21 PM, observation of Resident #78 revealed the resident was wearing an oxygen nasal cannula whose tubing was connected to a water bottle that was connected to an oxygen concentra...
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2) On 10/15/18 at 12:21 PM, observation of Resident #78 revealed the resident was wearing an oxygen nasal cannula whose tubing was connected to a water bottle that was connected to an oxygen concentrator set at 1 1/5 LPM (liters per minute). The oxygen tubing and water bottle were not labeled with the date initiated.
On 10/19/18 at 10:29 AM, observation of Resident #78 revealed that the resident was wearing an oxygen nasal cannula that was connected to a water bottle which was connected to an oxygen concentrator set at 2 LPM. The oxygen tubing and the humidifier water bottle was not labeled with the date.
On 10/19/18, a review of Resident #78's physician orders revealed a 10/12/18 order Oxygen tubing and water bottle: change on the 2nd and 15th of the month, label with date and a 10/12/18 order Oxygen continuous via NC (nasal cannula)) at 1 L to keep SP02 > 92 % every shift for SOB
The facility staff failed to follow the physician orders by failing to label Resident #78's oxygen tubing and water bottle with the date, and failing to ensure that Resident #78's oxygen rate was set at 1 LPM. On 10/19/18 at 10:40 AM, Staff #10 confirmed the findings.
Based on medical record review, observation and staff interview, it was determined the facility failed to 1) ensure that a resident that was placed on oxygen had a physician's order for oxygen with the amount of oxygen to be administered, 2) failed to develop a respiratory, resident centered care plan for a resident with Chronic Obstructive Pulmonary Disease (COPD) who was placed on oxygen, 3) failed to label oxygen tubing when initiated and 4) failed to ensure that oxygen was administered at the rate ordered by the physician. This was evident for 1 (#103) of 3 residents reviewed for discharge and 1 (#78) of 3 residents reviewed for respiratory care.
The findings include:
1) Review of the medical record for Resident #103 on 10/17/18 revealed a nursing admission note written on 9/10/18, which stated that the resident had an oxygen saturation level of 92% on 2L (liters) of oxygen. The resident's admitting diagnosis was CHF (congestive heart failure) along with hypertension, MI (myocardial infarction - heart attack), COPD and renal failure, requiring dialysis 3 times per week. The nursing notes also stated, lungs very diminished with crackles in the bases and on the 7th had a thoracentesis to remove 2L off the right. Thoracentesis is a procedure in which a needle is inserted into the pleural space between the lungs and the chest wall. This procedure is done to remove excess fluid, known as a pleural effusion, from the pleural space to help a patient to breathe easier.
The 9/11/18 at 10:01 AM social service note documented resident commonly suffers from SOB (shortness of breath) which is being monitored at {facility name}.
A 10/3/18 at 22:14 nursing note documented resident was laying in bed with oxygen (2L) on watching TV with an oxygen saturation of 92%. Oxygen was turned off for 5 minutes (nurse was conversing with resident) and dropped to 85%. Oxygen was reapplied. A 10/6/18 at 1:08 AM nursing noted stated, remained on oxygen at 3 liters with a sat of 91%. A 10/7/18 at 23:00 (11 PM) nursing note stated, Resident requested a breathing treatment at 20:36 for SOB. It was ineffective. An hour and a half later, resident complained of SOB, not being able to catch his/her breath along with chest tightness. The note documented oxygen saturation was 90% on 2L. Lungs were diminished with crackles in the left base. The resident was sent to the hospital at 10:30 PM.
The physician's orders for September and October 2018 for Resident #103 were void of oxygen administration orders. The order oxygen continuous via nasal canula at 2 LPM every shift was ordered and discontinued the same day on 9/9/18. The order was not renewed. On 10/19/18 at 11:15 AM, Staff #5 confirmed there was no order for oxygen. There were orders that the nurses were signing off that stated, oxygen tubing and water bottle: change on the 2nd and 15th of the month. Label with date.
Observation was made of the oxygen concentrator on 10/17/18 at 12:35 PM, and on 10/19/18 at 11:15 AM. The tubing and water bottle were not labeled and dated. Staff #5 was with the surveyor on 10/19/18 at 11:15 AM, and confirmed the finding.
Review of the care plans for Resident #103 failed to produce a care plan addressing respiratory care. Staff #5, while looking through the computer at care plans, confirmed there was no care plan for respiratory management.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0757
(Tag F0757)
Could have caused harm · This affected multiple residents
Based on review of the medical records, it was determined that the facility staff failed to ensure that each residents medication regimen was free from unnecessary drugs by failing to hold medications...
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Based on review of the medical records, it was determined that the facility staff failed to ensure that each residents medication regimen was free from unnecessary drugs by failing to hold medications when the residents' vital signs were below the physician prescribed parameters. This was evident for 1 (#100) of 6 residents reviewed for unnecessary medications.
The findings include:
Resident #100's medical record was reviewed on 10/19/18 at 10:17 AM. The residents prescribed medications included but were not limited to:
Lisinopril 10 mg (milligrams) 1 tablet by mouth in the morning for hypertension. Hold for SBP (systolic (upper) blood pressure) < (less than) 130, DBP (diastolic (lower) blood pressure) <55.
Isosorbide Mononitrate 10 mg give 1 tablet by mouth in the morning for chronic angina pectoris (chest pain). Hold if apical pulse (pulse obtained by listening to the heart with a stethoscope) <60, Hold for SBP <130.
Metoprolol Tartrate 25 mg give 1 tablet by mouth every 12 hours for hypertension. Hold if SBP less than 130, DBP <55, AP <60.
Lasix (a fluid pill) 20 mg by mouth one time a day for CHF (congestive heart failure) hold for SBP <130.
Review of Resident #100's MAR (Medication Administration Record) revealed that the resident's Metoprolol was administered when the resident's vital signs were below the ordered parameters at 9 AM on 10/2/18, 10/16/18, and at 9 PM on 10/1/18, 10/4/18, 10/5/18, 10/8/18 and 10/10/18. In addition, Resident #100's Lisinopril, Lasix, Isosorbide were also administered on 10/16/18 at 9 AM, when Resident #100's systolic blood pressure was below the prescribed parameters. Staff #1 was made aware of these finding on 10/19/18 at 2:15 PM.
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 and review of facility narcotic logs, it was determined the facility staff failed to ensure that narcotic c...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and review of facility narcotic logs, it was determined the facility staff failed to ensure that narcotic counts were performed with dual signatures, that opened refrigeratable medication was labeled with its open date and that medication carts were not left unlocked and unattended. This was evident on 1 (Terrace [NAME] Wing) of 4 hallways observed.
The findings include:
1) A review of the 1st floor med cart in the Terrace west wing nursing unit was performed on 10/18/18 at 9:07 AM. During the review, it was found that there was only one signature for the 10/8/2018 7am reconciliation and for the 10/19/18 3pm reconciliation. Change-of-shift reconciliation involves the oncoming and off-going charge nurses simultaneously accounting for all narcotic blister packs on their unit. The nurses conduct the review simultaneously to maintain accountability and then sign in a controlled substance log to represent their participation. Entries with only one signature suggest that the review did not take place with two nurses simultaneously and lacks the credibility of dual signatures.
2) During an observation of the 1st floor medication storage room in the Terrace west wing unit that took place on 10/18/18 at 9:07 AM, latanoprost eye drops were found that had no date on them. Medication Technician #29 was present and confirmed that there was no date.
3) Observation was made on 10/17/18 at 12:27 PM of an unlocked and unattended medication cart sitting on the first floor unit in the open sitting area. The surveyor observed the unlocked medication cart from the hallway and at the same time noted that Staff #13 came out of room [ROOM NUMBER]. Staff #13 walked up to the medication cart and locked it before showing the surveyor directions to another unit.
The Director of Nursing was advised on 10/18/18 at 4:00 PM.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Medical Records
(Tag F0842)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of residents' medical records and interview with facility staff, it was determined that the facility failed to m...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of residents' medical records and interview with facility staff, it was determined that the facility failed to maintain accurate and complete medical records. This was true for 5 (#114, #103, #97, #216, #77) of 45 residents reviewed during the investigation phase of the survey.
The findings include:
1) Resident #114's medical record did not reflect the resident's weight loss. Resident #114's medical record was reviewed on 10/17/18 at 11:19 AM. The resident was admitted to the facility on [DATE] with an admission weight of 181.0 lbs. The Resident's most recent weight was 164.8 lbs and it was taken on 10/17/2018. This was a loss of 8.95% over 2 months. Intervening weights also demonstrated a downward trend. There were 7 weights taken since 10/1/2018 and all of them had an associated weight warning that triggered as part of the electronic medical record system.
Progress notes were searched by type and there were no weight change notes. There were also no nutrition/dietary notes. A nutritional assessment was completed on 10/11/2018 that reported the resident does not know if there was a weight loss in the previous 3 months.
On 10/19/18 at 10:01 AM, the facility provided the survey team with a physician's progress note from 10/1/2018 that began by saying The resident has been on lasix and metalazone for leg edema, SOB. Metalazone was started for 3 doses. A good weight loss has been noticed with decrease in leg edema. An increase in CR has been noticed. Will continue to monitor BMP. Will taper lasix to 20mg every evening. Still has some mild pedal edema. The patient had an acute kidney injury due to rhabdomyolysis and is recovering from it.
Due to the lack of documentation that Resident #114's weight loss was being monitored by nursing staff and the nutritionist and communicated to the physician in the medical record, the facility is being cited for insufficient documentation of the monitoring of the resident's weight.
5) On 10/19/18, a review of Resident #77's medical record revealed a 10/3/18 physician order for weekly weights for 6 weeks, notify provider if greater than a 3-pound weight gain. Review of Resident #77's weights documentation revealed the residents last recorded weight was 10/2/18. Continued review of the medical record failed to reveal documentation that Resident #77 had been weighed weekly.
On 10/18/18 at 10:45 AM, during an interview, when asked how the facility staff would know to follow a physician's order to weigh a resident, the Director of Nurses (DON) stated that the order would be in the resident's Treatment Administration Record (TAR). At that time, the DON was made aware of the above findings and stated that the order had not been transcribed on the resident's TAR.
3) During an interview on 10/16/18 at 9:20 AM, Resident #97 indicated that he/she had lost about 4 pounds since his/her last weight and added that he/she gets Redi care supplements with meals. Review of the resident's record on 10/17/18 at 10:28 AM revealed a physician's order for Renal diet, regular texture with thin liquid consistency. There was no physicians order for nutritional supplements. A telephone interview was conducted with Staff #9, the Dietician on 10/18/18 at 12:14 PM. She indicated that she saw the resident on 10/11/18 and ordered the Magic Cup supplements at that time. Staff #1 was made aware of the above findings on 10/18/18 at 2:00 PM and later confirmed that there were no current orders in the residents record for the supplements, that an order for the Readi Care shake was not rewritten upon Resident #97's readmission however it was carried over on his/her care record. She indicated that somehow the Magic Cup order was added to the care record as well, but no physicians order had been written for the Magic Cup. Cross reference F-692.
4) Resident #216's record was reviewed on 10/15/18 at 12:09 PM and revealed a Physicians order written 10/6/18 for ACE wraps on every AM off every PM, however, the order did not specify where the ACE wraps were to be applied.
2) Review of Resident #103's medical record on 10/18/18 revealed a nutritional assessment, dated 9/10/18 at 17:20, with a lock date of 9/17/18 at 14:36. The nutritional assessment that was given to the surveyor on 10/18/18 at 10:00 AM had an initial nutritional assessment date of 9/10/18 with an admission date of 10/12/18. The Director of Nursing (DON) was asked about the discrepancy with the two dates (assessed on 9/10/18 but admitted on [DATE]). After extensive research, the DON and the assistant administrator stated that the electronic medical record system automatically pulls the most recent admission date. The nutritional assessment did not reflect the time period/admission date that it was intended to reflect. The assistant administrator stated they would submit a work ticket to the medical record vendor to correct the to problem.
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) During a medication administration observation that took place on 10/18/2018 at 9:40 AM, Certified Medication Aid (CMA) #30 w...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 5) During a medication administration observation that took place on 10/18/2018 at 9:40 AM, Certified Medication Aid (CMA) #30 was noted to transfer a tablet of Colace 100mg from one small plastic medicine cup to another using her bare hands. The Director of Nursing was notified of this observation during the course of the survey.
2) On 10/12/18 at 1:45 PM, observation of room [ROOM NUMBER]'s shared bathroom revealed 2 yellow, plastic fracture bed pans. Each bedpan was set on top of 1 of the 2 hand rails located on the long wall between the shower and the toilet. The bedpans were not labeled with the resident's name and were not covered or stored in a manner to prevent the spread of infection. A second observation of room [ROOM NUMBER]'s bathroom on 10/15/18 AM at 11:54 AM revealed a yellow, plastic fracture bed pan, that was set on the hand rail on the wall next to the shower. The bedpan was not labeled with the resident's name and not covered or stored in a manner to prevent the spread of infection. A 3rd observation of room [ROOM NUMBER]'s shared bathroom was made on 10/18/18 at 1:00 PM, and revealed a yellow, plastic fracture bed pan, that was set on the hand rail on the wall next to the shower. The bed pan was not labeled and not covered or bagged. Staff #7 confirmed the finding at that time.
2) On 10/12/18 at 2:14 PM, observation of room [ROOM NUMBER]'s shared bathroom revealed 2 clear, plastic graduated containers on top of the toilet tank. One was labeled with Resident #16's name and one was not labeled. Both containers were not covered or stored in a manner to prevent the spread of infection. On 10/15/18 at 11:15 AM, a 2nd observation of room [ROOM NUMBER]'s shared bathroom revealed 2 clear, plastic graduated containers on top of the toilet tank, one labeled with Resident #16's name and one labeled 105-b. The containers were not covered or stored in a manner to prevent the spread of infection. On the bathroom floor, under the sink, there were 2 gray, plastic basins that were unlabeled and not stored in a manner to prevent the spread of infection. On 10/18/18 at 12:45 PM, a 3rd observation of room [ROOM NUMBER]'s shared bathroom revealed 2 clear, plastic graduated containers on top of the toilet tank, one was labeled with Resident #16's name and one was labeled 105-b. The containers were not covered or bagged. Staff #7 confirmed the finding at that time.
3) On 10/15/18 at 11:15 AM, observation was made of Resident #16 lying in bed and the resident's urinary catheter drainage bag (bag connected to a tube which drains urine from the bladder) was observed lying on the floor next to the resident's bed. On 10/18/18, at 12:30 PM, a second observation was made by 2 surveyors of Resident #16's Foley catheter drainage bag lying on the floor next to the resident's bed. On 10/18/18, at 12:45 PM, Staff #7 confirmed the finding.
Based on observation and staff interview, it was determined that the facility staff failed to follow infection control practices and guidelines to prevent the development and transmission of disease by failing to: 1) properly label and store resident care items, 2) ensure that a resident's urinary catheter bag was properly kept off the floor and 3) ensure that nursing staff maintain proper hand hygiene practices during medication administration.
The findings include:
Resident room [ROOM NUMBER] was observed on 10/15/18 at 11:13 AM. The room was shared by Residents #216 and #107. In the bathroom, the surveyor observed several wash basins on the counter top to the right and left of the sink which contained tooth paste, body wash, several hair brushes a plastic cup with 4 tooth brushes and a tube of tooth paste in it. One wash basin contained an emesis (small curved) basin which held a tooth brush, an emery board, and several packets of Efferdent tablets. Under the sink on the floor, were 7 packages of incontinence briefs several were open. A fracture bed pan (a wedge-shaped bed pan) was located between the grab rail and wall of the shower with the open side against the shower wall. None of the items in the bathroom were labeled to indicate which resident they belonged nor were the tooth brushes, incontinence briefs or bed pan stored in a manner to prevent them from coming into contact or exposing other items with potentially harmful organisms. to. At 11:19 AM on 10/15/18, Staff #28 was made aware of the above findings. She indicated that the items in the bathroom belonged to Resident #216 because Resident #107 did not use the bathroom. Staff #28 also indicated that the bedpan should have been stored at the resident's bedside.
4) Resident #49 was observed sitting in his/her wheelchair in the Canal Side Height's dining room during the lunch-time meal on 10/18/18 at 12:50 PM. The resident had a urinary catheter (a bag connected to a tube which drains urine from the bladder.). The catheter bag was lying on the floor underneath the wheel-chair. Additionally, the content of the drainage bag was not covered to maintain the resident's dignity.
The director of nursing was notified of the findings on 10/19/18.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0725
(Tag F0725)
Could have caused harm · This affected most or all residents
Based on resident and staff interviews, surveyor observation and record reviews, it was determined that the facility failed to have sufficient nursing staff to assist residents in the dining room at m...
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Based on resident and staff interviews, surveyor observation and record reviews, it was determined that the facility failed to have sufficient nursing staff to assist residents in the dining room at mealtime, to provide restorative services to residents and failed to provide geriatric nursing assistant with yearly evaluations. The findings include:
1) On 10/15/18 at 12:00 PM, during an interview, Resident # 54 stated that residents from the Canal Side Terrace B unit werenot allowed to dine in the Fireside dining room at lunch or dinner when there were not enough nursing staff working on the unit. The resident stated that, when there are 4 GNA's working, the residents can dine in Fireside dining room, and when there are only 3 GNAs, the residents must stay on the floor. Resident #54 stated that 2 GNA's are required to be present with the residents during any meal at the Fireside dining room and 2 GNA's are required to be on the unit. Resident #54 stated that the residents only get to go to the Fireside dining room about once every 3 weeks. Resident #54 stated that, in the Fireside dining room, the food gets served on a plate and on the unit, the food comes on a tray. The resident said that, in the Fireside dining room, it's easier to ask for an alternative. On the unit, the resident can request an alternative, but it's a little harder because the resident doesn't know what he/she is getting until the tray comes.
On 10/15/18 at 12:06 PM, during an interview, when asked why the residents were not going to the Fireside dining on this day, Staff #12 stated it was because there were only 3 GNAs working today and for the resident's to be able to go, they need 4 GNA's, 2 to go to the Fireside dining room and 2 GNAs to stay on the unit, therefore all the residents must stay on the unit to eat.
2) Review of the medical record for Resident #30 on 10/19/18 revealed an order, written on 10/5/18, that stated d/c PT (discontinue physical therapy) begin RNP (restorative nursing program).
Review of Resident #30's medical record revealed a Rehab Discharge Program Physical Therapy form with a start date of 10/6/18 which had Restorative checked off and had directions for lower extremity range of motion/strengthening while seated, Active to hip, knee, ankle with 10 repetitions, 1 set. There were signatures of the 4 GNAs (Geriatric Nursing Assistants) that were trained by the physical therapist to do the range of motion.
On 10/19/18 at 10:30 AM, Staff #15 (a GNA) stated, we are short staffed and when we only have 3 people we can't get everything done and that includes walking. The acuity level on the second floor is higher. Staff #7, the resident's nurse, stated on 10/19/18 at 10:30 AM, that he/she was not aware of the restorative nursing order.
On 10/19/18 at 11:05 AM, the Director of Nursing stated that they did not have an active restorative program, as they did not have the staff to get that program working with dedicated restorative aids.
3) Review of 6 Geriatric Nursing Assistant (GNA) personnel files on 10/19/18 revealed athat ll 6 GNAs did not have a yearly evaluation in their personnel files for 2018. The DON stated they were done and in her office. The DON brought the surveyor evaluation forms that were dated June 2018 evaluation at the top of the form. The evaluation form had a rating scale of 1 to 5 with an average overall rating. There was management feedback written on the evaluation form, however, there was no employee feedback. The form was signed by the DON, however there was no date signed. The words declined meeting were written where the employee signatures were located. This was for all 6 GNA evaluations reviewed.
An interview was conducted with the DON on 10/19/18 at 1:30 PM. The DON stated that the staff declined the individual meetings of their performance reviews.
Staff #15 stated on 10/19/18 at 2:10 PM that he/she did not receive his/her yearly review. He/She stated that in June 2018, when increases were given out, he/she opted not to attend the meeting regarding individual evaluation.
Staff #17 stated on 10/19/18 at 2:07 PM that he/she did not receive a yearly review as to his/her strengths and weaknesses.
A performance evaluation is a formal procedure to measure an employee's work and results based on their job responsibilities. Performance evaluations also play a direct role in providing feedback to employees on areas of needed improvement and of the employee's strengths and weaknesses.
Discussed the findings with the assistant administrator on 10/19/18 at 2:30 PM.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0730
(Tag F0730)
Could have caused harm · This affected most or all residents
Based on review of Geriatric Nursing Assistant (GNA) personnel files and staff interview, it was determined the facility failed to conduct yearly performance reviews and review with the GNAs at least ...
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Based on review of Geriatric Nursing Assistant (GNA) personnel files and staff interview, it was determined the facility failed to conduct yearly performance reviews and review with the GNAs at least every 12 months, for 6 out of 6 personnel files reviewed.
The findings include:
1) A review was conducted of Staff #17, #21, #22, #12, #23 and #24's personnel files on 10/19/18. There were no yearly evaluations for 2018 found in the files. he Director of Nursing (DON) stated they were done and in her office. The DON brought the surveyor evaluation forms that were dated June 2018 evaluation at the top of the form. The evaluation form had a rating scale of 1 to 5 with an average overall rating. There was management feedback written on the evaluation form, however, there was no employee feedback. The form was signed by the DON, however, there was no date signed. The words declined meeting were written where the employee signatures were located. This was for all 6 GNA evaluations reviewed.
An interview was conducted with the DON on 10/19/18 at 1:30 PM. The DON stated that the staff declined the individual meetings of their performance reviews.
Staff #15 stated on 10/19/18 at 2:10 PM that he/she did not receive his/her yearly review. He/She stated that in June 2018, when increases were given out, he/she opted not to attend the meeting regarding individual evaluation.
Staff #17 stated on 10/19/18 at 2:07 PM that he/she did not receive a yearly review. as to his/her strengths and weaknesses.
A complaint survey was conducted at the facility on 1/19/18. The Plan of Correction (POC) stated, Performance Evaluations will be completed on all nurse aides hired prior to 1/1/18 would be completed by 6/15/18. A performance evaluation is a formal procedure to measure an employee's work and results based on their job responsibilities. Performance evaluations also play a direct role in providing feedback to employees on areas of needed improvement and of the employee's strengths and weaknesses.
Discussed the findings with the assistant administrator on 10/19/18 at 2:30 PM.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0801
(Tag F0801)
Could have caused harm · This affected most or all residents
Based on interview of facility staff, it was determined the facility failed to ensure that a full-time qualified dietetic service supervisor was responsible for oversight of food preparation and daily...
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Based on interview of facility staff, it was determined the facility failed to ensure that a full-time qualified dietetic service supervisor was responsible for oversight of food preparation and daily kitchen operation.
The findings include:
An initial tour of the facility's kitchen, on 10/12/18 at 11:10 AM, revealed that the full time Director of Dietary service (Staff #26) was not clinically qualified, as per Federal and state regulations. The Director of Culinary services indicated that he/she had not completed all the course work required prior to taking the certification exam to become a Certified Dietary Manager. The Director of Culinary Services revealed that his/her position has been effective since October 9, 2017.
Ongoing conversations with the Director of Culinary Services during the survey revealed that the facility had a part-time dietitian. The current registered dietitian was providing coverage to the the facility 12 hours a week. Review of the requested consultant dietitian's reports for the past 12 months did not reveal any consultation services to the Director of Dietary Services.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
QAPI Program
(Tag F0867)
Could have caused harm · This affected most or all residents
Based on staff interview, surveyor observations and review of the medical record, it was determined that the facility staff failed to have an effective quality assessment and assurance program. This w...
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Based on staff interview, surveyor observations and review of the medical record, it was determined that the facility staff failed to have an effective quality assessment and assurance program. This was evident during the survey process and review of the Quality Assurance Program.
The findings include:
Review of the facility's prior surveys and plans of correction revealed that the facility failed to implement effective corrective measures to correct deficient practices related to notification, developing, implementing and revising care plans, nurse aide performance reviews, dignity and medication storage resulting in recurrence of the same deficient practice. These findings were discussed with Staff #1 on 10/19/18 at 3:33 PM.
MINOR
(C)
Minor Issue - procedural, no safety impact
Deficiency F0577
(Tag F0577)
Minor procedural issue · This affected most or all residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and staff interview, it was determined the facility failed to have the results of a recent complaint survey...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and staff interview, it was determined the facility failed to have the results of a recent complaint survey posted in the survey binders that were accessible to residents, family members and legal representatives of residents. This was evident in four of four survey binders.
The findings include:
On 10/18/18, review of a survey binder, located on the Westview Heights wing near the main entrance to the nursing home, revealed that a complaint survey conducted on 5/4/18 was not available to be viewed. Review of the survey binder book found in a hallway next to the elevator near the nursing home administrator's office revealed that the complaint survey ending on 5/4/18 was not in the survey binder. A third survey binder on Canal [NAME] revealed that the 5/4/18 survey was not available. On 10/19/18 at 12:18 PM, the associate nursing home administer (staff#2) was informed of the missing survey results. The associate administrator revealed that there was a fourth survey binder on the upper most floor by the elevator. Review of the fourth survey binder was also missing the complaint survey ending on 5/4/2018.
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** #7) The facility failed to provide notice of transfer to Resident #92's responsible party. Resident #92's medical record was rev...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** #7) The facility failed to provide notice of transfer to Resident #92's responsible party. Resident #92's medical record was reviewed on 10/15/18 at 1:34 PM. During the review, it was found that the resident was hospitalized late in August of 2018 for evaluation of low blood oxygen levels and difficulty with breathing. There was no evidence in the medical record that the resident or the resident's representative received written notification of the reason for the resident's transfer to the hospital.
The Director of Nursing (DON) was interviewed on 10/15/2018 at 2:00 PM. During the conversation, the DON confirmed that, although residents and their representatives may be verbally informed of hospital transfers, nothing in writing is provided to either of them.
#8) The facility failed to provide notice of transfer to Resident #102's responsible party. Resident #102's medical record was reviewed on 10/17/18 at 9:24 AM. During the review, it was found that the resident was hospitalized early in September of 2018. There was no evidence in the medical record that the resident or the resident's representative received written notification of the reason for the resident's transfer to the hospital.
The Director of Nursing (DON) was interviewed on 10/15/2018 at 2:00 PM. During the conversation, the DON confirmed that, although residents and their representatives may be verbally informed of hospital transfers, nothing in writing is provided to either of them.
5) On 10/12/18 at 2:30 PM, a review of Resident #16's medical record revealed documentation that the resident was transferred to the emergency room via 911 on 5/14/18 for an acute change in condition related to hematuria (blood in urine) and vomiting blood. The resident was admitted to the hospital and readmitted to the facility on on 5/21/18. There was no documentation found in the medical record that the resident or the resident's responsible party was notified in writing of the reason for Resident #16's transfer to the hospital.
6) On 10/15/18 at 3:20 PM, a review of Resident #78's medical record revealed documentation, that on 9/29/18, Resident #78 was transferred to the hospital emergency room for evaluation of shortness of breath and an increased heart rate. The resident was admitted to the hospital and readmitted to the facility on [DATE]. There was no documentation found in the medical record that the resident or the resident's responsible party was notified in writing of the reason for the resident's transfer to the hospital.
On 10/19/18 at 10:45 AM, the DON confirmed that no written notices were given to residents. On 10/19/18 at 3:00 PM, during an interview, the Ombudsman stated that the facility has notified the Ombudsman of resident transfers and discharges since July 2018 and indicated that prior to July 2018, the facility had not notified the Ombudsman in writing of resident transfers and discharges
3) During an interview on 10/16/18, Resident #97 indicated that he/she had been hospitalized a couple of months prior, was very sick and could not remember any details as to why he/she was sent to the hospital. The resident's record was reviewed on 10/16/18 at 2:38 PM and revealed that Resident #97 was hospitalized [DATE] thru 9/6/18. Further review of the record revealed documentation that the resident had a change in condition, notification of the physician and that the resident's daughter was notified by telephone of the transfer. The documentation however failed to reveal evidence that the resident and or his/her representative had been given a written notice of the transfer to the hospital.
4) Resident #59's record was reviewed on 10/18/18 at 11:38 AM. The resident had been sent to the hospital on 8/18/18 after a fall. The record failed to reveal evidence that the resident and/or his/her representative had been notified in writing of Resident #59's transfer to the hospital.
During an interview, on 10/17/18 at 9:14 AM, Staff #1 confirmed that the facility staff call the residents' family regarding hospital transfers, but had not been providing written notification when a resident was transferred to the hospital.
Based on medical record review and staff interview, it was determined the facility failed to 1) notify the resident/resident representative in writing of a transfer/discharge of a resident, along with the reason for the transfer, and failed to notify the Ombudsman. This was evident for 8 (#11, #103, #97, #59, #16, #78, #92, #102) of 10 residents reviewed that were transferred to an acute care facility.
The findings include:
1) Review of Resident #11's medical record on 10/17/18 revealed documentation, dated 10/13/18, which stated labs reviewed by on call provider with order to send to {name of acute care facility} for evaluation secondary to abnormal labs with nausea/vomiting. The note continued 911 here with 2 attendants to transport resident to {name} ER, resident was placed on stretcher safely by 911 attendants. There was no written documentation that the resident or responsible party were notified in writing of the transfer.
2) Review of Resident #103's medical record, on 10/17/18, revealed nursing documentation, dated 10/7/18, which revealed that Resident #103 was complaining of shortness of breath, along with chest tightness. The on call physician gave an order for the resident to go to the hospital for evaluation. The resident left the faciity on [DATE] at 10:30 PM. There was no written documentation that the resident or responsible party were notified in writing of the transfer.
The Director of Nursing stated on 10/17/18 at 9:15 AM that the facility had not been sending in writing the transfer or the reason for the transfer to the resident or the resident's representative.
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** #7) The facility failed to give Resident #92 or his/her representative a bed hold policy when the resident was transferred to th...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** #7) The facility failed to give Resident #92 or his/her representative a bed hold policy when the resident was transferred to the hospital.
Resident #92's medical record was reviewed on 10/15/18 at 1:34 PM. During the review, it was found that the resident was hospitalized late in August of 2018 for evaluation of low blood oxygen levels and difficulty with breathing. There was no evidence in the medical record that the resident or the resident's representative received a copy of the facility's bed hold policy.
The Director of Nursing (DON) was interviewed on 10/15/2018 at 2:00 PM. During the conversation, the DON confirmed that residents and their representatives are not given a copy of the facility's bed hold policy.
#8) The facility failed to give Resident #102 or his/her representative a bed hold policy when the resident was transferred to the hospital. Resident #102's medical record was reviewed on 10/17/18 at 9:24 AM. During the review, it was found that the resident was hospitalized early in September of 2018. There was no evidence in the medical record that the resident or the resident's representative received a copy of the facility's bed hold policy.
The Director of Nursing (DON) was interviewed on 10/15/2018 at 2:00 PM. During the conversation, the DON confirmed that residents and their representatives were not given a copy of the facility's bed hold policy.
5) On 10/12/18 at 2:30 PM, a review of Resident #16's medical record documented the resident was transferred to the emergency room via 911 on 5/14/18 for an acute change in condition related to hematuria (blood in urine) and vomiting blood. There was no written documentation that the resident or resident representative were notified in writing of the bed-hold policy.
6) On 10/15/18 at 3:20 PM, a review of Resident #78's medical record documented that on 9/29/18, Resident #78 was transferred to the hospital emergency room for evaluation of shortness of breath and an increased heart rate. There was no written documentation that the resident or resident representative were notified in writing of the bed-hold policy.
3) During an interview on 10/16/18, Resident #97 indicated that he/she had been hospitalized a couple of months prior. The resident's record was reviewed on 10/16/18 at 2:38 PM, and revealed that Resident #97 was hospitalized [DATE] thru 9/6/18 and the resident's daughter was notified by telephone of the transfer. The documentation, however, failed to reveal evidence that the resident and or his/her representative had been provided with a copy of the facility's bed hold policy at the time of his/her transfer to the hospital.
4) Resident #59's record was reviewed on 10/18/18 at 11:38 AM. The resident was sent to the hospital on 8/18/18 after a fall. The record failed to reveal evidence that the resident and or his/her representative had been provided with a copy of the facility's bed hold policy at the time of his/her transfer to the hospital.
During an interview, on 10/17/18 at 9:14 AM, Staff #1 indicated that the residents and/or their representatives were provided with a copy of the facility's bed hold policy on admission. He/She confirmed that the facility was not providing a copy of the bed hold policy when the residents were transferred to the hospital.
Based on medical record review and staff interview, it was determined the facility failed to notify the resident/resident representative in writing of the bed-hold policy upon transfer of a resident to an acute care facility. This was evident for 2 (#11, #103) of 10 residents reviewed that were transferred to an acute care facility.
The findings include:
1) Review of Resident #11's medical record on 10/17/18 revealed documentation, dated 10/13/18, which stated labs reviewed by on call provider with order to send to {name of acute care facility} for evaluation secondary to abnormal labs with nausea/vomiting. The note continued 911 here with 2 attendants to transport resident to {name} ER, resident was placed on stretcher safely by 911 attendants. There was no written documentation that the resident or resident representative were notified in writing of the bed-hold policy.
2) Review of Resident #103's medical record on 10/17/18 revealed nursing documentation, dated 10/7/18, which revealed that Resident #103 was complaining of shortness of breath along with chest tightness. The on call physician gave an order for the resident to go to the hospital for evaluation. The resident left the faciity on [DATE] at 10:30 PM. There was no written documentation that the resident or resident representative were notified in writing of the bed-hold policy.
The Director of Nursing stated on 10/17/18 at 11:40 AM that the facility provided a copy of the bed hold policy to the resident/resident representative upon admission, however, no written copy was provided when being transferred to the hospital.
MINOR
(C)
Minor Issue - procedural, no safety impact
Deficiency F0655
(Tag F0655)
Minor procedural issue · This affected most or all residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the medical record and interview with staff, it was determined that the facility staff failed to develop base...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the medical record and interview with staff, it was determined that the facility staff failed to develop baseline care plans that included instructions needed to provide effective and person-centered care and failed to provide residents/representatives with a copy of their baseline care plan and medication list. This was evident for 7 (#92, #97, #59, #63, #103, #78) of 38 residents reviewed during the investigative phase of the survey.
The findings include:
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.
1) The facility failed to give Resident #92 a copy of the resident's baseline care plan related to his/her entry to the facility at the beginning of September, 2018. During review of Resident #92's medical record on 10/15/2018 at 1:34 PM, it was found that the resident was hospitalized at the end of August 2018 and returned at the beginning of September. There was no evidence in the medical record that a baseline care plan was given to the resident or the resident's representative.
During an interview on 10/15/2018 at 2:00 PM, the DON stated that the facility has not been giving residents a copy of their baseline careplan.
6) On 10/17/18, review of Resident #72's medical record revealed that the resident was admitted to the facility in the beginning of September 2018. Review of Resident #72's admission assessment, with a reference date of 9/17/18, documented that the resident had the diagnoses of Coronary Artery Disease, Deep Venous Thrombosis (DVT), Hypertension, Thyroid disorder, Arthritis, Dementia, Anxiety, Depression, Cerebrovascular disease, Obesity, Chronic Pain and Muscle weakness and documented that Resident #72 was receiving Hospice services.
Further review of the medical record failed to reveal evidence that a copy of the resident's base line care plan, along with a summary of his/her medications, had been provided to Resident #72 or the resident's representative.
6) On 10/19/18, a review of Resident #78's medical record revealed that the resident was admitted to the facility at the end of August 2018. On 8/30/18 at 2:15 PM, in an admission Summary note, the nurse documented that the resident was admitted to the facility following surgery for a fractured hip. Continued review of the medical record failed to reveal evidence that a baseline care plan along with a summary of medications had been provided to Resident #78 or to the resident's representative.
On 10/17/18, at 1:35 PM, the Director of Nurses confirmed that the base line care plan with a medication summary had not given to the provided to the residents or to the resident's representative.
2) Resident #97's record was reviewed on 10/16/18 at 2:38 PM. The record revealed that the resident had a change in condition and was hospitalized from [DATE] thru 9/6/18. The nursing progress notes revealed that the resident returned with a Percutaneous Cholecystostomy tube (a tube which is inserted through the abdominal wall to drain the gallbladder) with a drainage bag. Review of the resident's Interim Care Plan section 32. Surgical wound/drains included assess surgical and drain site on admission and every shift, change dressing as ordered, monitor drain site for infection, monitor drainage and assess for pain. The plan failed to identify the type and location of the residents drain, and the specific care and treatment Resident #97 was to receive related to the drain. Staff #1 was made aware on 10/18/18 at 2:00 PM.
3) Resident #59's record was reviewed on 10/18/18 at 11:38 AM. The resident was sent to the hospital for evaluation after a fall on 8/18/18. Upon his/her return from the hospital, an interim Care Plan was completed on 8/22/18. The plan failed to identify the resident's individual Nutritional or Activity needs and goals, nor the interventions staff were to implement to meet his/her needs/goals.
4) Resident #63 was readmitted to the facility on [DATE]. The resident's diagnoses included, but were not limited to, stage 3 Chronic Kidney Disease, Chronic Respiratory Failure, Atherosclerotic Heart Disease, Atrial Fibrillation (irregular heart beat), Major Depressive Disorder Glaucoma and Dysphagia (problem with swallowing). An Interim Care Plan was created to identify and plan Resident #63's individual care needs on 8/6/18. The sections 3. Visual function, 8. Mood State, 10. Life Enrichment, 12. Nutritional Status, 15. Dehydration/Fluid Maintenance and 26. Cardiac Care needs were not identified, and interventions were not initiated to address Resident #63's needs related to these areas. The Interim Care Plan included 17. Pressure Ulcer/Skin Care the identified Goa: Prevent/heal pressure ulcers and skin breakdown. The plan did was not resident specific by failing to identify if the resident had pressure ulcers or if the plan was created to prevent pressure ulcers from occurring.
During an interview on 10/16/18 at approximately 1:00 PM, Staff #27, an LPN (Licensed Practical Nurse) was asked how Interim Care Plans were developed. He/She indicated that the nursing staff developed the interim plan of care and reviewed it with the resident and/or their representative. He/She indicated that a copy of the plan and the residents' medications are not given to the resident/representative but can be requested, then added that someone else may provide a copy of the plan of care, and that someone may mail the medication list to the resident's family, but he/she was not sure. On 10/17/18, Staff #1 indicated that there was a breakdown as to who is giving the resident/representative a copy of the Interim Care Plan and medication list. He/She indicated it was possible that Social Services provided the copies. During an interview, Staff #20 Social Services indicated that the Social Workers discussed and provided the resident/representative a copy of the Discharge plan of care and confirmed that they have not provided a copy of the entire Interim Care Plan or medication list to the residents and/or their representatives.
5) Review of Resident #103's medical record on 10/17/18 revealed the resident was admitted to the facility on [DATE]. The resident was admitted with diagnoses of Congestive Heart Failure, Hypertension, Chronic Obstructive Pulmonary Disease (COPD) and Renal Failure. The resident received dialysis services 3 times per week.
Staff at the facility were asked if the resident received a copy of the baseline care plan after being admitted to the facility. Interview of Staff #20 on 10/17/18 at 11:30 AM revealed that the only care plan Staff #20 gave the resident was the discharge care plan. Staff #7 stated, I do not give the baseline care plan and I am not sure if anyone does. Staff #7 was the Registered Nurse (RN) assigned to the resident. Staff #5 stated at 12:35 PM i just came on duty and I know nothing about him/her. When Staff #5 was asked about baseline care plans, the response was my understanding is Social Work goes over the care plan with the resident and family. Nurses don't go over the initial care plan. Staff #13 stated on 10/17/18 at 12:27 PM, the baseline care plan is kept in the computer. I am not sure if the resident receives it. I don't do anything with it. I am task oriented. MDS does things that I am not aware of.
On 10/17/18 at 1:35 PM, the Director of Nursing (DON) stated, there is a communication breakdown related to who is giving the baseline care plan along with the medication list. The residents are not receiving the baseline care plan right now.
MINOR
(C)
Minor Issue - procedural, no safety impact
Staffing Information
(Tag F0732)
Minor procedural issue · This affected most or all residents
3) During the survey, daily observation was made of the posting of staff on the Canal Side Terrace-B unit. The daily shift posting of staff was located on a clip board, which was hung high up on the w...
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3) During the survey, daily observation was made of the posting of staff on the Canal Side Terrace-B unit. The daily shift posting of staff was located on a clip board, which was hung high up on the wall in the nursing station area of the unit. The clip board with the required staffing information was not in a readily accessible place for residents and visitors, and its location made it difficult to read from the height of a wheel chair bound resident.
Based on surveyor observation and interview with staff, it was determined that he facility failed to ensure the required nurse staffing information was posted in a prominent place readily accessible to residents and visitors. This was evident on 3 of 6 resident care areas observed during the survey.
The findings include:
On 10/16/18 at 2:16 PM, the surveyor observed the Canal Side Skylight unit. The unit had 8 bedrooms, housing 13 residents. It was the only unit located on an upper level and was accessible by an elevator or stairs. The surveyor was unable to locate nurse staffing information posted on the unit. Staff #21 a Geriatric Nursing Assistant (GNA) was present on the unit. When asked where the staffing information was posted, she indicated it was posted by the time clock, so staff can see their assignment for the day. When asked if it was posted on the nursing unit, she indicated yes, downstairs, referring to Canal Side Heights unit, which was located on the floor below and confirmed that it was not posted anywhere on the Canal Side Skylight unit (upper level). The surveyor then observed the Canal Side Heights - C unit (lower level). An 8 ½ by 11-inch paper titled Williamsport Nursing Home Unit Assignment Sheet indicated Unit: C-Wing. The paper was posted on the wall outside of the nurses' station doorway. The column 7-3 PM included the first initial and last name of the Charge nurse and the last names for 3 GNA's. The GNA Assignment section listed the room, bed numbers and initials of the GNA assigned to each room on both floors of the Canal Side units.
2) Based on daily observations of the daily shift posting of staff on the Canal Side Heights (A-wing), the posted staffing was not In a prominent place readily accessible to residents and visitors nor in a clear readable format which could be read by a wheel chair bound resident. The daily shift posting of staff was located on a clip board in the nursing station area of the unit. The clip board with the required staffing information was high up on the wall making it difficult to read from the height of a wheel chair bound resident.
Jul 2017
10 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0157
(Tag F0157)
Could have caused harm · This affected 1 resident
Based on medical record review and staff interview,it was determined that the facility staff failed to ensure that the family was notified of a bruise and timely notified of a fall. This was evident f...
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Based on medical record review and staff interview,it was determined that the facility staff failed to ensure that the family was notified of a bruise and timely notified of a fall. This was evident for 1(#83) of 3 residents reviewed for falls with an injury.
The findings include:
Review of the medical record for Resident #83 revealed documentation on 6/23/17 which stated new bruise. Documentation revealed that the physician was notified, but the family was not. Further review of Resident #83's medical record documented that, on 6/26/17 at 2:35 AM, staff was called to resident's room by the roommate who heard the resident cry out and was half way off the bed. The resident was noted with a dime size hematoma over the right eye that has a slight clear abrasion, some redness to right iliac crest. Documented by staff was communication: message sent via e-medical which indicated the physician was notified electronically. There was no documentation that the resident's family was notified.
Documentation in the medical record, on 6/28/17, noted that Resident #83's daughter called at approximately 4:00 PM to check on her mother, and asked when the resident had a fall. The daughter was then made aware of date and time of fall, and that the resident continued with bruising on the side of forehead.
Interview of Licensed Practical Nurse (LPN) #2 on 7/10/17 at 12:02 PM revealed that only Hospice and the doctor were notified of the fall and the bruise.
The Director of Nursing was advised on 7/11/17 at 11:45 AM.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0278
(Tag F0278)
Could have caused harm · This affected 1 resident
Based on review of medical record documentation and staff interview, it was determined that the facility failed to ensure that Minimum Data Set (MDS) assessments were accurately coded. This was eviden...
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Based on review of medical record documentation and staff interview, it was determined that the facility failed to ensure that Minimum Data Set (MDS) assessments were accurately coded. This was evident for 1 (#63) of 34 residents reviewed.
The findings include:
The Minimum Data Set (MDS) is part of the U.S. federally mandated process for clinical assessment of all residents. This process provides a comprehensive assessment of each resident's functional capabilities and helps nursing home staff identify health problems. At the end of the MDS assessment, the interdisciplinary team develops a plan for the resident to obtain optimal care.
Review of Resident #63's Significant Change MDS Assessment with an Assessment Reference Date (ARD) of 6/7/17, Section I4000, Other fracture, was blank and Section J1800C, fall with major injury was coded 0.
Review of Resident #63's medical record revealed a nurse's note, written on 5/17/17 at 5:00 AM, which stated that resident had a fall in the bathroom. At 6:11 PM, the resident complained of right hip pain and didn't want to get out of bed. On 5/18/17 at 12:39 PM, a physician's note documented that the resident could not move off his/her back or sit up in bed with assistance, therefore, an x-ray was ordered. At the time, the results indicated a right hip/lumbar/sacral x-ray. X-ray was positive for modest osteoarthritis of right hip and osteoporotic compression fractures of T11-L1, age old or indeterminate. The resident was treated with Tylenol.
A 5/22/17 at 19:23 PM note stated that Resident #63 was sent to an acute care facility due to complaints of pain and refusal to get out of bed. It was noted on 5/23/17 that the resident had a compression fracture of her L1 as seen in a lumbar/sacral x-ray. The provider wrote due to her essentially non-acute x-rays, a decision was made to transfer her to the ER for further imaging. In the ER x-ray showed a compression fracture of L1 and lucency consistent with acute injury.
Section I4000 should have indicated fracture and J1800 C should have been coded 1.
The Director of Nursing was advised on 7/11/17 at 1:35 PM.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0279
(Tag F0279)
Could have caused harm · This affected 1 resident
Based on medical record review and staff interview, it was determined the facility failed to initiate a care plan for Gastroesophageal reflux disease (GERD) when a resident was on multiple medications...
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Based on medical record review and staff interview, it was determined the facility failed to initiate a care plan for Gastroesophageal reflux disease (GERD) when a resident was on multiple medications for the disease along with frequent physician visits. This was evident for 1 (#136) of 5 residents reviewed for unnecessary medications.
The findings include:
Review of Resident #136's medical record revealed a 4/25/17 physician's note which stated seen today for follow up of chronic medical conditions. Recently started on Reglan for concern of upset stomach after eating and heartburn. Today, patient reports chronic belching and feeling overly full after eating. Reglan was started on 4/20/17 for a 10 day trial. Patient does not feel Reglan is working well. GERD/Eructation was the assessment and patient was educated about life style modification and diet modification. Diet low in spice, tomatoes, chocolate ordered, continue Maalox, prn (when necessary), Protonix 40 mg twice per day, Reglan to stop on 4/30/17. Ordered Simethicone PRN. Reglan is used short-term to treat heartburn caused by gastroesophageal reflux in people who have used other medications without relief of symptoms
A 5/26/17 physician's note stated patient reports chronic belching and feeling overly full after eating. Has nausea after meals, occasionally vomiting. Reglan was started for 10 day trial which resident reported wasn't effective. The plan was to continue Maalox prn, Protonix 40 mg twice per day and continue Simethicone PRN. Started Reglan 5 mg with lunch and dinner and requested a GI consult and a gallbladder sonogram.
A 6/26/17 psychiatric visit documented that discussions were made with nursing concerning the residents somatic concerns with GI upset and that the resident reported that he/she was receiving treatment for it.
On 7/10/17 at 10:27 AM, the Director of Nursing (DON) was asked, given all of the issues with the resident's GI system and GERD medications, if a care plan should have been initiated. The DON stated yes and confirmed that there was no care plan for GERD for Resident #136.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0280
(Tag F0280)
Could have caused harm · This affected 1 resident
Based on observation, staff interview, and medical record review, it was determined that the facility failed to update a care plan after a fall and for a resident with a urinary catheter. This was evi...
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Based on observation, staff interview, and medical record review, it was determined that the facility failed to update a care plan after a fall and for a resident with a urinary catheter. This was evident for 1 (#83) of 3 residents reviewed for accidents and 1 (#13) of 2 residents reviewed for urinary catheters.
The findings include:
1. Observation was made, on 7/10/17 at 11:50 AM, of Resident #83 lying on the resident's left side in a low bed with a positioning wedge and a bed bolster. Geriatric Nursing Assistant (GNA) #1 stated at that time that the resident had fallen out of bed. As a result of the fall, the resident sustained a hematoma to the head. After the fall, a bed bolster was placed in the bed.
Review of Resident #83's fall's care plan failed to have the intervention of bed bolster added to the care plan after the fall on 6/26/17.
2. Review of the medical record for Resident #13 revealed a 7/3/17 consultation report from the urologist where the resident was seen for constant leakage at the suprapubic catheter site, which left the resident with a feeling of having to urinate. The resident's brief got wet from time to time. The consultant's recommendation was to change the catheter every 4 to 6 weeks. A suprapubic catheter is a thin, sterile tube used to drain urine from the bladder when a person cannot urinate. This type of catheter is used if a catheter is unable to be inserted into the urethra. The urethra carries urine from the bladder out of the body.
Review of the care plan for indwelling suprapubic catheter related to urinary retention, perineal fistula and history of prostate cancer was not updated to reflect that the catheter should be changed every 4 to 6 weeks.
The Director of Nursing was advised on 7/11/17 at 1:35 PM.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0309
(Tag F0309)
Could have caused harm · This affected 1 resident
Based on medical record review and staff interview, it was determined that the facility failed to ensure that a resident received care and treatment according to a physician's summary of findings and ...
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Based on medical record review and staff interview, it was determined that the facility failed to ensure that a resident received care and treatment according to a physician's summary of findings and plan. This was evident for 1 (#63) of 5 residents reviewed for unnecessary medications.
The findings include:
Review of the medical record for Resident #63 revealed that the resident had a significant change in weight and, as of 6/8/17, the resident had a weight loss of 7.2 percent in one month. A 6/29/17 physician's visit documented a loss of about 13 pounds over the last 2 months. A summary of findings documented weight loss. Check serum TSH, dietician consult for supplements. A thyroid-stimulating hormone (TSH) blood test is used to check for thyroid gland problems.
Review of the lab section of the medical record was void of a serum TSH level. Licensed Practical Nurse (LPN) #1 was unable to find the lab in the chart and advised the surveyor that it was not done. Further review of the medical record revealed the last dietary consult was on 6/8/17.
On 7/11/17 at 11:14 AM, Physician #1 was interviewed regarding the 6/29/17 visit where the physician indicated that he/she wanted a serum TSH and dietary consult done. Physician #1 stated I can't tell you why I didn't write the order. Physician #1 then went on to explain that he/she works with the dietician and he/she writes everything down in his/her book and would have followed up on it. It was noted that 13 days had passed since the physician last saw the resident.
Discussed with the Director of Nursing (DON) on 7/11/17 at 1:35 PM. The DON was asked if it was expected of the nursing staff to read the physician's visit and follow up on any recommendations. The DON stated that it was expected that the nursing staff discuss with the physician the current status of the resident.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0332
(Tag F0332)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation of the medication administration pass, it was determined that the facility failed to administer medications...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation of the medication administration pass, it was determined that the facility failed to administer medications ordered on three different occasions.
The findings include:
1) During an observation of a med pass, on 07/10/2017 at 10:45 AM, with Resident #244, the surveyor observed CMA #1 crush the medications Metoprolol SR 125 mg orally and Potassium Chloride 20 MEQ (milliequivielent) orally. Review of the facility do not crush list, provided by the DON (Director of Nursing) on 07/10/2017 at 2:05 PM, indicated that Metoprolol SR 125 mg and Potassium Chloride 20 [NAME] oral pills should not be crushed.
2) During an observation of a med pass on 07/10/2017 at 10:24 AM with Resident #236, the surveyor observed CMA #1 administer the medication Cyanocobalamin orally. Review of Resident #236's physician orders revealed that the Cyanocobalamin should have been given sublingually (under the tongue) and not swallowed.
3) During an observation of a med pass on 07/10/2017 at 11:16 AM with Resident #246, the surveyor observed CMA #1 administer the inhaler, Elipta, and then gave Resident #246 a glass of water in which Resident #246 drank.
In an interview on 07/10/2017 at 2:05 PM, the DON indicated that the inhaled medication Elipta falls under the bronchodilator/beta agonists, and is also corticosteroid that the facility uses for oral inhalation administration.
Review of the facility oral inhalation policy on 07/10/2017, revealed that CMA #1 should have had Resident #246 rinsed out his/her her mouth before allowing Resident #246 to drink water. This would help to prevent oral cavity fungal infections.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0431
(Tag F0431)
Could have caused harm · This affected 1 resident
Based on observation and staff interview, it was determined that facility staff 1) failed to properly store medication as evidenced by failing to discard expired medications. This was evident for 1 of...
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Based on observation and staff interview, it was determined that facility staff 1) failed to properly store medication as evidenced by failing to discard expired medications. This was evident for 1 of 2 medication room refrigerators observed during stage 1 of the facility's annual Medicare/Medicaid survey. The facility staff also 2) failed to maintain a locked medication cart. This was observed one time during a medication administration observation.
The findings include:
1) On 7/6/17 at 9:30 AM, observation was made of the B Wing medication refrigerator and revealed 1 vial of Lantus 100 Units/milliliter labeled with Resident #153's name and labeled expiration 7/3/17.
According to the manufacturer's storage instructions, Lantus should be discarded after the medication has been opened for 28 days.
LPN # 2 was advised and confirmed the findings at that time.
2) During a medication observation, on 07/10/2017 a 10:09 AM, the surveyor observed CMA #1 walk away from his/her medication cart without taking steps to lock and secure the medication cart. CMA #1 walked four rooms down the hallway and entered another resident's room. There were no other residents located around the unlocked medication cart. The nursing staff must take steps to secure all medications in a locked compartment when not in use.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0441
(Tag F0441)
Could have caused harm · This affected 1 resident
Based on observation and staff interview, it was determined that the facility staff failed to store resident equipment in a manner to prevent the development and transmission of disease. This was evid...
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Based on observation and staff interview, it was determined that the facility staff failed to store resident equipment in a manner to prevent the development and transmission of disease. This was evident during the initial tour of the facility.
The findings include:
On 7/6/17 at 9:45 AM, an observation of the B Wing Sun Room revealed a clear plastic container labeled with Resident #134's name and labeled hand soak sitting on the counter next to the sink.
The plastic container was not stored in a manner that would prevent it from contaminating the counter with potentially harmful organisms.
CMA #1 was advised of the findings and confirmed the findings at that time.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0243
(Tag F0243)
Could have caused harm · This affected multiple residents
Based on resident and staff interviews, it was determined the facility failed to provide residents who attend monthly resident council meetings a space to comfortably accommodate them. This was eviden...
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Based on resident and staff interviews, it was determined the facility failed to provide residents who attend monthly resident council meetings a space to comfortably accommodate them. This was evident during the facility's annual Medicare/Medicaid survey.
Findings include:
An interview was conducted with Resident #50 on 7/7/17 at 1:50 PM and he/she was asked the question, Is there enough space for everyone who wants to attend resident council meetings? Resident #50 stated to the surveyor, We meet in the solarium and a lot of people show up, and the area is not big enough. Resident #50 went on to say that we would like more space to have our devotions, but was told there is not a space available right now. The resident further stated, we currently go up to C-Wing to have our devotions,and the tables in the room are not removed, which makes the space uncomfortable.
Review of the resident council minutes attendance sheets provided by the facility on 7/10/17 revealed that for January, March, April, May,and June 2017, anywhere from 5 to 10 residents attended the resident council meetings.
A tour was conducted with the Director of Enrichment Services (DES) on 7/11/17 at 12:10 PM, where the resident council meetings and devotions are held. Upon entrance into the Multipurpose Room on the A-Wing Canal Unit, there were tables observed which appeared to limit the space available in the room. During an interview conducted at the time of the tour, the DES stated to the surveyor, that the area was small. The surveyor asked if the tables in the room are removed for meetings and she stated, sometimes, but it depends if there are activities scheduled. The DES and surveyor toured the Canal Terrace and Solarium. Tables were also observed in this area. The DES stated that the tables are moved back, but it can get crowded depending upon how many residents attend. The DES stated that they are working on a larger space for the resident council meetings to be held. A larger space is provided for devotions presently.
The Director of Nursing was made aware on 7/11/17 at 1:00 PM.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0371
(Tag F0371)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On 7/6/17 at 9:30 AM, an observation was made of the B Wing Sun Room and revealed the following:
In the Sun Room resident refri...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On 7/6/17 at 9:30 AM, an observation was made of the B Wing Sun Room and revealed the following:
In the Sun Room resident refrigerator, there was 1 Dannon strawberry banana light and fit yogurt labeled with expiration date 6/30/17.
On the right side of Sun Room counter top, near the door, there was 1 PowerAde bottle containing blue liquid not labeled with name or date opened. There was 1 large Styrofoam cup with ice and blue liquid, not labeled with date. There was 1 large Styrofoam cup with clear liquid, labeled [NAME], not labeled with date and there was 1 large Styrofoam cup with clear liquid, labeled KS, not labeled with date.
CMA #1 was advised of the above and confirmed the findings at that time. When asked if any residents walked independently on the unit, CMA #1 stated maybe.
On 7/6/17 at 10:00 AM, observation was made of [NAME] View Terrace resident refrigerator and revealed 1 clear plastic pitcher, 1/4 full of brown liquid with tea bags in the bottom of the pitcher, dated 6/28/17. RN #2 was advised and confirmed the finding at that time.
On 7/6/17 at 10:30 AM, observation was made of the [NAME] View Heights refrigerator and revealed 1 clear plastic pitcher, 1/3 full of brown liquid with tea bags in the bottom of the pitcher, dated 6/28/17. RN #1 was advised and confirmed this finding at that time
Based on observations, it was determined the facility staff failed to date and label foods and remove expired food from the refrigerator. This was evident during an initial tour of the facility.
The findings include:
An initial tour of the main kitchen was conducted on 7/6/17 at 9:30 AM with the Dietary Manager (DM) present. The following concerns were identified:
Inside of Refrigerator #2 was a 1 gallon container of relish, with approximately 1/4 remainder, not date labeled.
Inside of the refrigerator on the Westview Heights Unit Pantry, there was (1) 8 oz container of vitamin D milk with an expiration date of 6/30/17.
The DM removed the items from the refrigerators at the time of the findings.
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 fines on record. Clean compliance history, better than most Maryland facilities.
Concerns
- • 85 deficiencies on record, including 1 serious (caused harm) violation. Ask about corrective actions taken.
- • Grade F (35/100). Below average facility with significant concerns.
Bottom line: Trust Score of 35/100 indicates significant concerns. Thoroughly evaluate alternatives.
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About This Facility
What is Williamsport's CMS Rating?
CMS assigns WILLIAMSPORT NURSING AND REHABILITATION CENTER an overall rating of 1 out of 5 stars, which is considered much 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 Williamsport Staffed?
CMS rates WILLIAMSPORT NURSING AND REHABILITATION CENTER's staffing level at 1 out of 5 stars, which is much below average compared to other nursing homes. Staff turnover is 54%, compared to the Maryland average of 46%. RN turnover specifically is 56%, which is notably high. RNs provide skilled clinical oversight, so turnover in this role can affect medical care quality.
What Have Inspectors Found at Williamsport?
State health inspectors documented 85 deficiencies at WILLIAMSPORT NURSING AND REHABILITATION CENTER during 2017 to 2025. These included: 1 that caused actual resident harm, 76 with potential for harm, and 8 minor or isolated issues. Deficiencies causing actual harm indicate documented cases where residents experienced negative health consequences.
Who Owns and Operates Williamsport?
WILLIAMSPORT NURSING AND REHABILITATION CENTER is owned by a non-profit organization. Non-profit facilities reinvest revenue into operations rather than distributing to shareholders. The facility operates independently rather than as part of a larger chain. With 121 certified beds and approximately 119 residents (about 98% occupancy), it is a mid-sized facility located in WILLIAMSPORT, Maryland.
How Does Williamsport Compare to Other Maryland Nursing Homes?
Compared to the 100 nursing homes in Maryland, WILLIAMSPORT NURSING AND REHABILITATION CENTER's overall rating (1 stars) is below the state average of 3.0, staff turnover (54%) is near the state average of 46%, and health inspection rating (1 stars) is much below the national benchmark.
What Should Families Ask When Visiting Williamsport?
Based on this facility's data, families visiting should ask: "Can you walk me through typical staffing levels on day, evening, and night shifts?" "Can I visit during a mealtime to observe dining assistance and food quality?" "How do you handle medical emergencies, and what is your hospital transfer rate?" "Can I speak with family members of current residents about their experience?" These questions are particularly relevant given the below-average staffing rating.
Is Williamsport Safe?
Based on CMS inspection data, WILLIAMSPORT NURSING AND REHABILITATION CENTER has a clean safety record: no substantiated abuse findings (meaning no confirmed cases of resident harm), no Immediate Jeopardy citations (the most serious violation level indicating risk of serious injury or death), and is not on the Special Focus Facility watch list (a federal program monitoring the lowest-performing 1% of nursing homes). The facility has a 1-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 Williamsport Stick Around?
WILLIAMSPORT NURSING AND REHABILITATION CENTER has a staff turnover rate of 54%, which is 8 percentage points above the Maryland average of 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 Williamsport Ever Fined?
WILLIAMSPORT NURSING AND REHABILITATION CENTER 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 Williamsport on Any Federal Watch List?
WILLIAMSPORT NURSING AND REHABILITATION CENTER is not on any federal watch list. The most significant is the Special Focus Facility (SFF) program, which identifies the bottom 1% of nursing homes nationally based on persistent, serious quality problems. Not being on this list means the facility has avoided the pattern of deficiencies that triggers enhanced federal oversight. This is a positive indicator, though families should still review the facility's inspection history directly.