TWIN OAKS CENTER
For profit - Limited Liability company
101 Beds
Independent
Data: November 2025
Trust Grade
5/100
#330 of 338 in MA
Photo by Twin Oaks Rehabilitation & Nursing Center
Photo by Twin Oaks Rehabilitation & Nursing Center
Photo by Twin Oaks Rehabilitation & Nursing Center
1 / 5 photos
Last Inspection: June 2025
Inspected within the last 6 months. Data reflects current conditions.
Overview
Twin Oaks Center in Danvers, Massachusetts has received a Trust Grade of F, indicating significant concerns and a poor overall performance. It ranks #330 out of 338 facilities in the state, placing it in the bottom half, and #44 out of 44 in Essex County, suggesting there are no better local options available. The facility is worsening, with issues increasing from 3 in 2024 to 19 in 2025, which is alarming for potential residents and their families. Staffing is rated poorly at 1 out of 5 stars, with a concerning turnover rate, despite having an average amount of registered nurse coverage. Additionally, the facility has faced $141,733 in fines, which is higher than 92% of Massachusetts facilities, indicating repeated compliance problems. Specific incidents highlight serious concerns, such as a resident being hospitalized after the facility failed to administer antipsychotic medication for six consecutive days, and another resident experiencing dehydration leading to hospitalization due to inadequate nutrition and hydration support. While the facility has a low staff turnover of 0%, which is a positive aspect, the overall conditions and recent findings suggest families should approach with caution.
- Trust Score
- F
- In Massachusetts
- #330/338
- Safety Record
- High Risk
- Inspections
- Getting Worse
- Staff Stability ○ Average
- Turnover data not reported for this facility.
- Penalties ✓ Good
- $141,733 in fines. Lower than most Massachusetts facilities. Relatively clean record.
- Skilled Nurses ⚠ Watch
- Each resident gets only 25 minutes of Registered Nurse (RN) attention daily — below average for Massachusetts. Fewer RN minutes means fewer trained eyes watching for problems.
- Violations ⚠ Watch
- 59 deficiencies on record. Higher than average. Multiple issues found across inspections.
5/100
Bottom 3%
Review needed
3 → 19 violations
★☆☆☆☆
1.0
Overall Rating
★☆☆☆☆
1.0
Staff Levels
★★★☆☆
3.0
Care Quality
★☆☆☆☆
1.0
Inspection Score
↔
Stable
2024: 3 issues
2025: 19 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 Massachusetts average (2.9)
Significant quality concerns identified by CMS
Federal Fines: $141,733
Well above median ($33,413)
Significant penalties indicating serious issues
The Ugly 59 deficiencies on record
4 actual harm
Jun 2025
19 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Resident Rights
(Tag F0550)
Could have caused harm · This affected 1 resident
Based on observations and interviews the facility failed to ensure a dignified dining experience on one out of three units. Specifically on the 1st floor unit, dining room staff failed to provide dign...
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Based on observations and interviews the facility failed to ensure a dignified dining experience on one out of three units. Specifically on the 1st floor unit, dining room staff failed to provide dignified dining experience and referred to residents as feeders, rather than by their name.
Findings include:
The facility policy titled Quality of Life- Dignity, dated as revised August 2009, indicated the following:
-Each resident shall be cared for in a manner that promotes and enhances quality of life, dignity, respect and individuality.
- Staff shall speak respectfully to residents at all times, including addressing the resident by his or her name of choice and not labeling or referring to the resident by his or her room number, diagnosis, or care needs.
On 6/17/25 beginning at 12:28 P.M., the surveyor made the following observations on the first floor unit:
-At 12:41 P.M., a Certified Nursing Assistant (CNA) walked into the dining room, gestured at a resident across the room and asked Nurse #1 if the resident was a feeder. Nurse #1 responded yes and failed to inform the CNA that residents should be referred to by their name, not as feeders.
-At 12:46 P.M., a Nurse said out loud We have a feeder left and gestured to a resident sitting at a table with four residents.
During an interview on 6/17/25 at 1:27 P.M., the Assistant Director of Nursing said staff should not refer to residents as feeders.
During an interview on 6/17/25 at 1:35 P.M., the Director of Nursing said staff should not refer to residents as feeders and said residents should be treated with dignity.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Report Alleged Abuse
(Tag F0609)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to 1.) report a fall, resulting in a head laceration requiring staples...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to 1.) report a fall, resulting in a head laceration requiring staples and, 2.) report a fall, resulting in a fracture of the right femoral neck (right thigh bone) requiring surgery, to the state agency as required for one Resident (#42), out of a total sample of 21 residents.
Findings include:
A review of the facility policy titled, Abuse Investigation and Reporting with a revision date of July 2017 indicated the following:
-All reports of resident abuse, neglect, exploitation, misappropriation of resident property, mistreatment and/or injuries of unknown source (abuse) shall be promptly reported to local, state, and federal agencies (as defined by current regulations) and thoroughly investigated by facility management. Findings of abuse investigations will also be reported.
-All alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of an unknown source and misappropriation of property will be reported by the facility Administrator or his/her designee to the following persons or agencies: The State licensing/certification agency responsible for surveying/licensing the facility.
-An alleged violation of abuse, neglect, exploitation, or mistreatment, (including injuries of unknown source and misappropriation of resident property) will be reported immediately, but no later than:
a. Two (2) hours if the alleged violation involves abuse or has resulted in serious bodily injury; or
b. Twenty-four (24) hours if the alleged violation does not involve abuse and has not resulted in serious bodily injury.
1. Resident #42 was admitted to the facility in March 2019 with diagnoses including bradycardia, adjustment disorder with anxiety, and anemia.
Review of Resident #42's most recent Minimum Data Set Assessment (MDS) dated [DATE], indicated that the Resident has a Brief Interview for Mental Status score of 2 out of 15 indicating severe cognitive impairment. Further review of the MDS indicated that the Resident is dependent on staff with activities of daily living.
Review of nursing progress notes indicated the following:
-Dated 6/11/25: This nurse had just come back from doing rounds, when she heard noise coming from the patient's room. On inspection, patient was observed lying on the floor on his/her left side. Vitals were stable, neuro's intact. At baseline resident is alert and oriented to self therefore, unable to provide a description of what happened. Resident was safely transferred back to his/her bed with the help of the CNA and I. Resident was not moaning or grimacing, he/she did not appear to be in pain. Physician was notified, he stated that they will come in and see him/her and legal guardian was left a message. Later on, when the aids for the next shift got the resident up in his/her wheel chair, they observed him/her bleeding from the scalp. This nurse and the oncoming nurse on duty was notified, this nurse called NP (nurse practitioner) who gave an order to send him/her out to the ED (emergency department)for further evaluation and a head CT scan. (Local) ambulance service was called to pick the resident and transport him/her to hospital, and they let this nurse know that they would be there in an hours time. This nurse let the on duty nurse know and also the ADON was made aware of the situation.
-Dated 6/11/25: Resident returned from Hospital s/p (status post) fall with injury to front head; via stretcher accompanied by 2 emergency personnel. Resident presented with laceration on front head. Resident returned with a staple to front of head.
Review of Resident #42's Hospital Discharge paperwork dated 6/11/25 indicated the following: - -Head: Midline forehead at the hairline there is an elliptical 2 cm laceration with slight blood oozing. Wound was closed with one staple. CT scan showed left forehead soft tissue laceration and edema. Follow-up with primary care physician in 2-3 days if not improving or for further concerns or follow-up sooner as needed. Staple removal in 7 days.
Review of the Health Care Facility Report System (HCFRS) failed to indicate the facility reported the incident to the state agency.
During an interview on 6/17/25 at 2:27 P.M., the Director of Nursing said she would expect the incident to have been reported to the state agency and said she thought the Administrator had reported the fall with head laceration with the staple.
During an interview on 6/18/25 at 8:08 A.M., the Administrator said he was aware of Resident #42's fall with head laceration and staple and said the injury should have been reported to the state agency but was not.
2. Review of Resident #42's progress notes indicated the following:
-Dated 2/23/25, Nurse Practitioner: Fall with injury. Patient had an unwitnessed fall. Patient does not ambulate independently, uses wheelchair at baseline. Staff did not see the fall, but patient was in common area for activity and attempted to get up unassisted, having a fall and was found on the floor. Patient complains of severe pain in the right knee and lower leg and will not allow staff to move or touch the leg. Indicates severe pain with any movements of the knee, not able to bear any weight on the joint with standing and there is moderate swelling/deformity of the knee. He/she also has a small hematoma to right side of forehead without active bleeding at this site. Limited flexion and extension of right knee, moderate right knees [NAME], guarding due to pain. Skin pink and dry, small hematoma about 1.5 inches in diameter to right forehead above the brow. This is an acute new problem condition is worsening. Significant knee pain with swelling and limitations to movement, concern for fracture given the injury/trauma.
-Dated 2/27/25, Nursing: Resident alert with baseline confusion. Returned from hospital last night s/p fall 3 days ago where he/she sustained a fracture in his/her right hip. Dressing on right hip intact with no drainage or signs of infection noted. Hip abduction pillow in place during shift. Resident received PRN Tylenol for pain with good effects. Resident was seen today by NP, new order placed to change hip dressing daily and as needed.
Review of Resident #42's Hospital Discharge paperwork dated 2/26/25 indicated the following: Fall and right hip fracture. Diagnosis: Close displaced fracture of right femoral neck. Status post-operative repair of closed fracture of right hip. Posterior Hip Precautions for 3months.
Review of the Health Care Facility Report System (HCFRS) failed to indicate the facility reported the incident to the state agency until 3/5/25, 10 days after the fall resulting in right femur fracture.
During an interview on 6/17/25 at 2:30 P.M., the Director of Nursing said she would expect the incident to have been reported to the state agency as required due to a resulting right leg fracture requiring surgery.
During an interview on 6/18/25 at 8:14 A.M., the Administrator said he would expect the fall with fracture to be reported per the state requirement and said he was not present during the time of the incident.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Comprehensive Care Plan
(Tag F0656)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to develop a person-centered behavior care plan for one Resident (#10...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to develop a person-centered behavior care plan for one Resident (#10) out of a total sample of 21 residents. Specifically, the facility failed to develop a person-centered care plan for a history of chronic paranoia and delusions.
Findings include:
A review of the facility policy titled 'Behavioral Assessment, Intervention and Monitoring' with a revision date of December 2016 indicated the following:
-Behavior is the response of an individual to a wide variety of factors. These factors may include medical, physical, functional, psychosocial, emotional, psychiatric, or environmental causes.
-As part of the initial assessment, the nursing staff and attending physician will identify individuals with a history of impaired cognition, altered behavior, or mental illness (e.g., bipolar disorder or schizophrenia).
-As part of the comprehensive assessment, staff will evaluate, based on input from the resident, family and caregivers, review of medical record and general observations, the resident's usual patterns of cognition, mood and behavior, the resident's typical or past responses to stress, fatigue, fear, anxiety, frustration and other triggers.
Resident #10 was admitted to the facility in April 2025 with diagnoses including schizophrenia, intellectual disability and post-traumatic stress disorder.
A review of the most recent Minimum Data Set (MDS), dated [DATE], indicated a Brief Interview for Mental Status (BIMS) score of 9 out of a possible 15 indicating moderate cognitive impairment.
A review of the hospital discharge medical record dated 3/20/25 indicated the following:
-Per social work notes: Resident has a history of chronic delusions, however staff from the respite, report his/her paranoia has been worse. The resident notes he/she does not want to go back to respite because the male staff scare him/her. He/she notes that he/she would like to go to a nursing home and have female staff. Staff confirm that the resident has paranoia around black males, and this has contributed to him/her refusing his/her medication when the staff is a black male. Resident reported his/her neighbors, who drink alcohol, whiskey, and do drugs broke into his/her apartment, beat him/her, did wicked things, sexually. Resident reports urinating in bottles in his/her room because he/she does not want to leave his/her room to use the bathroom.[sic]
A review of Resident #10's care plan failed to indicate a history of delusions and paranoia person-centered care plan.
During an interview and record review on 6/17/25 at 9:17 A.M., the Social Worker reviewed the hospital discharge paperwork with the surveyor. The Social Worker said a person-centered care plan with the Resident's chronic paranoia and delusions should be added to his/her care plan.
During an interview on 6/17/25 at 10:40 A.M., the Director of Nurses said the Resident's paranoia and delusions should be added in the care plan and person centered.
Refer to F699.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0658
(Tag F0658)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record review, the facility failed to provide Nursing services consistent with professiona...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record review, the facility failed to provide Nursing services consistent with professional standards of practice for two Residents #24 and #11 out of a total sample of 21 residents. Specifically;
1. For Resident # 24, the facility failed to include how much oxygen the Resident should be taking via nasal cannula, and how often the oxygen tubing should be changed in the physician's orders.
2. For Resident #11, the facility failed to implement a physician's order to administer tube feeding with correct enteral feeding and correct rate.
Findings include:
A review of the facility policy titled 'Oxygen Administration' indicated the following:
-The purpose of this procedure is to provide guidelines for safe oxygen administration.
-Verify that there is a physician's order for this procedure. Review the physician's orders or facility protocol for oxygen administration.
A Review of the Massachusetts Board of Registration in Nursing Advisory Ruling on Nursing Practice, dated as revised April 11, 2018, indicated:
-Nurse's Responsibility and Accountability: Licensed nurses accept, verify, transcribe, and implement orders from duly authorized prescribers that are received by a variety of methods (i.e., written, verbal/telephone, standing orders/protocols, pre-printed order sets, electronic) in emergent and non-emergent situations. Licensed nurses in a management role must ensure an infrastructure is in place, consistent with current standards of care, to minimize errors.
1. Resident #24 was admitted to the facility in December 2024 with diagnoses including dementia with behavioral disturbances and Chronic Obstructive Pulmonary Disease (COPD).
A review of the Minimum Data Set (MDS) dated [DATE] indicated a Brief Interview for Mental Status (BIMS) score of 11 out of a possible 15 indicating moderate cognitive impairment.
On 6/16/25 at 9:17 A.M., and 11:10 A.M., the surveyor observed Resident #24 in bed wearing a nasal cannula, oxygen was set at 4 liters, and the oxygen tubing was not labeled and dated.
During an interview on 6/16/25 at 11:10 A.M., Resident #24 said he/she has been on oxygen since admission.
On 6/17/25 at 7:47 A.M., and 9:48 A.M., the surveyor observed Resident #24 in bed wearing a nasal cannula, oxygen was set at 4 liters, and the oxygen tubing was not labeled and dated.
A review of the Respiratory therapist's progress note date 6/12/25 indicated the following:
-The Resident utilizes an oxygen concentrator from O2 (oxygen) safe. Oxygen saturation on 3 LPM (Liters Per Minute) is 97 percent, and his/her respiratory rate is 73 bpm (breatbs per minute).
A review of the Respiratory therapist's progress note dated 6/16/25 indicated the following:
The Resident utilizes an oxygen concentrator from O2 (oxygen) safe. His/her oxygen saturation on 3 LPM (Liters Per Minute) is 99 percent and his/her respiratory rate is 86 bpm (breaths per minute).
A review of Resident #24's physician's orders failed to indicate an oxygen administration via nasal cannula physician's order.
Further review of the shortness of breath (SOB) and COPD care plan initiated 4/10/25 failed to indicate an oxygen administration via nasal cannula plan of care.
During an interview, observation and record review on 6/17/25 at 10:15 A.M., the surveyor and the Assistant Director of Nurses (ADON) observed the Resident in bed, wearing the nasal cannula, oxygen set at 4 liters, and the oxygen tubing not labeled and dated. The ADON reviewed the physician's orders and could not find an order for oxygen administration. The ADON said there should be a physician's order in place indicating how much oxygen the resident should be taking, and how often the oxygen tubing should be changed.
During an interview and record review on 6/17/25 at 10:21 A.M., the Director of Nurses (DON) reviewed Resident #24's physician's orders and said oxygen administration physician's order should be in place. The DON said the physician's orders should indicate how much oxygen the resident should be on and how often the oxygen tubing should be changed.2. Resident #11 was admitted to the facility in March 2021 with diagnoses including respiratory failure, gastrostomy status, tracheostomy, and quadriplegia.
Review of the most recent Minimum Data Set (MDS) assessment, dated 5/25/25, indicated Resident #11 had a Brief Interview for Mental Status (BIMS) assessment, which indicated severe cognitive impairment. Further review indicated Resident #11 had tube feedings, and a tracheostomy.
Review of Resident #11's physician's order, initiated 5/9/25, indicated:
- Enteral Feed Order every shift Jevity 1.5 calories (cal) at 55 milliliters (ml) per hour (hr).
On 6/16/25 at 8:02 A.M., the surveyor observed Jevity 1.2 cal at 58 ml/hr being administered via gastrostomy (G-tube) to Resident #11.
On 6/17/25 at 7:33 A.M., the surveyor observed Jevity 1.2 cal at 58 ml/hr being administered via G-tube to Resident #11.
During an interview on 6/16/25 at 10:45 A.M., Nurse #1 reviewed Resident #11's physician's order and then observed the enteral feeding that was being administered to Resident #11 with the surveyor. She said she was not aware that Resident #11 was not receiving the enteral feeding that was ordered by the physician. She said she would expect that the physician ordered enteral feeding would match what the Resident was receiving.
During an interview on 6/17/25 at 11:50 A.M., the Director of Nursing (DON) said nurses should always follow the physician's orders. The DON said that if the enteral feed orders need to be changed for any reason, she would expect the order to be updated and to be followed.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Quality of Care
(Tag F0684)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview the facility failed to provide treatment and care in accordance with professio...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview the facility failed to provide treatment and care in accordance with professional standards of practice for one Resident (#56) out of a total sample of 21 residents. Specifically; the facility failed to change a wound dressing for three days.
Findings include:
Review of the facility policy titled Dressings, Dry/Clean dated revised September 2013, failed to indicate to follow a physician's order.
Resident #56 was admitted to the facility in February 2024 with diagnoses including peripheral vascular disease, anxiety and depression.
Review of the Minimum Data Set assessment dated [DATE], indicated Resident #56 scored an 11 out of 15 on the Brief Interview for Mental Status exam, indicating moderately impaired cognition.
On 6/16/25 at 8:10 A.M. the surveyors observed Resident #56 sitting on the edge of the bed. The surveyors then observed a soiled dressing on Resident #56's right ankle covering half the open wound and exposing the other half. The surveyors also observed that the dressing was dated 6/12/25.
On 6/16/25 at 12:50 P.M. the surveyor and Nurse #1 observed Resident #56 sitting on the edge of the bed with a soiled dressing on Resident #56's right ankle covering half the open wound and exposing the other half. They also observed that the dressing was dated 6/12/25 and had yellow/brown drainage.
Review of the physician's orders dated June 2025 indicated an order for:
Day Shift; Mupirocin External Ointment 2 % (Mupirocin)
Apply to Right medial ankle topically every day shift for Wound care - Start Date - 05/14/2025 0700 - D/C Date - 06/13/2025 0938
Further review indicated an order for:
Day Shift; Mupirocin External Ointment 2 % (Mupirocin) Apply to Right medial ankle topically every day shift for Wound care for 30 Days - Start Date - 06/14/2025 0700
Review of the Medication Administration Record dated June 2025, indicted that on 6/13/25, 6/14/25 and 6/15/25, nurses documented that they changed the dressing as ordered.
During an interview on 6/16/25 at 12:50 P.M. Nurse #1 said that the dressing should have been changed daily.
During an interview on 6/18/25 at 7:26 A.M. the Director of Nursing said that she expects the nurses to follow the physician's orders for dressing changes.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0688
(Tag F0688)
Could have caused harm · This affected 1 resident
Based on observation, interview, and record review, the facility failed to consistently provide range of motion (ROM) care and treatment in accordance with professional standards of practice for one R...
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Based on observation, interview, and record review, the facility failed to consistently provide range of motion (ROM) care and treatment in accordance with professional standards of practice for one Resident (#11) out of a total sample of 21 residents. Specifically, the facility failed to ensure staff implemented Resident #11's, physician ordered, rolled facecloth to contracted [left] hand every shift.
Findings include:
Review of the facility policy titled 'Resident Mobility and Range of Motion', revised July 2017, indicated:
- Residents will not experience an avoidable reduction in range of motion (ROM).
- Residents with limited ROM will receive treatment and services to increase and/or prevent a further decrease in ROM.
- Residents with limited mobility will receive appropriate services, equipment and assistance to maintain or improve mobility unless a reduction in mobility is unavoidable.
Resident #11 was admitted to the facility in March 2021 with diagnoses including contracture, unspecified joint.
Review of the most recent Minimum Data Set (MDS) assessment, dated 5/25/25, indicated Resident #11 had a Brief Interview for Mental Status (BIMS) assessment, which indicated severe cognitive impairment. This MDS also indicated Resident #11 had functional limitation in range of motion in bilateral upper and lower extremities.
Review of Resident #11's physician's order, initiated 4/21/24, indicated:
- Cleanse left hand with water and soap and dry. Inspect skin. Notify physician (MD) if impairment is noted and document in progress notes. Place a rolled washcloth to contracted hand, every shift (QS).
Review of Resident #11's plan of care related to alteration in musculoskeletal status left hand related to contracture, revised 2/16/22, indicated:
- washcloth in palm to prevent further contracture deterioration.
On 6/16/25 at 8:02 A.M., the surveyor observed Resident #11 lying in bed without a facecloth in his/her left hand.
On 6/17/25 at 7:34 A.M., the surveyor observed Resident #11 lying in bed without a facecloth in his/her left hand.
During an interview on 6/17/25 at 10:10 A.M., Certified Nurse Assistant (CNA) #2 said she regularly works on the unit with Resident #11, and he/she usually has a facecloth in his/her left hand, but she does not know why he/she hasn't had it for the past two days.
Review of Resident #11's medical record, including medication administration record (MAR), treatment administration record (TAR), and progress notes failed to indicate any rationale regarding why Resident #11 was not using a facecloth to his/her left hand.
During an interview on 6/17/25 at 10:45 A.M., Nurse #1 and surveyor reviewed Resident #11's order for facecloth to left hand and then observed that he/she did not have a facecloth in his/her left hand. She said that Resident #11 usually has a facecloth in his/her left hand, and it should be there according to physician's orders. Nurse #1 and surveyor reviewed Treatment Administration Record (TAR) and observed that the order for rolled facecloth to left hand is signed off every shift as completed.
On 6/17/25 at 10:50 A.M., the surveyor observed Resident #11 lying in bed without a facecloth in his/her left hand.
During an interview on 6/18/25 at 7:25 A.M., the Director of Nursing (DON) said if Resident #11 had a physician's order for a facecloth to be applied to his/her left hand, it should have been in place. The DON said if it was not in place, the rationale should be documented in the medical record.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0692
(Tag F0692)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record reviews and interviews, the facility failed to adequately maintain the nutrition and hydration sta...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record reviews and interviews, the facility failed to adequately maintain the nutrition and hydration status of one Resident (#1) out of a total sample of 21 residents. Specifically, for Resident #1 the facility failed to ensure significant weigh loss was assessed and continually monitored.
Findings include:
Review of the facility policy titled, Weighing and Measuring the Resident, dated as revised March 2011, indicated the following:
-The purposes of this procedure are to determine the resident's weight and height, to provide a baseline and an ongoing record of the resident's body weight as an indicator of the nutritional status and medical condition of the resident, and to provide a baseline height in order to determine the ideal weight of the resident.
-Reporting:
1. Report significant weight loss/weight gain to the nurse supervisor.
2. The threshold for significant unplanned and undesired weight loss/gain will be based on the following criteria.
a. 1 month- 5% loss is significant; greater than 5% is severe.
b. 3 months- 7.5% weight loss is significant; greater than 7.5% is severe.
c. 6 months- 10% weight loss is significant; greater than 10% is severe.
3. Notify the Nurse Supervisor if the resident refuses the procedure.
4. Report other information in accordance with facility policy and professional standards of practice.
Resident #1 was admitted to the facility in February 2025 with diagnoses including anxiety, depression, and bipolar disorder.
Review of Resident #1's most recent Minimum Data Set (MDS) dated [DATE], indicated the Resident had a Brief Interview for Mental Status (BIMS) of 12 out of a possible 15, which indicated he/she had moderate cognitive impairment.
Review of Resident #1's weights indicated the following:
-5/12/25 152.0 lbs.
-4/1/25 157.1 lbs.
-2/6/25 176.5 lbs.
-5/24/25 129.3 pounds (lbs.) 14.9 % decrease from 5/12/25; 17.7 % decrease from 4/1/25; 26.7 % decrease from 2/6/25.
Review of the Resident's medical record failed to indicate any record of weights during the month of March 2025 and failed to record any reweights or documentation of physician being notified of significant weight loss.
Review of the dietary notes indicated the following:
5/12/2025 10:50 Weight Note
Note Text: he/she triggered for loss this month
-10% from 2/6 176.5
Wt. Hx
2/6 176.5
4/1 157
5/12 152
-10% decrease
Diet mech (mechanical) soft in dining room
He/she reports UBW (usual body weight) 160. Appetite is variable, prefers sandwiches and cold cereal. He/she agreed to try the house supps (supplements) added to trays to prevent further loss. BMI is wnl [within normal limits] and insight loss x 30 days. Will cont [continue] to monitor and evaluate. [sic]
4/4/2025 12:15
Weight Note
Note Text: He/she triggered for wt. loss, -10% from admission.
He/she was seen in the dining room in his/her electric wheelchair with others. He/she reports his/her appetite is good and he/she prefers sandwiches. He/she declines supplements or any snacks and reports he/she gets enough to eat. He/she appears to be recorded ht/wt [height/weight] and adequately nourished. BMI is wnl [within normal limits].
Wt. HX
4/1 157
2/6 176.5
BMI 22.5 wnl
Diet mechanical soft.
Intakes 50-100%
Since he/she declines interventions no new concerns. Will cont to monitor. [sic]
During an interview on 6/17/25 at 10:45 A.M., Nurse #1 said she would report any significant weight loss to the dietitian and physician.
During a follow up interview on 6/17/25 at 1:12 P.M., Nurse #1 said she would ask for Resident to be reweighed if the weight was significantly different compared to previous weight. Nurse #1 said she was unaware of Resident #1's significant weight loss, but she said that he/she recently had mighty shakes ordered. She was unaware if the physician had been notified of weight changes.
During an interview on 6/17/25 at 12:52 P.M., the Registered Dietitian (RD) said she works at the facility two times per week. She said that she reviews the weight change progress report weekly to monitor for variances, attends risk meetings weekly and then writes progress notes to address any Resident's discussed. She said she would expect that nursing would identify any changes in Resident's weights or eating patterns before her and let her know so she could review and make recommendations. The RD said that if a weight was significantly different than the previous weight, she would ask for a reweight. If weight loss was still significant, she would expect the physician to be notified. She says that she does request reweights from nursing and that the need for reweights is also discussed in risk meetings but states that she does not have any documentation to support this.
Review of the Medication Administration Reports (MAR) for January 2025 to June 2025 failed to indicate the Resident refused the Mighty Shake supplement.
During an interview on 6/18/25 at 7:25 A.M., the Director of Nursing (DON) said she expects weights to be obtained at least monthly, reweighs to be obtained and recorded if there is a significant change and dietitian and physician to be notified if a significant weight change has occurred. The DON said she was unaware of Resident #1's weight loss and does not know why it did not get followed up on.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0699
(Tag F0699)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to develop a trauma informed care plan for two Residents #10 and #1 o...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to develop a trauma informed care plan for two Residents #10 and #1 out of a total sample of 21 residents. Specifically:
1. For Resident #10, the facility failed to develop a post-traumatic stress disorder (PTSD) care plan addressing the needs of trauma by minimizing triggers and re-traumatization.
2. For Resident #1, the facility failed to develop a care plan addressing PTSD with a history of suicide attempt.
Findings include:
A review of the facility policy titled 'Trauma Informed Care' with no revision date indicated the following:
-Trauma informed care is an approach to delivering care that involves understanding, recognizing and responding to the effects of all types of traumas. A trauma-informed approach to care delivery recognizes the widespread impact and signs and symptoms of trauma in residents, and incorporates knowledge about trauma into care plans, policies, procedures and practices to avoid re-traumatization.
-The facility will identify triggers which may re-traumatize residents with a history of trauma. Trigger specific interventions will identify ways to decrease the resident's exposure to triggers which retraumatize the resident, as well as identify ways to mitigate or decrease the effect of the trigger on the resident and will be added to the resident's care plan.
1. Resident #10 was admitted to the facility in April 2025 with diagnoses including schizophrenia, intellectual disability and PTSD.
A review of the most recent Minimum Data Set (MDS) dated [DATE] indicated a Brief Interview for Mental Status (BIMS) score of 9 out of a possible 15 indicating moderate cognitive impairment.
A review of the hospital discharge record dated March, 2025 indicated the following:
-Psycho-social history: History of trauma/life events impacting wellbeing: DDS (Department of Developmental Services) involvement in the childhood due to abuse and exposure to family violence. Chart review indicates there is some concern of prior sexual assault while admitted to the hospital in the past. The resident tells me he/she was raped by a stranger at age [AGE], physically assaulted by a stranger on the street as a young boy/girl. [sic]
A review of Resident #10's care plan failed to indicate a person-centered PTSD care plan identifying triggers which may re-traumatize the Resident.
A review of Resident #10's Trauma Informed Care Assessment with an effective date of 4/29/25 failed to indicate any identified trauma.
During an interview and record review on 6/17/25 at 9:17 A.M., the Social Worker reviewed the hospital discharge paperwork and the Trauma Informed Care Assessment with the surveyor. The Social Worker said the Trauma Informed Care Assessment should have identified the Resident's history of trauma. The Social Worker said a person-centered PTSD care plan identifying triggers that may re-traumatize the Resident should be put in place.
During an interview on 6/17/25 at 10:40 A.M., the Director of Nurses said the Resident should have a person-centered PTSD care plan identifying all his/her triggers.2. Resident #1 was admitted to the facility in February 2025 with diagnoses including anxiety, depression, bipolar disorder, and post-traumatic stress disorder (PTSD).
A review of the most recent Minimum Data Set (MDS) dated [DATE] indicated a Brief Interview for Mental Status (BIMS) score of 12 out of a possible 15 indicating moderate cognitive impairment. This MDS indicated a diagnosis of PTSD.
A review of physician progress note from a previous facility, dated 12/11/24 indicated the following:
-complicated psychiatric history dx of bipolar depression with anxiety, PTSD, insomnia with history of suicide attempt by jumping from 4th floor of building 5 years ago. He/she was last seen by behavioral health NP (nurse practitioner) for medication management on 11/4/24. [sic]
A review of Resident #1's care plan failed to indicate a person-centered PTSD care plan identifying triggers which may re-traumatize the Resident and/or identification of history of suicide attempt.
A review of Resident #1's Trauma Informed Care Assessment with an effective date of 2/7/25 failed to indicate any identified trauma.
During an interview on 6/17/25 at 10:45 A.M., Nurse #1 said she would expect a care plan to be in place to address the Resident's history of suicide attempts so staff would be aware of and monitor for any signs and symptoms.
During an interview on 6/17/25 at 10:40 A.M., the Director of Nurses said the Resident should have a person-centered care plan to identify his/her triggers and history of suicide attempt.
During an interview and record review on 6/17/25 at 12:42 P.M., the Social Worker reviewed the progress notes and the Trauma Informed Care Assessment with the surveyor. The Social Worker said the Trauma Informed Care Assessment should have identified the Resident's history of trauma. The Social Worker said a person-centered PTSD care plan identifying triggers that may re-traumatize the Resident should be put in place and should also address his/her history of suicide attempt.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Unnecessary Medications
(Tag F0759)
Could have caused harm · This affected 1 resident
Based on observation, interview and record review, the facility failed to ensure it was free from a medication error rate of greater than 5 percent. Specifically, one of two nurses observed made two e...
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Based on observation, interview and record review, the facility failed to ensure it was free from a medication error rate of greater than 5 percent. Specifically, one of two nurses observed made two errors in 33 opportunities resulting in a medication error rate of 6.06%. These errors impacted one Resident (#18) out of four residents observed.
Findings include:
Review of the facility policy titled Adverse Consequences and Medication Errors dated as revised April 2014 indicated the following:
-A medication error is defined as the preparation or administration of drugs or biological's which is not in accordance with physician orders, manufacturer specifications, or accepted professional standards and principles of the professional(s) providing services.
For Resident #18 the facility failed to administer medications as ordered by the physician.
Review of the current doctor's orders indicated an order for the following:
1. Lactose Fast Acting Relief Oral Tablet (Lactase) Give 2 tablets by mouth before meals for lactose intolerance. Start Date 6/13/25.
2. Saline Spray Nasal Solution (Saline) 1 spray in each nostril three times a day for dryness. Start Date 3/31/25.
During a medication pass on 6/17/25, at 8:50 A.M. the surveyor observed Nurse #3 prepare and administer the following medications:
1.Lactose Fast Acting Relief Oral Tablet (Lactase) -two tablets given after the breakfast meal was consumed. The surveyor observed a staff member feeding Resident #18 just prior to the medication pass. The breakfast tray was observed on the over bed table with consumed food during the medication pass.
2. Saline Spray Nasal Solution (Saline)- two sprays were administered in each nostril.
During an interview on 6/17/25 at 8:55 A.M., Nurse #3 said he should have administered the medication before the breakfast meal and said he always gives the Resident two sprays per nostril and said he should have followed the physician order for one spray.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Medical Records
(Tag F0842)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interviews, the facility failed to accurately document in the medical record for one Res...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interviews, the facility failed to accurately document in the medical record for one Resident (#56 ) out of a total sample of 21 residents. Specifically, for Resident #56 the facility documented a dressing change was completed for three days when it was not.
Findings include:
Resident #56 was admitted to the facility in February 2024 with diagnoses including peripheral vascular disease, anxiety and depression.
Review of the Minimum Data Set assessment dated [DATE] indicated Resident #56 scored an 11 out of 15 on the Brief Interview for Mental Status exam, indicating moderately impaired cognition.
On 6/16/25 at 8:10 A.M. two surveyors observed Resident #56 sitting on the edge of the bed. The surveyors then observed a soiled dressing on Resident #56's right ankle covering half the open wound and exposing the other half. The surveyors also observed that the dressing was dated 6/12/25.
On 6/16/25 at 12:50 P.M. the surveyor and Nurse #1 observed Resident #56 sitting on the edge of the bed with a soiled dressing on Resident #56's right ankle covering half the open wound and exposing the other half. They also observed that the dressing was dated 6/12/25 and had yellow/brown drainage.
Review of the physician's orders dated June 2025 indicated an order for:
Day Shift: Mupirocin External Ointment 2 % (Mupirocin) Apply to Right medial ankle topically everyday shift for Wound care. Start Date 5/14/25 7:00 A.M., D/C (discontinued) Date 6/13/25 at 9:38 A.M.
Further review indicated an order for:
Day Shift: Mupirocin External Ointment 2 % (Mupirocin) Apply to Right medial ankle topically everyday shift for Wound care for 30 Days. Start Date: 6/14/25 at 7:00 A.M.
Review of the Medication Administration Record (MAR) dated June 2025, indicated that on 6/13/25, 6/14/25 and 6/15/25, nurses documented that they changed the dressing as ordered.
During an interview on 6/16/25 at 1:45 P.M., Nurses #1 and the surveyor observed Resident #56 sitting on the edge of the bed with a dressing on the right ankle dated 6/12/25. The surveyor and Nurse #1 then observed the MAR and Nurse #1 said that nurses should not be documenting they changed the dressing when they did not.
During an interview on 6/18/25 at 7:23 A.M., the Director of Nursing (DON) said she expects nurses to document accurately in the medical record. The DON then said that she cannot locate a facility policy regarding accurate documentation in the medical record.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0883
(Tag F0883)
Could have caused harm · This affected 1 resident
Based on record review and interviews, the facility failed to offer the Influenza vaccine during influenza season to one Resident out of a sample of five residents reviewed. Specifically, the facility...
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Based on record review and interviews, the facility failed to offer the Influenza vaccine during influenza season to one Resident out of a sample of five residents reviewed. Specifically, the facility failed to offer Influenza vaccination on admission to the facility or during their stay at the facility.
Findings include:
Review of the facility policy, titled 'Influenza Vaccine', undated, indicated the following:
-All residents and employees who have no medical contraindications to the vaccine will be offered the influenza vaccine annually to encourage and promote the benefits associated with vaccinations against influenza.
-Between October 1st and March 31st each year, the influenza vaccine shall be offered to residents and employees, unless the vaccine is medically contraindicated or the resident or employee has already been immunized.
A review of five resident medical records indicated one out of the five residents had not been vaccinated for Influenza.
During an interview on 6/17/25 at 11:37 A.M. the Director of Nurses (DON) said she does not track vaccinations in the building but expects the Infection Preventionist to be tracking the vaccinations.
During an interview on 6/17/25 at 11:44 A.M. the Infection Preventionist said he has only been working in the facility for the past month and did not have any information on the vaccination program.
During an interview on 6/18/25 at 8:04 A.M., the Administrator said the Vaccination program should be implemented and followed and said he is not aware of the status of vaccinations in the building at this time. He said he hires staff specialized in clinical areas to manage those issues and expects the requirements to be met.
During a phone interview on 6/18/25 at 10:40 A.M., the Medical Director said he started as the facility's Medical Director in April 2025. He said he would expect Residents' vaccination status to be obtained upon admission and for them to be offered the Influenza vaccine if admitted during Influenza season.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0887
(Tag F0887)
Could have caused harm · This affected 1 resident
Based on record review and interviews, the facility failed to offer the COVID-19 (Coronavirus disease) vaccine to one out of five sampled residents. Specifically, the facility failed to offer a COVID-...
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Based on record review and interviews, the facility failed to offer the COVID-19 (Coronavirus disease) vaccine to one out of five sampled residents. Specifically, the facility failed to offer a COVID-19 vaccination to a resident on admission to the facility or during their stay at the facility.
Findings include:
Review of the facility policy, titled 'Coronavirus Prevention and Control', dated as revised January 2023, indicated the following:
-Facility leadership and clinical staff are responsible to take reasonable measures to protect the health and safety of residents and staff during the current outbreak of coronavirus disease (COVID-19).
A review of five resident medical records indicated one out of the five residents had not been vaccinated for COVID-19.
During an interview on 6/17/25 at 11:37 A.M. the Director of Nurses (DON) said she does not track vaccinations in the building but expects the Infection Preventionist to be tracking the vaccinations.
During an interview on 6/17/25 at 11:44 A.M. the Infection Preventionist said he has only been working in the facility for the past month and did not have any information on the vaccination program.
During an interview on 6/18/25 at 8:04 A.M., the Administrator said the Vaccination program should be implemented and followed and said he is not aware of the status of vaccinations in the building at this time. He said he hires staff specialized in clinical areas to manage those issues and expects the requirements to be met.
During a phone interview on 6/18/25 at 10:40 A.M., the Medical Director said he started as the facility's Medical Director in April 2025, and he has heard that residents have not been receiving Covid vaccines. He said he would expect residents' vaccination status to be obtained upon admission and for them to be offered the Covid vaccine in the facility if they had not received prior to being admitted .
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0761
(Tag F0761)
Could have caused harm · This affected multiple residents
Based on observations and interviews, the facility failed to ensure 1.) a medication cart was locked when unattended, on one of three nursing units, 2.) medications were labeled, and dated once opened...
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Based on observations and interviews, the facility failed to ensure 1.) a medication cart was locked when unattended, on one of three nursing units, 2.) medications were labeled, and dated once opened, according to manufacturer's guidelines on one out of three medication carts sampled, 3.) store medications at proper temperatures and other appropriate environmental controls to preserve their integrity.
Findings include:
Review of the facility policy titled, Storage of Medications, dated as revised April 2007, indicated:
The facility shall store all drugs and biologicals in a safe, secure, and orderly manner.
-Compartments (including, but not limited to, drawers, cabinets, rooms, refrigerators, carts, and boxes.) containing drugs and biologicals shall be locked when not in use, and trays or carts used to transport such items shall not be left unattended if open or otherwise potentially available to others.
-Only a person authorized to prepare and administer medications shall have access to the medication room, including keys.
-Medication requiring refrigeration must be stored in a refrigerator located in the drug room at the nurses' station or other secured location. Medication must be stored separately from food and must be labeled accordingly.
1.The facility failed to ensure medications were stored in locked compartments on one of three nursing units.
On 6/17/25 at 8:08 A.M., the surveyor observed a medication cart left unlocked and unattended on the third-floor unit. The surveyor was able to open the medication cart and gain access to the medications. There were no staff present at or around the medication cart and residents were observed walking past the unlocked medication cart.
During an interview on 6/17/25 at 8:18 A.M., Nurse #3 said the medication cart must be locked at all times and said he did not realize it was unlocked.
During an interview on 6/17/25 at 3:20 P.M., the Director of Nursing (DON) said medication carts must remain locked and said no one should have access to the medications except the nursing staff who have the keys to unlock the cart and gain access to the medication stored inside.
2.The facility failed to ensure medications were labeled, and dated once opened, according to manufacturer's guidelines in one out of four medication carts sampled.
On 6/17/25 at 8:50 A.M., the surveyor and Nurse #3 observed the following on the 3rd floor medication cart:
-Artificial Tears Lubricant Eye Drops ½ FL Oz 15ml., open undated.
During an interview on 6/17/25 at 8:52 A.M., Nurse #3 said medications must be dated when opened and said he is not sure when the bottle was opened.
During an interview on 6/17/25 at 3:20 P.M., the Director of Nursing (DON) said the Artificial Tears should have been dated when opened and said she expects staff to document on the bottle when a medication if first opened.
3.The facility failed to ensure storage of medications at proper temperatures and other appropriate environmental controls to preserve their integrity.
On 6/17/25 at 12:18 P.M., the surveyor made the following observations on the 1st floor unit:
-One Medication refrigerator was located inside of the medication storage room. There was no thermometer located inside of the refrigerator and the inside of the refrigerator felt cool not cold. Condensation was observed on the medications located inside of the refrigerator.
-There was one digital thermometer located on the outside of the refrigerator that was not operatable and had a blank screen.
-One April 2025 Temperature Log containing 12 documented temperatures out of 30 days.
The following medications were observed inside of the refrigerator:
-One box of Latanoprost Ophthalmic Solution 0.005% Store unopened bottle in refrigeration at 2 degrees Celsius to 8 degrees Celsius (2°C to 46°C) /36 degrees Fahrenheit to 46 degrees Fahrenheit. (36°F to 46°F)
-Six Vitals of Humalog CAR 100 Units. Store in a refrigerator at approximately 36°F to 46°F.
-15 Insulin Injection Pens. Store in a refrigerator at approximately 36°F to 46°F
-1 Box Repatha (evolocumab) Prefilled Syringe Injection - Store in a refrigerator at approximately 36°F to 46°F.
-1 Box Risperdal Consta Risperidone Long-Acting Injection Single Use Dose Pack - Store in refrigerator at approximately 36°F to 46°F.
During an interview on 6/17/25 at 12:24 P.M., Nurse #2 said the refrigerator should have daily temperature logs and said the overnight staff are responsible for maintaining the logs. Nurse #2 said the Assistant Director of Nursing took the thermometer out this morning because it was not working.
During an observation and interview on 6/17/25 at 1:04 P.M., the Assistant Director of Nursing (ADON) said the temperature of the refrigerator was too high and said he took the thermometer out this morning and did not place a new thermometer inside of the refrigerator. The surveyor along with the ADON observed the refrigerator and observed condensation, melting frost and water on the inside of the refrigerator that contained medications. The bottles and bags were wet to the touch. The ADON said the overnight nurse reported to him that the refrigerator was not working and that it was warm. The ADON said the medications must be within parameters and said all he knows is that the temps were high according to the overnight nurse, but he does not know what the temperature was and does not know how long the refrigerator was warm. The ADON then said he does not have any temperature logs and said the staff should be documenting the temperature every night.
During an interview on 6/17/25 at 2:37 P.M., the Director of Nursing said it is her expectation that the temperature of the refrigerators are checked each night and monitored for safety within the appropriate temperatures. The DON said she was not aware of the warm refrigerator and said the medications must be thrown away because they do not know how long they have been warm.
During an interview on 6/18/25 at 10:38 A.M., the Medical Director said it is his expectation that medications are stored according to the manufactures guidelines and said he expects staff to monitor temperature controls and remove medications that have been compromised.
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 records reviewed and interviews, the facility failed to ensure it provided appropriate administrative oversight in a manner that enabled the facility to use its resources effectively to attai...
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Based on records reviewed and interviews, the facility failed to ensure it provided appropriate administrative oversight in a manner that enabled the facility to use its resources effectively to attain the highest practicable physical, mental, and psychosocial well-being of each resident. The facility administration failed to ensure pre-employment health requirements and dementia training was provided to all staff to provide competent, safe, and effective resident care as well as ensuring the governance and leadership members sustain a sufficient Quality Assurance Performance Improvement (QAPI) program during transitions in leadership and staffing. Specifically, the facility administration failed to:
1. Ensure effective systems were in place for education, and training for licensed staff to ensure competent, and safe practice.
2. Establish and maintain an IPCP (Infection Prevention Control Program) designed to provide a safe, sanitary, and comfortable environment and to help prevent development and transmission of disease and infection.
3. Develop an Antibiotic Stewardship program that promotes the appropriate use of antibiotics and includes a system of monitoring to improve resident outcomes and reduce antibiotic resistance.
Findings include:
During the survey process it was identified that the Administration's failure to orient and educate staff on policies and procedures specifically related to dementia care. During the survey process, it was also identified that the Administration's failure to implement an infection control program for identifying, tracking, and monitoring, including the failure to develop and implement an Antibiotic Stewardship Program.
During an interview on 6/18/25 at 9:39 A.M., the Administrator said it is his expectation that the clinical staff are trained appropriately and have the required completed clinical competencies on file. The Administrator said he was not aware that 3 out of the 5 new hire employee records reviewed were lacking proof of dementia training. He then said that he could provide no documentation of clinical concerns brought to the QAPI meetings including infection control measures, antibiotic stewardship or dementia education.
During a phone interview on 6/18/25 at 10:40 A.M., the Medical Director said he started as the facility's medical director in April 2025, and he is aware that there is no Infection Control Program in place. He said it is something they are working on and will address through the Quality Assurance and Performance Improvement (QAPI) program. He said he would expect the facility to be monitoring and tracking infections, including antibiotic stewardship and the vaccinating of residents and staff when appropriate, data collecting and recording and calculating infection rates so this information can be brought to the QAPI committee, and they can be involved in interpretation of the data.
During an interview on 06/18/25 11:10 A.M., the Administrator said that he had not informed the [NAME] president of Operations or the governing body of the lack of QAPI in the facility prior to February.
During an interview on 6/18/25 at 11:23 A.M., the [NAME] President of Operations said he was not made aware of the lack of QAPI being performed in the building from September 2024 through February 2025. He then said that he expects the Administrator is ensuring QAPI and infection control programs are in place. I expect them to follow the system and QAPI programs. I do not review the QAPI minutes to make sure that the administration is following the QAPI program.
Refer to F837, F880 and F881
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0837
(Tag F0837)
Could have caused harm · This affected most or all residents
Based on interview and record review, the facility failed to ensure that the governing body provided oversight and accountability for:
1. The maintenance of an effective QAPI program.
2. The provision...
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Based on interview and record review, the facility failed to ensure that the governing body provided oversight and accountability for:
1. The maintenance of an effective QAPI program.
2. The provision of an infection control/antibiotic stewardship program.
Findings include:
Review of the facility policy titled, Quality assurance Performance Improvement Plan, dated January 2025, indicated that the Administrator has responsibility and is accountable to the governing body for ensuring that QAPI is implemented throughout our facility. QAPI activities and discussion will be a standing item on our governing body board meeting agendas.
During the survey period the surveyor requested the infection control program information for tracking infections, including line listings, reporting data and antibiotic stewardship. The facility failed to have any documented information related to tracking and reporting of infections or antibiotic stewardship in the facility.
Review of the QAPI program failed to indicate that a QAPI had been initiated for the implementation of the infection control/antibiotic stewardship programs.
During an interview on 6/18/25 at 10:50 A.M., the Administrator said that the QAPI program had not been implemented since ownership changed hands in June 2024 until February 2025. The Administrator said that he could not find any QAPI meeting minutes or projects June 2024 through February 2025. The Administrator said that he was not aware that the infection control and antibiotic stewardship programs were not being implemented. The Administrator said that it is his expectation that the facility follows an infection prevention and control program that includes a system for appropriate infection surveillance. The Administrator also said that he would expect that the facility is implementing an antibiotic stewardship program. The Administrator said that the lack of complete infection control and antibiotic stewardship programs would warrant the inclusion in QAPI.
During an interview on 6/18/25 at 10:56 A.M., the [NAME] President of Operations/owner said that he was not aware of who the Governing Body representative was for the facility.
During an interview on 06/18/25 at 11:10 A.M., the Administrator said that he had not informed the governing body of the lack of QAPI in the facility prior to February.
During an interview on 6/18/25 at 11:23 A.M., the [NAME] President of Operations/owner said he was not made aware of the lack of QAPI being performed in the building from September 2024 through February 2025. He then said that he expects the facility to follow the system and QAPI programs.
Refer to F880 and F881
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0865
(Tag F0865)
Could have caused harm · This affected most or all residents
Based on interview and document review, the facility failed to implement and maintain a Quality Assurance and Performance Improvement (QAPI) program which addressed the full range of care and services...
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Based on interview and document review, the facility failed to implement and maintain a Quality Assurance and Performance Improvement (QAPI) program which addressed the full range of care and services, was comprehensive and data-driven, and focused on indicators of outcomes of quality of life, quality of care, and services to residents in the facility. Specifically, the facility developed QAPI plans related to staff education and infection control once these concerns were identified by the Administrator.
Findings include:
Review of the facility policy titled, Quality Assurance and Performance Improvement (QAPI) Program, dated January 2025, indicated the following:
-Purpose: To ensure the delivery of the highest standard of care and services to our residents. Our QAPI program is designed to monitor, assess, and continuously improve all aspects of care and operations, addressing areas for improvement proactively, and ensuring that quality outcomes are consistently achieved.
- Program Overview: The QAPI program is comprehensive, facility-wide, data-driven approach aimed at identifying and addressing quality gaps in clinical care, resident safety, patient satisfaction, operational efficiency, and regulatory compliance. Our program aligns with the Centers for Medicare & Medicaid Services (CMS) QAPI standards and promotes a culture of continuous improvement.
-The 2025 QAPI program will focus on person-centered care, infection prevention, staff development, resident safety, and regulatory compliance while utilizing ongoing data collection and feedback to guide improvements.
-Further review indicated that the QAPI committee will meet monthly and include representatives from key departments.
Review of 5 out of 9 new employee records, hired in the past four months, indicated the following:
-3 had no dementia training.
-3 had no Certified Nurse Aide (CNA) registry check before their hire date.
- The Director of Nursing did not have a license check.
-1 did not have a preemployment physical.
-2 did not have a tuberculin test prior to employment.
-1 did not have any indication of a COVID vaccine or declination.
During an interview on 6/18/25 at 10:50 A.M., the Administrator said that he had been at the facility for only a couple of months. He said that the Director of Nurses was responsible for the Infection Control and Prevention Program before his arrival at the facility and she was in the process of training the Assistant Director of Nurses to manage the program. The Administrator said that the QAPI program had not been implemented since ownership changed hands in June 2024 until February 2025. The Administrator said that he could not find any QAPI meeting minutes or projects June 2024 through February 2025. The Administrator said that he was not aware that the Infection Control and Antibiotic Stewardship programs were not being implemented. The Administrator said that it is his expectation that the facility follows an infection prevention and control program that includes a system for appropriate infection surveillance. The Administrator also said that he would expect that the facility is implementing an Antibiotic Stewardship Program. The Administrator said that the lack of complete Infection Control and Antibiotic Stewardship programs would warrant the inclusion in QAPI.
During an interview on 6/18/25 at 10:50 A.M., the Director of Nursing said that the expectation is that an Infection Control and Antibiotic Stewardship Program is maintained and followed in the facility. She said she does not know how the facility was following antibiotic use prior to her arrival four months ago at the facility but said that currently she is training the Assistant Director of Nursing on the program.
During a phone interview on 6/18/25 at 10:40 A.M., the Medical Director said he started as the facility's medical director in April 2025, and he is aware that there is no Infection Control Program in place. He said it is something they are working on and will address through the Quality Assurance and Performance Improvement (QAPI) program. He said he would expect the facility to be monitoring and tracking infections, including antibiotic stewardship and the vaccinating of residents and staff when appropriate, data collecting and recording and calculating infection rates so this information can be brought to the QAPI committee, and they can be involved in interpretation of the data.
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 observation, review of the Quality Assurance Performance Improvement (QAPI) plan, and interview, the facility failed to ensure that the Quality Assurance Committee met quarterly, identified q...
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Based on observation, review of the Quality Assurance Performance Improvement (QAPI) plan, and interview, the facility failed to ensure that the Quality Assurance Committee met quarterly, identified quality deficient areas to develop and implement an appropriate corrective action plan, to ensure satisfactory outcomes.
Findings Include:
Review of the facility policy titled, Quality Assurance and Performance Improvement (QAPI) Program, dated January 2025, indicated the following:
-Purpose: To ensure the delivery of the highest standard of care and services to our residents. Our QAPI program is designed to monitor, assess, and continuously improve all aspects of care and operations, addressing areas for improvement proactively, and ensuring that quality outcomes are consistently achieved.
- Program Overview: The QAPI program is comprehensive, facility-wide, data-driven approach aimed at identifying and addressing quality gaps in clinical care, resident safety, patient satisfaction, operational efficiency, and regulatory compliance. Our program aligns with the Centers for Medicare & Medicaid Services (CMS) QAPI standards and promotes a culture of continuous improvement.
The 2025 QAPI program will focus on person-centered care, infection prevention, staff development, resident safety, and regulatory compliance while utilizing ongoing data collection and feedback to guide improvements.
Further review indicated that the QAPI committee will meet monthly and include representatives from key departments.
During a phone interview on 6/18/25 at 10:40 A.M., the Medical Director said he started as the facility's medical director in April 2025, and he is aware that there is no Infection Control Program in place. He said it is something they are working on and will address through the Quality Assurance and Performance Improvement (QAPI) program. He said he would expect the facility to be monitoring and tracking infections, including antibiotic stewardship and the vaccinating of residents and staff when appropriate, data collecting and recording and calculating infection rates so this information can be brought to the QAPI committee, and they can be involved in interpretation of the data.
During an interview on 6/18/25, at 10:50 A.M., the Administrator said that the QAPI program had not been implemented since ownership changed hands in June 2024 until February 2025. The Administrator said that he could not find any QAPI meeting minutes or projects June 2024 through February 2025.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected most or all residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview, the facility failed to establish and maintain an infection prevention and con...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. Specifically, the facility failed to implement an infection control surveillance plan for identifying, tracking, monitoring and/or reporting of infections, communicable diseases and outbreaks among residents and staff.
Findings include:
Review of the facility policy titled 'Surveillance for Infections', dated as revised September 2017, indicated the following:
-The infection preventionist (IP) will conduct ongoing surveillance for healthcare-associated infections (HAI's) and other epidemiologically significant infections that have substantial impact on potential resident outcomes and that may require transmission-based precautions and other preventative interventions.
1. The purpose of the surveillance of infections is to identify both individual cases and trends of epidemiologically significant organisms and HAI's, to guide appropriate interventions, and to prevent future infections.
2. The criteria for such infections are based on current standard definitions of infections.
5. Nursing staff will monitor residents for signs and symptoms that may suggest infection, according to current criteria and definitions of infections, and will document and report suspected infections to the charge nurse as soon as possible.
6. If a communicable disease outbreak is suspected, this information will be communicated to the charge nurse and Infection Preventionist immediately.
7. When infection or colonization with epidemiologically important organisms is suspected, cultures may be sent, if appropriate, to a contracted laboratory for identification or confirmation. Cultures will be further screened for sensitivity to antimicrobial medications to help determine treatment measures.
8. The charge nurse will notify the attending physician and the IP of suspected infections.
9. If transmission-based precautions or other preventative measures are implemented to slow or stop the spread of infections, the IP will collect data to help determine the effectiveness of such measures.
10. When transmission of HAI's continues despite documented efforts to implement infection control and prevention measures, the appropriate state agency and/or specialist in infections control and epidemiology will be consulted for further recommendations.
-The IP or designated infection control personnel are responsible for gathering and interpreting surveillance data and calculating infection rates. The infection control committee and/or QAPI committee may be involved in interpretation of the data.
Review of the Facility assessment dated [DATE], indicated the following: Diseases /conditions, physical and cognitive disabilities.
-Infectious Diseases: COVID-19, Skin and Soft Tissue Infections, Respiratory Infections, Urinary Tract Infections, Infections with Multi-Drug-Resistant Organisms (MDRO), Septicemia, Viral Hepatitis, Clostridium difficile, Influenza.
-Infection prevention and control: Identification and containment of infections, prevention of infections
-Management of Medical Conditions: Assessment, early identification of problems/deterioration, management of medical and psychiatric symptoms and conditions such as heart failure, diabetes, chronic obstructive pulmonary disease (COPD), gastroenteritis, infectious such as UTI (Urinary Tract Infection) and gastroenteritis, pneumonia, hypothyroidism, Hospice/Palliative Care.
-Staff training/education and competencies: Infection control training is provided to staff upon hire, annually, and as needed.
-Evaluation of Infection Prevention and Control Program: facility conducts monthly/quarterly QAPI meetings, and review infection control trends. Surveillance rounds are completed; clinical rounds are done daily to discuss residents who are on antibiotics and who have active infections.
During the survey period the surveyor requested the infection control program information for tracking infections, including line listings and reporting data. The facility failed to have any documented information related to tracking and reporting of infections in the facility.
Further review indicated the facility failed to have any documented information for the months of August 2024, September 2024, October 2024, November 2024, December 2024, January 2025, February 2025, March 2025, April 2025, May 2025, June 2025.
During the course of the survey the facility was unable to provide surveillance data and documentation of follow-up activity in response to the active antibiotic use in the facility.
Review of the electronic Antibiotic Order Listing report dated 6/18/25, indicated the following prescribed antibiotics for the following infections:
June 2025 Antibiotics for cystitis.
May 2025 Antibiotics for toe infection, wound infection, Urinary Tract Infection (UTI), positive sputum culture.
April 2025 Antibiotics oral infection, periodontal infection and UTI.
March 2025 Antibiotics for sinus infection, bacterial infections, UTI's, pyelonephritis, cellulitis, respiratory infection and C-diff.
February 2025 Antibiotics for sinus infection, bacterial infection, wound infection, and UTI.
January 2025 Antibiotics for bacterial infection, respiratory infection, and UTI's.
December 2024 Antibiotics for osteomyelitis and bacterial infection.
November 2024 Antibiotics for bacterial infection and cellulitis.
October 2024 Antibiotics for UTI and skin Infections.
August 2024 Antibiotics for bacterial infection and UTI's.
During an interview on 6/17/25 at 11:37 A.M. the Director of Nurses (DON) said infections and surveillance of infections should be tracked, monitored, documented and reported. The DON said she does not know the rate of infections and said she has no data available and relies on what is reported to her by nursing staff. The DON said she is unaware of the infections and has no information available regarding tracking, surveillance or outbreak information available.
During an interview on 6/17/25 at 11:44 A.M. the Infection Preventionist was not able to provide evidence of any infection prevention program in place in the facility including line listing, antibiotic stewardship, tracking and trending of signs of symptoms of infections, vaccination program for staff and employees, and surveillance criteria.
During an interview on 6/18/25 at 8:04 A.M., the Administrator said the Infection Control program should be implemented and followed and said he is not aware of the infections in the building and said he hires staff specialized in clinical areas to manage those issues and expects the requirements to be followed.
During a phone interview on 6/18/25 at 10:40 A.M., the Medical Director said he started as the facility's medical director in April 2025, and he is aware that there is no Infection Control Program in place. He said it is something they are working on and will address through the Quality Assurance and Performance Improvement (QAPI) program. He said he would expect the facility to be monitoring and tracking infections, including antibiotic stewardship and vaccinating residents and staff when appropriate, data collecting and recording and calculating infection rates so this information can be brought to the QAPI committee, and they can be involved in interpretation of the data.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Antibiotic Stewardship
(Tag F0881)
Could have caused harm · This affected most or all residents
Based on record review and interviews, the facility failed to implement an Antibiotic Stewardship Program to promote and monitor the appropriate use of antibiotics.
Findings include:
Review of the fac...
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Based on record review and interviews, the facility failed to implement an Antibiotic Stewardship Program to promote and monitor the appropriate use of antibiotics.
Findings include:
Review of the facility policy titled Antibiotic Stewardship, undated, indicated the following:
-Antibiotics will be prescribed and administered to residents under the guidance of the facility's antibiotic stewardship program.
-The purpose of our Antibiotics Stewardship Program is to monitor the use of antibiotics in our residents.
-Orientation, training and education of staff will emphasize the importance of Antibiotic Stewardship and will include how appropriate use of antibiotics affects individual residents and the overall community.
-Training and education will include emphasis on the relationship between antibiotic use and:
a. Gastrointestinal disorders.
b. Opportunistic infections (e.g., C. difficile, candida albicans, etc.).
c. Medication interactions; and
d. The evolution of drug-resistant pathogens.
During the survey period the surveyor requested infection control line listings and antibiotic stewardship information. The facility failed to have any documented information related to tracking, follow up or review with the physician or nurse practitioner following the initiation of the antibiotics for 3 out of 3 active physician antibiotic orders prescribed.
Further review indicated the facility failed to have any documented information for the months of August 2024, September 2024, October 2024, November 2024, December 2024, January 2025, February 2025, March 2025, April 2025, May 2025, June 2025.
During an interview on 6/17/25 at 11:37 A.M. the Director of Nurses (DON) said infections and surveillance of infections should be tracked, monitored, documented and reported. The DON said she does not know the rate of infections and said she has no data available and relies on what is reported to her by nursing staff. The DON said she is unaware of the infections and has no information available regarding tracking, surveillance or outbreak information available.
During an interview on 6/17/25 at 11:44 A.M. the Infection Preventionist was not able to provide evidence of any infection prevention program in place in the facility including line listing, antibiotic stewardship, tracking and trending of signs of symptoms of infections, vaccination program for staff and employees, and surveillance criteria.
During an interview on 6/18/25 at 8:04 A.M., the Administrator said the Infection Control program/Antibiotic Stewardship program should be implemented and followed. He then said he is not aware of the infections in the building and said he hires staff specialized in clinical areas to manage those issues and expects the requirements to be followed.
During a phone interview on 6/18/25 at 10:40 A.M., the Medical Director said he started as the facility's medical director in April 2025, and he is aware that there is no Infection Control Program in place. He said it is something they are working on and will address through the Quality Assurance and Performance Improvement (QAPI) program. He said he would expect the facility to be monitoring and tracking infections, including antibiotic stewardship and vaccinating residents and staff when appropriate, data collecting and recording and calculating infection rates so this information can be brought to the QAPI committee, and they can be involved in interpretation of the data.
Jul 2024
3 deficiencies
2 Harm
SERIOUS
(G)
Actual Harm - a resident was hurt due to facility failures
Deficiency F0692
(Tag F0692)
A resident was harmed · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to adequately maintain the nutrition and hydration status of one Resid...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to adequately maintain the nutrition and hydration status of one Resident (#37) out of a total sample of 18 residents. Specifically, the facility failed to provide adequate hydration for a Resident who requires assistance to full dependence for eating and drinking, resulting in a hospitalization due to dehydration, an acute kidney injury, and hypernatremia.
Findings include:
Review of the facility policy titled Resident Hydration and Prevention of Dehydration, dated 1/22/2015, indicated the following:
-This facility will endeavor to provide adequate hydration and to prevent and treat dehydration.
-Nursing will assess for signs and symptoms of dehydration as needed and notify the provider to determine needs for hydration.
-If potential inadequate intake and/or signs and symptoms of dehydration are observed, dehydration protocol will be initiated and documented. Provider will be notify [sic] for further interventions.
-Orders may be written for extra fluids to be encouraged between meals and/or with medication passes.
-If nursing assessment indicates significant signs and symptoms of dehydration, labs may be ordered as needed.
Resident #37 was admitted to the facility in 10/2018 with diagnoses including nontraumatic acute subdural hemorrhage, hypertension, peripheral vascular disease, and cognitive decline.
Review of the most recent Minimum Data Set (MDS) assessment, dated 6/19/24, indicated that Resident #37 scored a 9 out of a possible 15 on the Brief Interview for Mental Status exam, indicating severe cognitive impairment. Review of the MDS, dated [DATE], indicated Resident #37 required limited assist to one person physical assistance with eating and drinking.
Review of the Comprehensive Nutrition Evaluation, dated 9/26/23, indicated Resident #37 had a decline in ability to feed self and required cueing with assistance and, at times, needed to be fed completely. The Dietitian recommended an occupational therapy evaluation. The notes provided by occupational therapy failed to indicate that Resident #37 had been evaluated for eating.
Review of the Comprehensive Nutrition Evaluation, dated 12/26/23, indicated Resident #37 required continued assistance to full dependence on staff at meals.
Review of the lab results for Resident #37, dated 12/27/23, indicated Resident #37 had an elevated sodium level of 157, an elevated chloride level of 122, and an elevated blood urea nitrogen (BUN) of 32. [BUN is a test used to assess kidney function and hydration status. Sodium and Chloride are tested to assess hydration status. The normal range for BUN is 10-24 mg/dL (milligrams per deciliter), the normal range for sodium is 133-145 mmol/L (millimoles per liter), and the normal range for chloride is 96-108 mmol/L.]
Review of the Nurse Practitioner progress note, dated 12/29/23, does not indicate that the Nurse Practitioner addressed the elevated lab values.
There is no indication in the clinical record that any hydration protocol was put in place for Resident #37 to address the elevated labs.
Review of a second lab panel, dated 1/3/24, 5 days after the initial labs drawn, indicated Resident #37 had a critically high sodium level of 160, an elevated chloride level of 122, and an elevated BUN of 30.
During an interview on 7/10/24 at 1:18 P.M., the lab company confirmed that Nurse #1 was notified of the critically high labs via telephone on 1/3/24 at 8:06 P.M.
Review of the progress note, dated 1/4/24 at 12:01 P.M., 16 hours after the facility received notification of the elevated labs, indicated to send the Resident to the hospital due to dangerously high sodium levels.
Review of the progress note, dated 1/4/24, indicated Note Text: Resident alert and confused, new order from NP to send resident to ER for abnormal result, 2 attends of Beauport ambulance picked him up at 5:30 pm.
Review of Resident #37's hospital discharge paperwork indicated Resident #37 was treated in the hospital for hypernatremia (elevated blood sodium), dehydration, and an acute kidney injury.
During an interview on 7/11/24 at 7:54 A.M., the Medical Director said that if a resident comes back with an elevated sodium level, then he would expect that resident to be treated with D5W (intravenous dextrose solution to treat dehydration) and if that could not be performed, then the resident should be sent out to the hospital. The Medical Director said he would expect to be notified immediately of any critically high or high laboratory levels and any sodium above 145 is considered to be high. The Medical Director said that Nurse #1 should have notified the Nurse Practitioner or physician immediately and considers this a delay in treatment for Resident #37.
See tag F773.
SERIOUS
(G)
Actual Harm - a resident was hurt due to facility failures
Deficiency F0773
(Tag F0773)
A resident was harmed · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to promptly notify the physician/ nurse practitioner (NP) of a critica...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to promptly notify the physician/ nurse practitioner (NP) of a critically high sodium lab for one Resident (#37), out of a total sample of 18 residents.
Findings include:
Review of the facility policy titled Resident Hydration and Prevention of Dehydration, dated 1/22/2015, indicated the following:
- This facility will endeavor to provide adequate hydration and to prevent and treat dehydration.
- Nursing will assess for signs and symptoms of dehydration as needed and notify the provider to determine needs for hydration.
- If potential inadequate intake and/or signs and symptoms of dehydration are observed, dehydration protocol will be initiated and documented . Provider will be notify [sic] for further interventions.
- Orders may be written for extra fluids to be encouraged between meals and/or with medication passes.
- If nursing assessment indicates significant signs and symptoms of dehydration, labs may be ordered as needed.
Review of the Laboratory Services Agreement indicated the following:
- Notification of Findings: As applicable, Laboratory shall provide immediate telephone notice of results of any critical lab value. Laboratory shall promptly report all other findings as appropriate to the facility.
Resident #37 was admitted with 10/2018 with diagnoses including nontraumatic acute subdural hemorrhage, hypertension, peripheral vascular disease, and cognitive decline.
Review of Resident #37's most recent Minimum Data Set (MDS) assessment, dated 6/19/24, indicated that Resident #37 scored a 9 out of a possible 15 on the Brief Interview for Mental Status exam, indicating severe cognitive impairment. Review of the MDS, dated [DATE], indicated Resident #37 required limited assist to one person physical assistance with eating and drinking.
Review of the lab results for Resident #37, dated 12/27/23, indicated Resident #37 had an elevated sodium level of 157, an elevated chloride level of 122, and an elevated blood urea nitrogen (BUN) of 32. [BUN is a test used to assess kidney function and hydration status. Sodium and Chloride are tested to assess hydration status. The normal range for BUN is 10-24 mg/dL (milligrams per deciliter), the normal range for sodium is 133-145 mmol/L (millimoles per liter), and the normal range for chloride is 96-108 mmol/L.]
Review of the clinical record failed to indicate that the physician or NP were notified.
Review of the Nurse Practitioner progress note, dated 12/29/23, does not indicate that the Nurse Practitioner addressed the elevated lab values. There is no indication in the clinical record that any hydration protocol was put in place for Resident #37 to address the elevated labs.
Review of a second lab panel, dated 1/3/24, 5 days after the initial labs drawn, indicated Resident #37 had a critically high sodium level of 160, an elevated chloride level of 122, and an elevated BUN of 30.
During an interview on 7/10/24 at 1:18 P.M., the lab company confirmed that Nurse #1 was notified of the critically high labs via telephone on 1/3/24 at 8:06 P.M. Review of the clinical record failed to indicate that the physician or NP was notified of the critically high sodium level upon notification from the laboratory.
Review of the progress note, dated 1/4/24 at 12:01 P.M., 16 hours after the facility's initial notification of the elevated labs, indicated to send the Resident to the hospital due to dangerously high sodium levels.
Review of the progress note, dated 1/4/24, indicated Note Text: Resident alert and confused, new order from NP to send resident to ER for abnormal result, 2 attends of ambulance picked him up at 5:30 pm.
Review of Resident #37's hospital discharge paperwork indicated Resident #37 was treated in the hospital for hypernatremia (elevated blood sodium), dehydration, and an acute kidney injury.
During an interview on 7/11/24 at 7:54 A.M., the Medical Director said that if a resident comes back with an elevated sodium level, then he would expect that resident to be treated with D5W (intravenous dextrose solution to treat dehydration) and if that could not be performed, then the resident should be sent out to the hospital. The Medical Director said he would expect to be notified immediately of any critically high or high laboratory levels and any sodium above 145 is considered to be high. The Medical Director said that Nurse #1 should have notified the Nurse Practitioner or physician immediately and considered this a delay in treatment for Resident #37.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0658
(Tag F0658)
Could have caused harm · This affected multiple residents
2. For Resident #48, the facility failed to notify the health care proxy before administering intravenous (IV) hydration.
Resident #48 was admitted to the facility in August 2020 with diagnoses includ...
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2. For Resident #48, the facility failed to notify the health care proxy before administering intravenous (IV) hydration.
Resident #48 was admitted to the facility in August 2020 with diagnoses including dementia and diabetes.
Review of Resident #48's most recent Minimum Data Set (MDS) assessment, dated 4/16/24, indicated Resident #48 scored an 8 out of a possible 15 on the Brief Interview for Mental Status exam, indicating moderate cognitive impairment. The MDS further indicated Resident #48 has an activated healthcare proxy in place.
Review of the medical record indicated the following physician order dated 4/17/24: -Sodium chloride solution 0.9% use 1000 ml intravenously one time only for Dehydration for 1 Day Infuse 250Ml/Hr through the peripheral line.
Review of the medical record indicated:
-A nurse's progress note dated 4/17/24: Per order, Patient received IV Normal saline for dehydration. No adverse reactions noted. will continue to monitor.
-A nurses note dated 4/19/24: Order received to d/c 22G PIV to resident's RIGHT arm no complication, resident tolerated well with no s/sx of pain or discomfort. Site with no s/sx of infection or infiltration. Line D/c and secured with 2x2 gauze and tape.
Review of Resident #48's medical record:
-Failed to indicate labs were obtained in April 2024 to determine if the Resident was clinically dehydrated.
-Failed to indicate the invoked health care proxy was notified or consented to the IV placement and IV hydration.
-Failed to indicate the Resident was assessed for dehydration or had a change in condition assessment completed.
Review of Resident #48's MOLST (Medical Orders for Life- Sustaining Treatment) form indicated that the Resident did not want any artificial hydration.
During an interview on 7/11/24 at 8:31 A.M., the Director of Nursing said that if a Resident presents with dehydration, then the facility would try other non-invasive ways of introducing hydration before administering an IV. The Director of Nursing said that if a Resident has a health care proxy, then consent is always needed before proceeding and the health care proxy should be notified. The Director of Nursing said that the IV technician also makes sure they get full consent before administering any IV. The Director of Nursing further said that if a Resident has a MOLST signed indicating no artificial hydration the healthcare proxy can make the decision to rescind and allow for IV hydration.
During an interview on 7/11/24 at 10:59 A.M., the Regional Manager of the IV company said that for a PIV (peripheral intravenous line), the technician would not get consent and would expect that the facility got consent prior. If the technician received consent, then it would be documented on a separate consent form with a witness signature. 4. For Resident #24 the facility failed to obtain his/her Depakote level as ordered by the Physician.
Resident #24 was admitted to the facility in October 2022 with diagnoses that included hemiplegia and hemiparesis, anxiety and vascular dementia.
Review of Resident #24's most recent Minimum Data Set (MDS) assessment, dated 4/9/24, indicated Resident #24 was assessed by nursing staff to have severe cognitive impairment.
Review of Resident #24's most recent Physician note, dated 7/1/24, indicated Recently seen by psychiatry with no new recommendations. Depakote (an anticonvulsant drug that treats seizures, migraines, and bipolar disorder) level to be obtained on Monday, 7/8/2024.
Review of Resident #24's most recent Nurse Practitioner progress note, dated 7/4/24, indicated Depakote level to be obtained on Monday, 7/8/2024.
Review of Resident #24's active physician orders, indicated the Resident receives Depakote by mouth twice daily.
Review of Resident #24's physician order, dated 7/4/24, indicated Check Depakote level on Monday 7/8/24.
Review of Resident #24's nursing progress notes did not indicate that the Resident had refused a lab draw.
During an interview on 7/10/24 at 10:40 A.M., the Director of Nurses said Monday is not the facility's regular lab day but nursing staff could have called the lab to book the lab draw for 7/8/24. The Director of Nurses said the lab was not drawn yet.
3. For Resident #63, the facility failed to assess his/her hydration status, draw labs or notify the responsible party before administering intravenous (IV) hydration.
Resident #63 was admitted to the facility in February 2023 with diagnoses that included asthma and hyperlipidemia.
Review of Resident #63's most recent Minimum Data Set (MDS) assessment, dated 4/23/24, indicated Resident #63 was assessed by staff to have severe cognitive impairment.
Review of Resident #63's physician orders, dated 4/17/24, indicated the following orders:
-Normal Saline Flush Intravenous Solution 0.9 %. Use 1 dose intravenously one time only for Dehydration for 1 Day.
-Sodium chloride solution .9%. Use 1000 ml intravenously one time only for dehydration for 1 day. Infuse 125ml/hr through the peripheral line.
Review of Resident #63's medical record:
-Failed to indicate labs were obtained in April 2024 to determine if the Resident was clinically dehydrated.
-Failed to indicate the guardian was notified or consented to the IV placement and IV hydration.
-Failed to indicate the Resident was assessed for dehydration or had a change in condition assessment completed.
During an interview on 7/10/24 at 12:01 P.M., Resident #63's guardian said that he was never notified that Resident #63 was dehydrated or that an IV had been inserted on 4/17/24.
During an interview on 7/11/24 at 8:31 A.M., the Director of Nursing said that if a Resident presents with dehydration then the facility would try other non-invasive ways of introducing hydration before administering an IV. The Director of Nursing said that if a Resident has a guardian, then consent is always needed before proceeding and the guardian should be notified. The Director of Nursing said that the IV technician also makes sure they get full consent before administering any IV.
During an interview on 7/11/24 at 10:59 A.M., the Regional Manager of the IV company said that for a PIV (peripheral intravenous line), the technician would not get consent and would expect that the facility got consent prior. If the technician received consent, then it would be documented on a separate consent form with a witness signature.
Based on record review and interview the facility failed to meet professional standards of quality for four Residents (#55, #48, #63 and #24) out of a total sample of 18 residents. Specifically:
1. For Resident #55, #48 and #63 the facility failed to assess their hydration status, draw labs or notify the responsible party before administering intravenous (IV) hydration.
2. For Resident #24 the facility failed to obtain his/her Depakote level as ordered by the Physician.
Findings include:
1. For Resident #55, the facility failed to assess his/her hydration status, draw labs or notify the responsible party before administering intravenous (IV) hydration.
Resident #55 was admitted in 9/2021 with diagnoses including depression.
Review of the most recent Minimum Data Set (MDS) assessment, dated 5/9/24, indicated Resident #55 scored a 7 out of a possible 15 on the Brief Interview for Mental Status exam, indicating severe cognitive impairment. The MDS further indicated Resident #55 has an activated health care proxy in place.
Review of the progress note, dated 5/3/24, indicated the following: Note Text: Resident alert and awake, 22 gauze piv inserted this shift as per MD order for IV fluids due to dx of dehydration as per MD order. Order given to infuse 1 litter of normal saline at rate 125 cc per hour. Site is clean and intact with no s/sx of infection,IV line is patent, flushing with no obstruction at this time. All parties notified, safety maintained.
Review of the clinical record prior to 5/3/24 failed to indicate Resident #55 was assessed for hydration status or labs were performed to assess the Resident's hydration status. The clinical record failed to indicate that the health care proxy consented to the IV hydration.
During an interview on 7/10/24 at 11:53 A.M., Resident #55's health care proxy said she was never made aware of the facility using IV hydration on Resident #55. The health care proxy said she has no idea why the facility would not call her before administering an IV and that she was upset about that.
During an interview on 7/11/24 at 8:31 A.M., the Director of Nursing said that if a Resident presents with dehydration then the facility would try other non-invasive ways of introducing hydration before administering an IV. The Director of Nursing said that if a Resident has a health care proxy, then consent is always needed before proceeding and the health care proxy should be notified. The Director of Nursing said that the IV technician also makes sure they get full consent before administering any IV.
During an interview on 7/11/24 at 10:59 A.M., the Regional Manager of the IV company said that for a PIV (peripheral intravenous line), the technician would not get consent and would expect that the facility got consent prior. If the technician received consent, then it would be documented on a separate consent form with a witness signature.
Review of the IV paperwork for Resident #55 did not indicate that consent was obtained before inserting the PIV.
Dec 2023
1 deficiency
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0568
(Tag F0568)
Could have caused harm · This affected 1 resident
Based on records reviewed and interviews for one of three sampled residents (Resident #1), who has entrusted the facility to manage his/her Personal Needs Account (PNA), the Facility failed to ensure ...
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Based on records reviewed and interviews for one of three sampled residents (Resident #1), who has entrusted the facility to manage his/her Personal Needs Account (PNA), the Facility failed to ensure they maintained a system of accounting that assured Resident #1 monthly PNA checks, that were received and processed by the Facility, were then deposited into the correct account, when two of Resident #1 monthly PNA checks were somehow deposited into the Facility's Operations Account, which resulted in Resident #1's account balance to be inaccurate for several months.
Findings include:
Review of Resident #1's Resident Statement Landscape (PNA), from 6/03/23 to 8/06/23, indicated the following:
- there was no record of deposit to the account in the amount of $72.80 a month in June 2023, July 2023, and August 2023 (totaling $218.40), in PNA funds that were unaccounted for.
During an interview on 12/12/23 at 11:10 A.M., Resident #1 said the Facility manages his/her Personal Needs Account (PNA) by receiving and depositing a monthly check of $72.80 into his/her PNA. Resident #1 said on 10/02/23 he/she attempted to make a withdrawal from his/her PNA only to discover there was less than $50 in his/her PNA instead of approximately $200. Resident #1 said it was determined that his/her PNA was missing a couple of monthly deposits in the amount of $72.80 (each check).
Resident #1 said he/she was notified that two of his/her PNA checks were inadvertently deposited into the Facility's Operating Expense Account, instead of his/her PNA, and that a third PNA check was unaccounted for and missing.
Resident #1 said he/she was concerned that the Facility was unaware of these incidents and said they were unable to demonstrate to him/her that there was a system in place to ensure his/her checks arriving to the Facility were safe, and deposited into his/her PNA each month, as expected.
During an interview on 12/12/23 at 3:00 P.M., the Executive Assistant said she worked at the receptionist desk by the front entryway, and performed tasks, such as electronically depositing checks received by the facility into various accounts. The Executive Assistant said although there was a secure box at the receptionist desk for the mail carrier to place mail inside, said it was not always used and that mail has been found left at the reception desk. The Executive Assistant said she had worked five days a week from 8:00 A.M. to 2:00 P.M. until September 2023.
The Executive Assistant said she did not know which residents received checks for their PNA's, other than the ones with checks that were in the pile of mail that arrived. The Executive Assistant said although she could and has called the Regional Business Office Manager for guidance, said there was no system or documented guide in place to know which checks get deposited electronically into the Facility's operating expense account (referred to as Regions) or a Residents' PNA (referred to as Resident Funds Management Service), The Executive Assistant said there was no system in place to make sure mail was not left on the reception desk, where it could can be accessed by anyone in her absence.
The Executive Assistant said Resident #1's PNA checks are not issued by Social Security, so it was not clear to her that they were supposed to be deposited into his/her PNA. The Executive Assistant said she used her own judgment and made a mistake depositing Resident #1's checks into the Facility's operating expense account.
During an interview on 12/12/23 at 12:50 P.M., the Regional Business Office Manager said Resident #1's Commonwealth of Massachusetts checks for his/her June 2023 and July 2023 PNA funds, (in the amount of $72.80 each), were incorrectly deposited into the Facility's operating account instead of his/her PNA.
The Regional Business Office Manager said the error was not discovered until the month of October 2023 when Resident #1 came forward to report the concern. The Regional Business Office Manager said both checks, totaling $145.60, has since been deposited into Resident #1's PNA (as of 10/20/23).
The Regional Business Office Manager said Resident #1's PNA check for August 2023 remains unresolved as there was no record of its deposit in any of the account records reviewed and the check could not be located or confirmed as being received at the Facility. The Regional Business Office Manager said there is no system in place for tracking purposes, to see if residents received their monthly checks that are to be deposited into their PNA.
During an interview on 12/12/23 at 1:40 P.M., the Administrator, in the presence of the Regional Business Office Manager, said the Facility has placed more than 10 telephone calls in the presence of Resident #1 to the Commonwealth of Massachusetts to determine if Resident #1's August 2023 check was mailed to the Facility, with no resolution to date.
May 2023
35 deficiencies
2 Harm
SERIOUS
(G)
Actual Harm - a resident was hurt due to facility failures
Accident Prevention
(Tag F0689)
A resident was harmed · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, observation and record review, the facility failed to 1. ensure that one Resident (#18) received adequate as...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, observation and record review, the facility failed to 1. ensure that one Resident (#18) received adequate assistance to prevent an injury, and 2. failed to provide supervision for 1 Resident (#31) out of a total sample of 34 residents. Specifically, on 4/22/23, Resident #18 was transferred out of a bed that was elevated too high and prevented his/her feet to reach the floor. As a result, Resident #18 lost his/her footing and hit his/her left leg on his/her wheelchair and sustained a laceration that required sutures. Specifically, on 4/18/23, supervision was not provided to Resident #31, resulting in Resident #31 entering another resident's room, being screamed at, and falling as he/she exited the room, resulting in an injury and emergency room visit.
Findings include:
1. Resident #18 was admitted to the facility in January 2022 with a diagnoses including venous insufficiency, muscle weakness, abnormalities of the gait and mobility, dysphagia, anxiety, legal blindness and lack of coordination.
Review of the Minimum Data Set (MDS) assessment, dated 3/28/23, indicated Resident #18 could make him/her self understood and he/she has the ability to understand others. The MDS indicated his/her vision was severely impaired and required glasses. Resident #18 required an assist of 2 for bed mobility and transfers. The MDS also indicated that during surface-to-surface transfers (transfer between bed and chair or wheelchair) Resident #18 is not steady and only able to stabilize with staff assistance. The MDS further indicated Resident #18 had one venous and arterial ulcers that required dressing changes.
Review of Resident #18's plan of care related to falls, dated as revised 4/11/23, indicated he/she is legally blind and for nursing to assist with transfers
Review of Resident #18's plan of care related to activities of daily living, indicated self-care performance deficit r/t [related to] activity Intolerance, fatigue, legally blind, pain, history of venous wound and included the following interventions:
- 4/9/23, BED MOBILITY: The resident requires extensive assist by 1-2 staff to turn and reposition in bed and as necessary.
- 4/9/23, TRANSFER: The resident requires extensive assist of 1-2 by staff to move between surfaces and as necessary. Level of assist varies depending on level of fatigue.
During an interview on 4/30/23, at 10:55 A.M., Resident #18 said a 'guy' transferred him/her alone into his/her wheelchair. Resident #18 said that the bed was too high, he/she did not have a walker and his/her feet were not on the floor before he/she was transferred. Resident #18 said that he/she lost his/her footing during the transfer and 'crashed' into the side of the wheel chair and said his/her leg started to bleed.
Review of the progress note, dated 4/22/23, indicated during a transfer Resident #18 sustained an open area below the left knee. The note indicated Resident #18 was transferred to the hospital.
During an interview on 5/2/23, at 2:36 P.M., Certified Nurse Aide (CNA) #4 said that Resident #18 requires a gait belt and rolling walker for transfers.
During an interview on 5/2/23, at 1:52 P.M., Certified Nurse Assistant #3 said that Resident #18 told her that the bed was too high during the transfer. CNA #3 said that she worked with the Director of Nursing (DON) and CNA #5 on 4/22/23, and said she was not asked to assist with the transfer.
During an interview on 5/2/23, at 4:20 P.M., Certified Nurse Assistant #5 said that on 4/22/23, he was assigned to Resident #18. CNA #5 said that Resident #18 wanted to go to the bathroom. He said that he brought the wheel chair next to the bed; CNA #5 said the bed was higher than the wheelchair and moved Resident #18 by himself. CNA#5 said he did not use a walker or a gait belt and said he could not remember what was on Resident #18's feet.
During an interview on 5/3/23, at 8:57 A.M., the Director of Nursing (DON) said he was the assigned nurse on 4/22/23. The DON said that he was alerted by CNA #5 that Resident #18 was bleeding. The DON said he was not sure what Resident #18 hit his/her leg on but the 'skin tear' would not stop bleeding. The DON and the surveyor reviewed Resident #18's plan of care related to transfers and the DON said 1-2 assist would require constant re-evaluation and is not appropriate. The surveyor asked the DON about precipitating factors regarding this incident. The DON said to the surveyor that you (the surveyor) have already spoken to the staff and you know what the staff has told you. The DON declined to answer any further questions from the surveyor regarding the incident on 4/22/23. The DON told they surveyor what you have in front of you is what you get.
During an observation on 5/3/23, at 9:20 A.M., with the Assistant Director of Nursing (ADON) and the Certified Occupational Therapy Assistant (COTA) the surveyor observed Resident #18's sutures. Resident #18 said to the ADON and to the COTA that happened when the 'guy' went to transfer him/her out of bed, the bed was too high and his/her feet were not on the floor when the 'guy' started to transfer him/her. Resident #18 said that he/she lost his/her footing and went 'crashing' into the wheel chair and said his/her leg started to bleed. The COTA said this was not the first time that Resident #18 had mentioned the bed height caused his/her laceration.
2. For Resident #31 the facility failed to ensure supervision was provided, resulting in Resident #31 entering another resident room, being screamed at by the Resident and upon exiting fell and sustained a cut above the right eye.
Resident #31 was admitted to the facility in 12/2019 and has diagnoses that include unspecified dementia with other behavioral disturbance, Alzheimer's disease, and generalized anxiety disorder.
Review of Resident #31's Minimum Data Set Assessment, with an Assessment Reference Date of 3/7/23 indicated Resident #31 had a staff assessment of severely impaired cognition, ambulated in the hall with supervision and did not use a mobility device.
On all days of survey, 4/30/23 through 5/3/23 Resident #31 was observed walking in the hall. Resident #31 was observed with a faded yellow area above his/her right eye.
Review of Resident #31's medical record indicated the following:
*A fall risk assessment dated [DATE] with a score of 14, indicating Resident #31 was a high fall risk.
*A care plan, Focus Falls, Resident has the potential for falls r/t (related to) general weakness, psychotropic drug use, history of falls, wandering, incontinence, poor safety awareness, revision on 3/23/23. Interventions: Assist with transfers,
*A care plan Focus Resident has an ADL (activities of daily living self-care performance deficit, r/t Alzheimer's, he/she refuses haircuts, revision on 6/20/22. Interventions: Locomotion on/off unit, Resident is continual supervision on unit as he/she is intrusive wanders unit daily, needs assist in evenings when fatigued, date initiated 12/23/19.
Review of an un-witnessed incident report dated 4/18/23 at 20:20 (8:20 P.M.,), indicted the following:
Incident location: hallway.
*Incident description: Resident entered into room [ROOM NUMBER] and was screamed at by the other resident. When he/she ran out of the room, he/she hit him/herself at the door and fell. Sustained a cut on right sided eye. Resident was non-compliant to care. Called third eye (on-call medical service) and was ordered to transfer to the ER (emergency room.)
During an interview on 5/3/23 at 8:08 A.M., Nurse #2 said she was not here at the time of the fall but was told about it on report that he/she (Resident #31) hit his/her head on the doorway on the way out of a resident's room. Nurse #2 said Resident #31 is not oriented and could have been frightened by what happened.
During further interview on 5/03/23 at 8:21 A.M., Nurse #2 said both Resident (#31) and Resident (#67) who screamed at Resident #31 have behaviors. Nurse #2 Resident #31 requires redirection from staff, and staff need to keep an eye on him/her. Nurse #2 said the unit has 2 CNA's and 1 Nurse on in the evening shift and if staff are with other residents providing care, they listen to hear if he/she is being told to get out (of rooms) by others.
Review of the hospital paperwork from the emergency room, dated 4/19/23 at indicted Face: Soft tissues: right periorbital hematoma.
SERIOUS
(H)
Actual Harm - a resident was hurt due to facility failures
Deficiency F0760
(Tag F0760)
A resident was harmed · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure that 2 Residents (#40 and #370), were free of significant me...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure that 2 Residents (#40 and #370), were free of significant medication errors.
Specifically, the facility failed to:
1) implement necessary action when daily administration of Clozapine (an antipsychotic) was ordered by the Physician/NP and was omitted from Resident #40's medication administration for six consecutive days resulting in hospitalization.
2) administer a medication used to treat schizoaffective disorder, resulting in Resident #370 having an increase in symptoms of psychosis and distress.
Findings include:
1. Resident #40 was admitted to the facility in October 2018 with diagnoses including paranoid schizophrenia, major depressive disorder and diabetes.
Review of the manufacture's Clozapine (an atypical antipsychotic used in treatment-resistant schizophrenia) safety information packet indicated that the medication can cause severe Neutropenia (low white blood cell count) which could lead to life threatening infections, so an ANC (Absolute Neutrophil Count) baseline test should be obtained prior to the initiation of the medication and at least every month thereafter. Further review indicated that Clozapine is only available through a restricted program called the Clozapine Risk Evaluation and Mitigation Strategy (REMS) program run by the Food and Drug Administration (FDA).
Review of the FDA website, updated 11/2/22, indicated that Abrupt discontinuation of clozapine can result in significant complications for patient treatment.
Review of the doctor's orders indicated an order dated 12/17/20, for Clozapine give 150 milligrams (mg) by mouth one time a day at 8:00 A.M Further review indicated an order dated 12/11/20, for Clozapine give 200 mg by mouth at bedtime.
Review of the Medication Administration Record (MAR) dated January 2023 indicated that Clozapine, give 150 milligrams (mg) by mouth one time a day at 0800 (8:00 A.M.) was held on 1/23/23, 1/24/23 and 1/25/23. Further review indicated that Clozapine, give 200 milligrams (mg) by mouth at bedtime was held on 1/21/23, 1/22/23, 1/23/23 and 1/24/23. Further review indicated that on 1/25/23 at 8 P.M. and 1/26/23 at 8:00 A.M. and 8:00 P.M. the medication was administered as ordered however, the medication had not been delivered to the facility, by the pharmacy, until 1/28/23.
Review of the nurse's notes dated 1/19/23, indicated that the pharmacy informed the nurse that Resident #40's Clozapine could not be refilled because Resident #40 needs to be enrolled in a Clozapine REMS program that Resident #40 is not currently enrolled in. Informed the Doctor (Medical Director) and Nurse Practitioner (#1).
Review of the nurse's note dated 1/21/23, indicated that medication (Clozapine) is not available. Pharmacy requested patient to be involved in a program. Doctor (Medical Director) will register patient, if not pharmacy said they will not send medication.
Review of the nurse's note dated 1/22/23, indicated medication (Clozapine) not available. Pharmacy requested for patient to be involved in a program. Doctor (Medical Director) aware. Will register the patient. If not pharmacy said they will not send.
Review of the Nurse's note dated 1/25/23, indicated that Resident #40 fell to the floor in the bathroom and required an assist of 2 to transfer back to the wheelchair.
Review of the nurse's note dated 1/27/23, at 8:37 A.M., (written by the nurse who had worked the previous 3:00 P.M.- 11:00 P.M. and the 11 :00 P.M.- 7:00 A.M. shifts, 1/26/23) indicated that she had place a call to the pharmacy for Resident #40's Clozapine and they assured her that they had everything they need, and will deliver the medication by 11:00 A.M., but by 3:00 P.M. the medication had not arrived. Further review indicated that the nurse called the pharmacy again and the pharmacy told her that they will deliver the medication between 7:00 P.M. and 8:00 P.M. The nurse's note then indicated that the medication had not been delivered as of 8:00 A.M. on 1/27/23. The nurse's note then indicated that the pharmacy was called again and the nurse was given the same assurance that the medication would arrive.
Review of the nurse's note dated 1/27/23, at 8:05 A.M., indicated Nurse Practitioner #2 was notified of Resident #40's increasing general weakness. Further review indicated that the Nurse Practitioner #2 gave the order to send Resident #40 to the hospital for evaluation.
Review of the hospital psychiatry note dated 1/28/23, indicated that Resident #40 expressed the sensation of being paralyzed to the psychiatrist. Further review indicated that this is most likely a psychotic conversion symptom from being off of his/her Clozeril (Clozapine).
Review of the hospital Discharge summary dated [DATE], indicated that Resident #40 was in his/her usual state of health until about 8 days ago when his/her Clozapine medication was discontinued due to paperwork. Since then, the patient started to have generalized weakness which progressively worsened and prompted an ED (emergency department) visit.
During an interview on 5/2/23, at 2:05 P.M., the Medical Director said that all people taking Clozapine have to be registered in the REMS program. The Medical Director said that he became Resident #40's doctor in November of 2022. He said that he knew that both the doctor's and patients needed to be registered with the program in order for Clozapine to be dispensed. He then said that he went into the website and registered Resident #40 as soon as he was made aware of the need but could not tell the surveyor the date he did so. The Medical director then said that the pharmacy needs to have ANC labs entered into the program before they will deliver Clozapine. The Medical Director said he is not sure why the pharmacy did not get the labs that were ordered, sent to them.
During an interview on 5/3/23, at 10:10 A.M. the Operations Manager (OM) for the pharmacy the facility uses, said that since the new program started 11/15/21, the pharmacy has been informing the facility of the need to register the Resident but the facility never did. The OM then said that he again notified the facility in October 2022. The OM said that the pharmacy had been entering a rational for why the Resident was not registered, into the REMS program in order to send Resident #40 the Clozapine for a year. The OM then said that the pharmacy had been asking the facility to register Resident #40 again, since the Resident's doctor changed. The OM said that the program would no longer take the pharmacy's rational's as to why the Resident was not registered, at which point he called the facility on 1/19/23, to inform them that the pharmacy could not refill Resident #40's Clozapine until he/she was registered into the REMS program. The OM said that on 1/23/23, he saw that Resident #40 had been registered but that there was no recent ANC in the system. He said that late on 1/25/23 the blood work arrived but that the refill wasn't put in until 1/26/23. The OM then said that the medication was awaiting approval by the insurance and they had difficulty finding a driver to deliver the medication.
During an interview on 5/3/23, at 11:15 A.M., Family Member (FM) #1 said that she was aware that Resident #40 had been sent to the hospital 1/27/23. FM #1 said that the hospital told her the reason why Resident #40 had been sent to the hospital was because he/she did not receive the Clozapine for a week and that caused Resident #40 to became very weak and even more confused. FM #1 said it is very detrimental for Resident #40 to miss his/her medication. FM #1 said that she was also told that the reason it took so long for the pharmacy to send out the medication once Resident #40 had been registered was because the pharmacy was in New York and they couldn't find a driver to deliver so far.
2. For Resident #370 the facility failed to administer a medication used to treat schizoaffective disorder for over 27 days, resulting in Resident #370 having an increase in symptoms of psychosis and distress.
Review of the facility's policy, titled Reconciliation of Medications on Admission dated 9/1/16, indicated the following: Policy Statement, Resident safety and medication safety is achieved by accurately accounting for the resident's medications, routes, and dosages upon admission or readmission to the facility.
Policy Interpretation and Implementation
1. Upon admission, a medication review is completed.
2. Sources of information include
a. The resident/patient,
b. Family members or caregivers,
c. Primary care physician,
d. Pharmacy,
e. Hospital discharge paperwork, and /or
f. Prescriptions bottles.
3. Reconciliation of medications will include;
a. Prescription medications,
b. Over-the-counter medications, and
c. Supplements.
4. Every effort will be made to accurately identify all medications, doses, and routes during the reconciliation process.
5 Medication reconciliation includes medication the resident/patient took at home, took in the hospital, and is currently prescribed upon admission to the facility.
6. All identified discrepancies will be addressed with the physician.
7. The pharmacy will be utilized to assist in the medication reconciliation as needed.
Review of the Nursing Drug Book, 2014, by Wolters Kluwer/[NAME] and [NAME] indicated the following: Perphenazine, therapeutic class: Antipsychotics. Nursing considerations:
-Don't withdraw drug abruptly unless severe adverse reaction occurs.
-After abrupt withdrawal of long-term therapy, gastritis, nausea, vomiting, dizziness, tremor, feeling of warmth or cold, diaphoresis, tachycardia, headache, or insomnia can occur.
On 4/30/23, at 8:20 A.M., the surveyor observed Resident #370 resting on his/her bed.
During an interview on 4/30/23, at 8:20 A.M., Resident #370 said he/she is in pain. Resident #370 said she/he was beat up by a gorilla and said the gorilla was an animal.
On 4/30/23, at 10:30 A.M., the surveyor observed Resident #370 resting on top of his/her bed. Both his/her right and left feet were exposed and observed with yellow and blue areas of discoloration on the outer aspect, extending from the ankle to the smaller toes. Resident #370 was crying and said he/she was beat up by a gorilla. When asked he/she said it was an animal.
On 5/3/23, at 12:30 P.M., the surveyor observed Resident #370 in bed, crying and calling out. Nurse #2 said Resident #370 was crying for water and food and was told lunch would be coming soon.
Review of Resident #370's medical record indicated the following:
*A Discharge Care Plan and Home Medications document from the behavioral health hospital indicated Resident #370 was hospitalized from 9/2022 through 3/2023. Resident #370 was admitted to the facility from the behavioral health hospital for further care.
Review of the medication list on the hospital referral indicated:
*Perphenazine (an antipsychotic medication, used to treat schizophrenia) oral 16 milligrams tab, start dated 10/10/22, indication (for use) psychosis, PO (by mouth) BID (two times a day)
Review of Resident #370 current Medication Review Report indicated Perphenazine was ordered on 4/27/23. Resident #370 was not administered the Perphenazine since his/her admission to the facility.
Review of the progress notes failed to indicate any progress note or order to discontinue the Perphenazine upon admission.
During an interview on 5/1/23, at 10:47 A.M., Nurse #2 said she was the Nurse who did the admission paperwork for Resident #370. Nurse #2 said when a resident is admitted the medications are reviewed with the nurse practitioner or doctor. Nurse #2 said an on-call service was used to reconcile the medication from the information that came with the Resident. Nurse #2 said although the antipsychotic (Perphenazine) medication was on the hospital paperwork, it was not on the facility medication orders for administration to Resident #370.
Review of the document on-call physician's orders document, dated 3/29/23, and timed 7:36 P.M., indicated:
Available documentation reviewed, orders and medications approved until patient is evaluated by primary team- except add duration prn (as needed) lorazepam x 14 days, 2. Obtain and review all acute care documentation and orders with primary team when available.
During an interview on 5/1/23, at 1:30 P.M., the Assistant Director of Nursing (ADON) said when residents are admitted to the facility, the discharge orders are reviewed with the doctor or the covering service. For Resident #370 the ADON reviewed the medical record and said the order for the Perphenazine was not transcribed on to the facility physician's orders for administration and therefore Resident #370 was not administered the medication and that it (the omission) was an oversight.
During an interview on 5/2/23, at 10:36 A.M., the Certified Nurse Practitioner (CNP), who provided behavioral health services to the facility, said she does medication reviews for residents and saw Resident #370 shortly after his/her admission to the facility. The CNP said she did not see documentation in the record as to why the antipsychotic Perphenazine was not continued upon admission for a resident who has a known history of schizoaffective disorder. The CNP said it may have been an issue with consent. The CNP said her first visit with Resident #370 he/she was depressed, tearful and calm and on her second visit (just over 3 weeks later) Resident #370 was more agitated, no longer able to hold a conversation and his/her symptoms were consistent with someone who is not on their antipsychotic medication. The CNP said that on her first visit, the Resident was more based in reality and on the second visit he/she could not put his/her thoughts together but did ask for, and wanted, his/her antipsychotic medication. The CNP then said the Resident was asking for a blood pressure cuff, and other medical items. The CNP said she recommended to start the Perphenazine at 4 milligrams because he/she was off it for a while and wanted to start the medication slower, she said the effect of the medication could take up to 1-2 weeks. The CNP said the absence of the antipsychotic medication became a distressing event for Resident #370.
During an interview on 5/2/23, at 12:11 P.M., the Social Worker (SW) said Resident #370 was alert and oriented when he/she was admitted and discussed wanting magazines. The SW said as time went on Resdient #370 was not as lucid and not the same as the beginning, becoming more disoriented and making loud noises.
During an interview on 5/2/23, at 2:06 P.M., Resident #370'S facility doctor said the medication Perphenazine should have continued upon admission, for a chronic condition like schizoaffective disorder, to keep the Resident stable. The Medical Director said an antipsychotic medication should not be stopped abruptly and without a plan.
During an interview on 5/8/23, at 11:32 A.M., the Legal Guardian for Resident #370 said she has been the Guardian for Resident #370 for nearly nine years. She said Resident #370 has always been treated with an antipsychotic due to the diagnosis of schizophrenia. The Legal Guardian said about five years ago, a doctor discontinued his/her anitpsychotic medication and Resident #370 had a breakdown and never came back to his/her prior level of function. The Guardian said she was not made aware until the last week of April that Resident #370 was not being administered the antipsychotic medication.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0552
(Tag F0552)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to obtain informed consent for the administration a psychotropic medic...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to obtain informed consent for the administration a psychotropic medication (Depacote Sprinkles) prior to administration for one Resident (#27) out of a total sample of 34 residents.
Resident #27 was admitted in October, 2022 with diagnoses including anxiety and dementia. Review of the Minimum Data Set (MDS), dated [DATE], indicated that Resident #27 scored a 99 on the Brief Interview for Mental Status (BIMS), indicating he/she could not participate. The MDS indicated Resident #27 is severely cognitively impaired.
Review of the physician orders for Resident #27 indicated the following:
- Depakote Sprinkles (a psychotropic medication used to treat seizures and bipolar disorder) Capsule Delayed Release 125 milligrams (mg); give 2 capsule by mouth at bedtime and 1 capsule by mouth two times a day.
During an interview on 5/01/23, at 8:23 A.M., the Director of Nursing said that there should be a consent for Depakote in the chart. The Director of Nursing said that he could not find the consent.
Review of the Resident's medical record did not indicate that a consent was signed for the administration of Depakote Sprinkles.
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** Based on observation, record review and interview, the facility failed to file a grievance for missing personal property for 1 R...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview, the facility failed to file a grievance for missing personal property for 1 Resident (#21) out of a total of 34 residents.
Findings include:
Review of the facility policy titled Grievances and dated 3/2021, indicated the following:
*Any resident, his or her representative (sponsor), family member, or appointed advocate may file a grievance or complaint concerning treatment, medical care, behavior of the other residents, staff members, missing items, theft of property, etc., without fear of reprisal in any form.
*Grievances and/or complaints may be submitted orally or in writing.
*Staff members are encouraged to assist residents in filing a grievance and/or complaint when the resident believes that his/her rights have been violated.
*The grievance will be investigated and communicated to the filer within 72 hours.
*Upon receipt of a grievance, complaint report or the missing items form, the Director of Social Services will begin an investigation into the allegations. The department director of an involved employee will be notified of the nature of the complaint and that an investigation is underway.
Resident #21 was admitted to the facility in July 2018 with diagnoses including Type II diabetes mellitus.
Review of the Minimum Data Set (MDS) dated [DATE], indicated that Resident #21 scored a 13 out of 15 on the Brief Interview for Mental Status (BIMS), which indicates the Resident is cognitively intact.
During an interview on 4/30/23, at approximately 8:00 A.M., Resident #21 said that he/she has been missing 6 pairs of black sweatpants for several months, and had initially told the nursing staff about his/her missing sweatpants 3 months ago.
Review of Resident #26's inventory list indicated 6 pairs of black sweatpants.
On 4/30/23, at approximately 8:00 A.M., the surveyor was unable to locate any black sweatpants in Resident #21's dresser or room.
Review of the facility grievance binder failed to indicate that a grievance was filed for Resident #21's missing clothing.
During an interview on 5/1/23, at 12:04 P.M., Social Worker (SW) #1 said that the expectation is that nursing staff fills out a grievance form on behalf of the resident if a resident verbalizes a grievance. Then the completed grievance is submitted to the SW or administrator. SW #1 said a grievance should have been filed for missing clothing. SW #1 also said that she was unaware of Resident #26's grievance, as the nursing staff had failed to file a grievance for Resident #26's missing clothing.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Report Alleged Abuse
(Tag F0609)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview the facility failed to report in the required timeframe 1. an injury of unknow...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview the facility failed to report in the required timeframe 1. an injury of unknown source for one Resident (#370) and 2. a resident-to-resident (Resident #67 and Resident #31) verbal altercation resulting in a fall with an injury for one Resident (#31) out of a total sample of 34 residents.
Findings include:
Review of the facility's policy titled, Abuse Investigation and Reporting, dated March 2017 indicated the following:
All reports of resident abuse, neglect, exploitation, misappropriation of resident property, mistreatment and/or injuries of unknown source (abuse) shall Be Promptly reported to local, state, and federal agencies (as defined by current regulations) and thoroughly investigated by facility management. Findings of abuse investigations will also be reported.
Reporting 1. All alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of an unknown source and misappropriation of property will be reported by the facility administrator, or his/her designee, to the following persons or agencies. A. The state licensing/certification agency responsible for surveying/licensing the facility. 2 Suspected abuse, neglect, exploitation, or mistreatment (including injuries of unknown source and misappropriation of resident property) will be reported within two hours.
1. Resident #370 was admitted in March, 2023 with diagnoses of schizoaffective disorders, type 2 diabetes's with unspecified complications. adjustment disorders with mixed anxiety and depressed mood, chronic atrial fibrillation, unspecified.
Review of the Minimum Data Set Assessment (MDS) with an assessment reference date of 4/5/23, indicated Resident #370 had a Brief Interview for Mental Status exam, score of 13 out of 15 indicating intact cognition. Further review of the MDS indicated that Resident #370 required extensive assistance with bed mobility, hygiene, dressing and supervision with walking.
Review of Resident #370's clinical record indicated he/she had a court appointed legal guardian/surrogate indicating he/she is not his/her own decision maker.
On 4/30/23 at 8:06 A.M., Resident #370 was observed resting in his/her bed. Resident #370's right foot was exposed and observed with yellowed and blue discoloration on the outside aspect of his/her right foot, extending from the ankle to the toes. The surveyor was unable to see the outer aspect of his/her left foot.
On 4/30/23 at 8:20 A.M., Residents #370 was resting on his/her bed. Resident #370 said he/she is in pain. Resident #370 said he/she was beat up by a gorilla and said the gorilla was an animal. Both his/her right and left feet were observed with yellow and blue areas of discoloration consistent with fading bruises.
On 4/30/23, at 10:30 A.M., the surveyors observed Resident #370. Resident #370 was resting on top of his/her bed. Both his/her right and left feet were exposed and observed with yellow and blue areas of discoloration on the outer aspect, extending from the ankle to the smaller toes. Resident #370 was crying and said he/she was beat up by a gorilla. When asked he/she said it was an animal.
On 4/30/23 at 12:35 P.M., staff was observed entering Resident #370's room then exiting the room. The surveyor entered and observed the right foot, which was exposed with yellow, fading blue discoloration on the outer aspect of his/her right foot.
Review of Resident #370's medical record indicated the following:
*A nursing progress note dated, 4/16/23, Resident alert this shift. Slept on/off with intermittent crying. Nursing assessed resident and noticed discolored bruising on both feet, Resident ambulated with no complained (sic) pain assessment completed resident denies pain in feet. nursing asked resident-how did he/she get the bruising, resident stated, I don't know Nursing monitored any changes throughout the shift, NP notified.
* A skin assessment dated , 4/16/2023, discolored bruising on left and right foot.
During an interview on 4/30/23 at 2:07 P.M., Nurse #2 said if during a skin check or at anytime a Resident has new skin areas, the Director of Nursing (DON) is informed. Nurse # 2 said she did not think Resident #370 had any current skin changes, or anything reported.
On 4/30/23 at 2:11 P.M., the surveyor and Nurse #2 went to Resident #370's room. Resident #370 said to Nurse #2 that a gorilla broke his/her neck. Nurse #2 observed Resident #370's feet and said the Resident had fading bruises on both feet, and that she had seen them before. Nurse #2 said she told the oncoming nurse and reported it to the Nurse Practitioner. Nurse #2 said she may not have done an incident report and did not report the bruises to the Director of Nursing. Nurse #2 said when she noticed the bruising the Resident was unable to say how they may have occurred.
During an interview on 4/30/23 at 2:27 P.M., The DON said he did not have any incident reports or reportable incidents for Resident #370. The DON said an incident of any unknown cause including bruising would require to be reported to him and a full investigation would need to be completed.
During an interview on 5/1/23 at 9:07 A.M., the DON said he was not made aware on 4/16/23 that Resident #370 had bruising on both his/her right feet.
2. For Resident #31 and #67 an incident of a resident to resident altercation (alleged verbal abuse) was not reported to the state agency.
Resident #31 was admitted to the facility in 12/2019 and has diagnoses that include unspecified dementia with other behavioral disturbance, Alzheimer's disease, and generalized anxiety disorder.
Review of Resident #31's Minimum Data Set Assessment, with an Assessment Reference Date of 3/7/23 indicated Resident #31 had a staff assessment of severely impaired cognition, ambulated in the hall with supervision and did not use a mobility device.
Resident #67 was admitted to the facility in December, 2022 with diagnoses that includes, Alzheimer's disease, dementia in other diseases classified elsewhere, mild, with other behavioral disturbance, dysphagia, glaucoma, and aphasia.
Review of the comprehensive Minimum Date Set (MDS) with an Assessment Reference Date of 1/4/23 indicated Resident #67 had a Brief Interview for Mental Status exam score of 8, indicating moderate cognitive impairment and required supervision and limited assistance for daily care. Further review of the MDS indicated Resident #67 did not display any patterns of behaviors.
Review of an incident report, unsigned, dated 4/18/23 at 20:20 (8:20 P.M.) indicated the following:
Resident (#31) entered into room [ROOM NUMBER] and was screamed at by the Resident in the room (Resident #67, per census for date 4/18/23.) When he/she (Resident #31) ran out of the room, he/she hit him/herself at the door and fell. Sustained a cut on the right sided eye. Resident was non-compliant to care. Called third-eye health and was ordered to transfer to the ER (emergency room) Resident description: Resident unable to give description. The incident report failed to indicate the Administrator was notified of the alleged verbal abuse.
During an interview on 5/03/23 at 8:08 A.M., Nurse #2 said she was not here at the time of Resident #31's fall incident but was told about it on report. Nurse #2 reviewed the incident report and said staff would intervene, redirect the residents and the incident of verbal altercation should be reported up the chain of command. Nurse #2 said the Resident who fell is not oriented but still could have been frightened by what happened.
During an interview on 5/03/23 at 11:49 AM the Director of Nursing said Resident #31 fell coming out of the room of another a Resident (#67) who is known to be behavioral. He said he reviewed the incident report and passed it up above him, to the Administrator. The DON said no further incident reports regarding the other Resident (Resident #67's) verbal altercation towards Resident #31 as completed.
On 5/03/23 at 3:33 P.M. after the Administrator reviewed the incident report, he said the DON determined the incident between Resident #31 and Resident #67 did not need to be reported. He said this determination was made after the DON spoke to the nurse who provided the information for the incident report. When asked about the policy for reporting resident to resident verbal altercation the Administrator said he was unable to provide any further information about the incident.
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** Based on record review and interview the facility failed to 1. thoroughly Investigate a bruise of unknown source for one Residen...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to 1. thoroughly Investigate a bruise of unknown source for one Resident (#370) and 2. failed to investigate a resident-to-resident verbal abuse (Resident #31 and Resident #67) out of a total sample of 34 residents.
Review of the facility's policy titled, Abuse Investigation and Reporting, dated March 2017 indicated the following:
All reports of resident abuse, neglect, exploitation, misappropriation of resident property, mistreatment and/or injuries of unknown source (abuse) shall Be Promptly reported to local, state, and federal agencies (as defined by current regulations) and thoroughly investigated by facility management. Findings of abuse investigations will also be reported.
Reporting 1. All alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of an unknown source and misappropriation of property will be reported by the facility administrator, or his/her designee, to the following persons or agencies. A. The state licensing/certification agency responsible for surveying/licensing the facility. 2 Suspected abuse, neglect, exploitation, or mistreatment (including injuries of unknown source and misappropriation of resident property) will be reported within two hours.
1. Resident #370 was admitted in 3/2023 with diagnoses of schizoaffective disorders, type 2 diabetes's with unspecified complications. adjustment disorders with mixed anxiety and depressed mood, chronic atrial fibrillation.
Review of the Minimum Data Set Assessment (MDS) with an assessment reference date of 4/5/23, indicated Resident #370 had a Brief Interview for Mental Status exam, score of 13 out of 15 indicating intact cognition. Further review of the MDS indicated that Resident #370 required extensive assistance with bed mobility, hygiene, dressing and supervision with walking.
Review of Resident #370's clinical record indicated he/she had a court appointed legal guardian/surrogate indicating he/she is not his/her own decision maker.
On 4/30/23 at 8:06 A.M., Resident #370 was observed resting in his/her bed. Resident #370's right foot was exposed and observed with yellowed and blue discoloration on the outside aspect of his/her right foot., extending from the ankle to the toes. The surveyor was unable to see the outer aspect of his/her left foot.
On 4/30/23 at 8:20 A.M., Residents #370 was resting on his/her bed. Resident #370 said he/she is in pain. Resident #370 said she was beat up by a gorilla and said the gorilla was an animal. Both his/her right and left feet were observed with yellow and blue areas of discoloration consistent with fading bruises.
On 4/30/23, at 10:30 A.M., the surveyors observed Resident #370. Resident #370 was resting on top of his/her bed. Both his/her right and left feet were exposed and observed with yellow and blue areas of discoloration on the outer aspect, extending from the ankle to the smaller toes. Resident #370 was crying and said he/she was beat up by a gorilla. When asked he/she said it was an animal.
On 4/30/23 at 12:35 P.M., staff was observed entering Resident #370's room then exiting the room. The surveyor entered and observed the right foot, which was exposed with yellow, fading blue discoloration on the outer aspect of his/her right foot.
Review of Resident #370's medical record indicated the following:
*A nursing progress note dated, 4/16/23, Resident alert this shift. slept on off this with intermittent crying. Nursing assessed resident and noticed discolored bruising on both feet, Resident ambulated with no complained (sic) pain assessment completed resident denies pain in feet. nursing asked resident-how did she get the bruising, resident stated, I don't know Nursing monitored any changes throughout the shift, NP notified.
During an interview on 4/30/23 at 2:07 P.M., Nurse #2 said if during a skin check there are new findings, including a bruise of unknown source the Director of Nursing (DON) needs to be notified.
On 4/30/23 at 2:11 P.M., the surveyor and Nurse #2 went to Resident #370's room. Nurse #2 said that the Resident had fading bruises on both feet, and she had noticed it before and told the oncoming nurse and reported it to the Nurse Practitioner. Nurse #2 said she may not have done an incident report and did not report the bruises to the Director of Nursing. Nurse #2 said when she noticed the bruising the Resident was unable to say how they may have occurred.
During an interview on 4/30/23 at 2:27 P.M., The Director of Nursing said he did not have any incident reports or reportable incidents for Resident #370. The DON said an incident of any unknown cause including bruising would require to be reported to him and a full investigation would need to be completed, which would include interviewing staff on prior shifts and reviewing the medical record.
2. For Resident #31 and #67 an incident of alleged verbal altercation was not investigated.
Resident #31 was admitted to the facility in 12/2019 and has diagnoses that include unspecified dementia with other behavioral disturbance, Alzheimer's disease, and generalized anxiety disorder.
Review of Resident #31's Minimum Data Set Assessment, with an Assessment Reference Date of 3/7/23 indicated Resident #31 had a staff assessment of severely impaired cognition, ambulated in the hall with supervision and did not use a mobility device.
Resident #67 was admitted to the facility in 12/2022 with diagnoses that includes, Alzheimer's disease, dementia in other diseases classified elsewhere, mild, with other behavioral disturbance, dysphagia, glaucoma, and aphasia.
Review of the comprehensive Minimum Date Set (MDS) with an Assessment Reference Date of 1/4/23 indicated Resident #67 had a Brief Interview for Mental Status exam score of 8, indicating moderate cognitive impairment and required supervision for and limited assistance for daily care. Further review of the MDS indicated Resident #67 did not display any patterns of behaviors.
Review of an un-signed, incident report, dated 4/18/23 at 20:20 (8:20 P.M.) indicated the following:
Resident (#31) entered into room [ROOM NUMBER] and was screamed at by the Resident in the room (Resident #67, per census for date 4/18/23.) When he/she (Resident #31) ran out the room he/she hit him/herself at the door and fell and sustained a cut on the right sided eye. Resident was non-compliant to care. Called third-eye health and was ordered to transfer to the ER (emergency room) Resident description: Resident unable to give description. The incident report failed to indicate the Administrator was notified of the alleged verbal abuse and therefore an investigation into the event did not occur.
During an interview on 5/03/23 at 8:08 A.M., Nurse #2 said she was not here at the time of Resident #31's fall incident but was told about it in report. Nurse #2 reviewed the incident report and said staff would intervene, redirect the residents and the incident of verbal altercation should be reported up the chain of command. Nurse #2 said the Resident who fell is not oriented but still could have been frightened by what happened.
During an interview on 5/03/23 at 11:49 AM the Director of Nursing said Resident #31 fell coming out of the room of another a resident (#67) who is known to be behavioral. He said he reviewed the fall incident report and passed it up above him, to the Administrator. The DON said no further incident reports or investigation was completed regarding the Resident #67's verbal abuse towards Resident #31.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0638
(Tag F0638)
Could have caused harm · This affected 1 resident
Based on record review and interview the facility failed to complete Quarterly Minimum Data Set (MDS) Assessments in a timely manner for 3 Residents (#30, #56, and #9) out of a total sample of 34 resi...
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Based on record review and interview the facility failed to complete Quarterly Minimum Data Set (MDS) Assessments in a timely manner for 3 Residents (#30, #56, and #9) out of a total sample of 34 residents.
Findings include:
Review of the Resident Assessment Instrument (RAI) manual 3.0 indicated the following:
The Quarterly MDS must be completed no later than 14 days from the assessment reference date (ARD).
1. For Resident #30 review of the MDS's indicated a Quarterly assessment with an ARD of 9/22/22, with a completion date of 11/15/22, 40 days late. Further review indicated a Quarterly assessment with an ARD 12/20/22, and a completion date of 1/10/23, 7 days late.
2. For Resident #56 review of the MDS's indicated a Quarterly assessment with an ARD of 11/8/23, and a completion date of 1/10/23, 49 days late. Further review indicated a Quarterly assessment with an ARD of 1/24/23, and a completion date of 4/11/23, 63 days late.
3. For Resident # 9 review of the MDS's indicated a Quarterly assessment with an ARD of 9/22/22, and a Completion date of 11/15/22, 38 days late. A Quarterly assessment with an ARD of 12/20/22, and a Completion date of 1/10/23, 7 days late and A Quarterly assessment with an ARD of 3/21/23, and a Completion date of 4/11/23, 7 days late.
During an interview on 5/01/23, at 3:45 P.M., the MDS Coordinator said that the problem was insufficient staffing to get all of the MDS's done timely. She then said that she simply didn't have any help.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Assessment Accuracy
(Tag F0641)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. For Resident #22 the facility failed to ensure that staff coded the use of oxygen on the Minimum Data Set Assessment (MDS).
...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. For Resident #22 the facility failed to ensure that staff coded the use of oxygen on the Minimum Data Set Assessment (MDS).
Resident #22 was admitted to the facility in January 2023 with diagnosis including end stage renal disease, syncope, anxiety, major depressive disorder, panic disorder, hypotension, atrial fibrillation and weakness.
Review of Resident #22's MDS dated [DATE] and 4/18/23, indicated he/she did not require oxygen.
Review of the the Admission/readmission Evaluation V2 assessment, dated 1/22/23, indicated Resident #22 required oxygen.
Review of the physician's order, dated 2/19/23, indicated:
-Oxygen therapy at 3L/m [3 liters per minute (LPM)] via nasal cannula. Further review of the order indicated the order was incomplete and did not include the frequency that the oxygen is needed.
Review of the plan of care on 4/30/23, indicated there was no documentation to support that Resident #22 required oxygen.
Review of the the Admission/readmission Evaluation V2 assessment, dated 4/26/23, indicated Resident #22 required oxygen.
During observations on 4/30/23, 5/1/23, 5/2/23 and 5/3/23 Resident #22 was observed to be wearing oxygen.
During an interview on 5/3/23 at 10:00 A.M., the Regional MDS Nurse said that the oxygen should have been coded on the MDS assessments. Based on record review and interview the facility failed to accurately complete the Minimum Data Set (MDS) assessment for 3 Residents (#50, #22 and #67) out of a total sample of 34 residents.
Findings include:
1. Resident #50 was admitted to the facility in July 2022 with diagnoses including Alzheimer's, heart disease and chronic obstructive pulmonary disease.
Review of the medical record indicated the following weights:
Date Time Weight
4/2/2023 15:07
113.8 Lbs (pounds)
3/29/2023 11:55
113.8 Lbs
3/22/2023 15:00
113.8 Lbs
3/15/2023 15:45
113.4 Lbs
3/1/2023 14:23
112.8 Lbs
2/22/2023 14:48
112.4 Lbs
2/8/2023 14:21
111.0 Lbs
2/1/2023 13:59
117.5 Lbs
1/25/2023 13:25
118.4 Lbs
1/18/2023 14:17
118.4 Lbs
1/11/2023 09:24
117.0 Lbs
1/4/2023 13:34
117.0 Lbs
12/21/2022 14:05
117.3 Lbs
12/21/2022 14:04
117.3 Lbs
12/17/2022 07:53
117.0 Lbs
11/16/2022 15:47
146.9 Lbs
10/26/2022 13:40
148.5 Lbs
10/19/2022 12:56
149.5 Lbs
Review of the medical record indicated that Resident #50 a history of significant weight loss in the past 6 months.
Review of the MDS assessment dated [DATE], indicated that Resident #50 weighed 114 pounds (lbs). Further review indicated that Resident #50 did not have a significant weight loss in the past 6 months.
During an interview on 5/01/23, at 3:45 P.M., the MDS Coordinator said that the MDS should have indicated significant weight loss for Resident #50.
3. For Resident #67 the facility failed to accurately assess behavioral patterns for the comprehensive and quarterly Minimum Data Set assessments.
Resident #67 was admitted to the facility in 12/2022 with diagnoses that included, Alzheimer's, dementia in other diseases classified elsewhere, mild, with other behavioral disturbance, dysphagia, glaucoma, and aphasia.
Review of the comprehensive Minimum Date Set (MDS) with an Assessment Reference Date (ARD) of 1/4/23, indicated Resident #67 had a Brief Interview for Mental Status exam score of 8, indicating moderate cognitive impairment and required supervision and limited assistance for daily care. Further review of the MDS indicated Resident #67 did not display any patterns of behaviors.
Review of the MDS with an ARD of 4/4/23, indicated Resident #67 had a staff assessment indicating severe cognitive impairment and did not display any patterns of behaviors.
On all days of survey from 4/30/23, through 5/3/23, Resident #67 displayed verbal behavioral symptoms including threatening others, screaming, and cursing at others.
Review of Resident #67's medical record indicted the following:
*A behavioral health progress note dated 12/29/23, that indicated target symptoms of agitation. Resident being seen per staff request due to behaviors since arriving at the facility.
*Progress notes in the seven day look back period from 1/4/23, indicated Resident #67 displayed behaviors of wandering, cursing and combative with care.
*Progress notes in the seven day look back period from 4/4/23, indicated Resident #67 displayed behaviors daily including wandering, yelling cursing at self and others.
During an interview on 5/01/23, at 2:27 P.M., the Social Worker (SW) said she does the behavior section on the MDS. She said she uses her own observations, will talk with staff about a resident's behavioral symptoms for MDS coding. The SW said Resident #67 displayed behaviors from the get go, meaning since admission to the facility. The SW said there was a discrepancy between the MDS not having any behaviors coded and Resident #67's displaying patterns of behaviors.
During an interview on 5/1/23, at 4:23 P.M. the Director of Nursing said Resident #67 was displaying behaviors right from admission and the MDS should reflect the Resident's behaviors.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0658
(Tag F0658)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on records reviewed, policy review and interview the facility failed to 1. ensure that nursing administered medications th...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on records reviewed, policy review and interview the facility failed to 1. ensure that nursing administered medications that met professional standards of quality for 1 Resident (#22) and 2. failed to ensure professional standards of care for one Resident's (#23) skin, out of 34 sampled Residents.
Findings include:
Review of the facility policy titled, Administering Medications, undated, indicated:
- Medications must be administered in accordance with the orders.
- The following information must be checked/verify for each resident prior to administering medications.
a. vital signs
1. Resident #22 was admitted to the facility in January 2023 with diagnoses including end stage renal disease, syncope, anxiety, major depressive disorder, panic disorder, hypotension, atrial fibrillation and weakness.
Review of the Minimum Data Set (MDS) assessment dated [DATE], indicated Resident #22 is able to be understood and he/she had the ability to understand others. The MDS further indicated Resident #22 does not have any behaviors and he/she requires assistance for activities of daily living. The MDS indicated he/she received dialysis and did not require oxygen.
Review of the physician's order, dated 4/12/23, indicated:
Midodrine - HCl (medication used to treat hypotension) 10 milligram tablet, give 1 tablet by mouth three times a day for Hypotension Hold if SBP >130 millimeters of mercury [systolic blood pressure is greater than 130 mmHg]
Review of Resident #22's Medication Administration Record, dated April 2023, indicated the Midodrine was administered on the following dates:
- 4/12/23 at 6:00 A.M., blood pressure 132/78
- 4/12/23 at 11:00 A.M., blood pressure 132/70
- 4/15/23 at 11:00 A.M., blood pressure 138/84
- 4/15/23 at 4:00 P.M., blood pressure 137/88
- 4/16/23 at 11:00 A.M., blood pressure 137/76
- 4/16/23 at 4:00 P.M., blood pressure 132/74
- 4/17/23 at 11:00 A.M., blood pressure 145/76
- 4/18/23 at 4:00 P.M., blood pressure 148/76
- 4/19/23 at 6:00 A.M., blood pressure 136/78
- 4/19/23 at 4:00 P.M., blood pressure 138/74
- 4/20/23 at 11:00 A.M., blood pressure 139/74
- 4/22/23 at 4:00 P.M., blood pressure 141/76
- 4/23/23 at 6:00 A.M., blood pressure 136/76
- 4/25/23 at 4:00 P.M., blood pressure 135/70
- 4/28/23 at 4:00 P.M., blood pressure 146/80
- 4/29/23 at 11:00 A.M., blood pressure 137/71
- 4/29/23 at 4:00 P.M., blood pressure 140/81
- 4/30/23 at 6:00 A.M., blood pressure 143/68
During an interview on 5/2/23, at 8:43 A.M., Nurse #5 said that he should have followed the physician's order for medication administration.
During an interview on 5/3/23, at 9:40 A.M., the Assistant Director of Nursing said that nursing should not have administered the medication when the SBP blood pressure was greater than 130 mmHg.
During an interview on 5/3/23, at 10:07 A.M., the Regional MDS Nurse and the Regional MMQ nurse said that nursing should not have administered the Midodrine when the SBP blood pressure was greater than 130 mmHg.
2. For Resident #23 the facility failed to accurately document Resident #23's skin and failed to ensure a plan was developed to monitor Resident #23's multiple areas of red and scabbed red skin .
Resident #23 was admitted to the facility in February 2023 with diagnoses including sepsis, unsteadiness on feet, asthma, type 2 diabetes mellitus, unspecified dementia, and schizophrenia.
Review of the Minimum Data Set Assessment (MDS) with an Assessment Reference Date (ARD) of 2/28/23, indicated Resident #23 had a primary language of Spanish, scored 7 out of 15 on the Brief Interview for Mental Status Exam (BIMS) indicating severe cognitive impairment and required extensive assistance from staff for bed mobility, dressing, hygiene and was dependent on staff for bathing. Further, the MDS did not indicate Resident #23 displayed behaviors and did not indicate under section M skin, that Resident #23 had any open skin areas, that were not pressure areas.
The surveyor made the following observations:
-On 4/30/23, at 8:23 A.M., Resident #23 was observed with multiple reddened, circular scabbed areas on both his/her upper right and left arms.
-On 5/1/23, at 12:42 P.M., Resident #23 was in his/her room all morning. Resident #23 was picking at his/her skin on his/her leg. His/her right leg had an area of blood coming from a scabbed area. Both his/her arms and shoulder area was observed with multple, red, pencil eraser size spots and scabs.
Review of Resident #23's medical record indicted the following:
-Nursing: Skin check, dated 2/25/23, describe and document any skin issues: right shoulder (front) description left blank, further down indicated generalized scabs.
-Nursing skin check, dated 3/21/23, skin condition, dry fragile, irritation/redness.
-Nursing skin check, dated 3/28/23, skin condition: intact.
-Nursing skin check, dated 4/4/23, skin condition: intact.
-Nursing skin check, dated 4/11/23, skin condition: intact
-Nursing skin check, dated 4/18/23, skin condition: intact.
-Nursing skin check, dated 4/26/23, skin condition: intact.
-A care plan: Diabetes Mellitus, with an intervention dated 3/1/23, to check all of body for breaks in skin and treat promptly as ordered by the doctor.
-A Care summary document, dated as of 5/3/23, failed to indicate interventions related to Resident #23's multiple red, scabbed skin
-A Nurse Practitioner/Doctor progress note with an encounter date 4/24/23, indicted Pruritus unspecified (a medical term for itchy skin), continue with Benadryl as indicted. Further, the note indicated under physical exam Skin: no rash, warm and dry.
-A Nurse Practitioner/Doctor progress note with an encounter date 4/20/23 indicated under physical exam: skin: no rash, warm and dry.
Review of the Nurse Practitioner/Doctor progress notes with encounter dates 4/18/23, 4/13/23, 4/10/23, 4/7/23, 4/5/23, 4/3/23, 3/29/23, 3/13/23, 3/6/23, 3/6/23, 3/3/23, 3/1/23, and 2/28/23 all indicated Resident #23's skin: No rash, warm and dry.
Review of the physician order summary report, of active orders as of 5/2/23, indicated an order for Benadryl allergy oral tablet 25 mg, give 1 tab by mouth every 6 hours as needed for itching, dated initiated 2/24/23. Review of the orders failed to indicate any treatment or monitoring of Resident #23 scabbed, red circular areas in his/her skin.
During an interview on 5/02/23, at 8:55 A.M., Nurse #2 said Resident #23 had scattered scabs all over his/her body and has the behavior of picking and scratching his/her skin since admission to the facility. Nurse #2 said visitors of Resident #23's said this was not a new issue and he/she had always picked/scratch his/her skin. Nurse #2 said the treatment for Resident #23 is Benadryl as needed. Nurse #2 said the sheets are changed daily due to blood spotting from the scabs and staff should apply moisturizing cream during care.
On 5/02/23, at 9:30 A.M. the surveyor with Nurse #2, observed Resident #23's skin. Nurse #2 described Resident #23's skin as scattered scabs on both arms and legs. Resident #23's shoulder area, was observed with circular bright red spots.
Nurse #2 reviewed the weekly Nursing skin checks and said they do not indicate all the scabbing and skin areas that Resident #23 had since admission and his/her skin has not been intact. She said nursing staff should be monitoring Resident #23's skin for redness, swelling, and drainage changes in the areas identified. The medical record failed to indicate that any monitoring of Resident #23's scabbed area, scratched areas or red circular areas were being monitored for potential treatment.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0676
(Tag F0676)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview, the facility failed to provide feeding assistance to 1 Resident (#27), resul...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview, the facility failed to provide feeding assistance to 1 Resident (#27), resulting in the Resident not eating a meal, out of a total sample of 34 residents.
Findings include:
Resident #27 was admitted in October, 2022 with diagnoses including dysphagia and dementia.
Review of the Minimum Data Set (MDS), dated [DATE], indicated Resident #27 is severely cognitively impaired. Further review of the MDS indicated that Resident #27 requires extensive assist of one person with eating.
Review of the activities of daily living care plan indicated the following:
*Requires 1 ASSIST with eating r/t DX (diagnosis) of Dysphagia , Behaviors and confusion, will not complete meals without staff assist, eats in DR (dining room).
On 4/30/23, at 12:36 P.M., the surveyor observed Resident #27 at a table in the dining room with food in front of him/her. A certified nursing aide (CNA) came over and put a spoon in Resident #27's ice cream and then walked away. At 12:41 P.M., Resident #27 wheeled away from the table, down the hall, and went back to bed. Resident #27 did not eat the lunch meal.
On 5/1/23, at 12:30 P.M., the surveyor observed Resident #27 sitting in the dining room with food in front of him/her. No staff were present in the room. At 12:34 P.M., a staff member came in the room and Resident #27 waved at the staff member to get their attention and the staff member walked out of the room. No staff members assisted Resident #27. Resident #27 proceeded to leave the food on the table and wheel down the hall to his/her room. Resident #27 did not eat the lunch meal.
During an interview on 5/1/23, at 1:35 P.M., the Occupational Therapist said that Resident #27 was eating independently the last time he saw the Resident. The Occupational Therapist said that if there is a change in feeding status then a screen should be done, but he has never received a screen for Resident #27.
During an interview on 5/1/23, at 1:53 P.M., CNA #12 said that she knows the residents. CNA #12 said that Resident #27 needs assistance with feeding or he/she will not finish his/her meals.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
ADL Care
(Tag F0677)
Could have caused harm · This affected 1 resident
Based on observation, record review and interview the facility failed to ensure care was provided for one Resident (#23), who required extensive assistance. Specifically, Resident #23 was not provided...
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Based on observation, record review and interview the facility failed to ensure care was provided for one Resident (#23), who required extensive assistance. Specifically, Resident #23 was not provided nail care, resulting unclean fingernails out of a total sample of 34 residents.
Findings include:
Resident #23 was admitted to the facility in February 2023 with diagnoses including sepsis, unsteadiness on feet, asthma, type 2 diabetes mellitus, unspecified dementia, and schizophrenia.
Review of the Minimum Data Set Assessment (MDS) with an Assessment Reference Date (ARD) of 2/28/23, indicated Resident #23 had a primary language of Spanish, scored 7 out of 15 on the Brief Interview of Mental Status Exam (BIMS) indicating severe cognitive impairment and required extensive assistance from staff for bed mobility, dressing, hygiene and was dependent on staff for bathing.
During the survey, the surveyor observed the following:
*On 4/30/23, at 8:23 A.M. Resident #23, was resting in bed. Both his/her right and left hands had uneven fingernails, with debris under nail beds.
*On 4/30/23, at 12:53 P.M., Resident 23 was observed in the dining room, both of his/her right- and left-hand fingernails were long, uneven and had dark colored debris underneath the nails.
*On 5/1/23, at 8:25 A.M., Resident #23 was observed sitting in a wheelchair in his/her room. His/her fingernails on both hands were various lengths and dark debris under the nails.
*On 5/1/23, at 12:42 P.M., Resident #23 was in his/her room all morning. Resident #23 was picking at his/her skin on his/her leg. Resident #23's fingernails were uneven with dark colored debris under the nails and around the nail bed.
*On 5/2/23, at 8:38 A.M., Resident #23 was sitting in a wheelchair in his/her room. His/her fingernails on both hands were uneven and had dark debris under the nails.
During an interview on 5/2/23, at 8:45 A.M., Certified Nursing Assistant (CNA) #1 said the CNAs are responsible for providing nail care. CNA #1 and the surveyor went into Resident #23's room. CNA #1 said Resident #23's scratches his/her skin and his/her nails should be kept clean. CNA #1 said keeping residents' nails clean is part of daily care.
On 5/2/23, at 9:30 A.M., Nurse #2 and the surveyor went in Resident #23's room. Nurse #2 observed Resident #23's fingernails on both hands and said they were dirty and needed to be cleaned. Nurse #2 said Resident #23 has the behavior of scratching his/her skin since admission.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Quality of Care
(Tag F0684)
Could have caused harm · This affected 1 resident
Based on observations, record review and interview, the facility failed to ensure quality care was provided to one Resident (#18), out of a total sample of 34 residents. Specifically when on 4/22/23, ...
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Based on observations, record review and interview, the facility failed to ensure quality care was provided to one Resident (#18), out of a total sample of 34 residents. Specifically when on 4/22/23, Resident #18 sustained a laceration to his/her left leg and was transferred to the hospital. Resident #18 returned from the hospital with sutures to his/her left leg and nursing obtained a telehealth visit which resulted in recommendations for antibiotic use and a suture removal date. The facility failed to ensure nursing implemented orders for an antibiotic and a plan for on-going monitoring and assessment of the wound.
Findings include:
Resident #18 was admitted to the facility in January 2022 with a diagnoses including venous insufficiency, muscle weakness, abnormalities of the gait and mobility, dysphagia, anxiety, legal blindness and lack of coordination.
Review of the Minimum Data Set (MDS) assessment, 3/28/23, indicated Resident #18 could make themselves understood and he/she has the ability to understand others. The MDS indicated his/her vision was severely impaired and required glasses. Resident #18 required two assistance for bed mobility and two assistance for transfers. The MDS also indicated that during surface-to-surface transfers (transfer between bed and chair or wheelchair) Resident #18 is not steady, only able to stabilize with staff assistance. The MDS indicated Resident #18 had one venous and arterial ulcers that required dressing changes.
Review of the progress note, dated 4/22/23, indicated that during a transfer, Resident #18 sustained an open area below the left knee. Further review of the note indicated that Resident #18 was transferred to the hospital.
Review of Resident #18's medical record indicated there was no documentation from the hospital emergency room visit on 4/22/23.
Review of the telemedicine note dated 4/22/23, indicated to administer Doxycycline (antibiotic) and to remove sutures on 5/2/23.
Review of the telemedicine note dated 4/22/23, (addendum), indicated Resident #18 returned from the ER [emergency room] with an order for Doxycycline 100 mg (milligrams) po (by mouth) bid (twice/day) x 5 days.
Review of the nursing progress note, dated 4/22/23, and timed 22:23, indicated Resident #18 was sent out due to a laceration on the left leg, and was readmitted with new order for antibiotic Doxycycline 100 mg bid x 5 days.
Review of the nursing note dated 4/29/23, indicated that the provider was made aware of the hospital recommendations and there was an order obtained for a CBC with diff [complete blood count with differential, test used to check labs values] and Doxycycline 100 mg BID [twice a day] for 5 days.
Review of the Medication Administration Record, dated April 2023, indicated that the Doxycycline was not implemented until 4/29/23, 7 days following the initial recommendation.
Review of the late entry progress note, dated on 5/1/23, back dated to 4/23/23, written by the Assistant Director of Nursing, indicated that Resident #18 did not start Doxycycline; as it did not meet criteria. MD [physician] aware and gave directive.
Review of the Specialty Physician wound evaluation and management summary, dated as 4/26/23, indicated Resident #18 had a non-pressure wound of the left anterior lower knee caused by trauma. Measuring 9.5 centimeters (cm) x 0.5 cm x 0.1 cm, and recommended an ABD pad (Abdominal Pads, also known as ABD Pads, are used to treat large wounds or wounds that require a lot of absorbency) covered with a gauze roll once daily.
Review of the Skin Assessment, dated 4/26/23, indicated Resident #18 had left lower extremity (LLE) venous wounds. Further review indicated there was no documentation to support the recent laceration to the left lower leg
During observations on 4/30/23, 5/1/23, 5/2/23, and 5/3/23 the surveyor observed sutures on Resident #18 left leg.
During an interview on 5/1/23, at 1:22 P.M., the Director of Nursing (DON) said he was the nurse on duty when Resident #18 sustained the 'skin tear'. He said he transferred the Resident to the hospital. The DON said no paperwork returned from the hospital, but should have.
During an interview on 5/1/23, on 1:33 P.M., the Assistant Director of Nursing (ADON) said she worked on the antibiotic with DON yesterday (4/30/23). The ADON said she was unable to locate the hospital paper paper work.
During an interview on 5/2/23, at 8:27 A.M., Nurse #4 said that Resident #18 returned during his shift on 4/22/23, on the 3:00 P.M.- 11:00 P.M., shift. Nurse #4 said he reviewed the paperwork and was made aware of the antibiotic recommendation. Nurse #4 said he thought the DON implemented the order in the computer for the antibiotic. Nurse #4 said he was unable to start the antibiotic because the medication was not available. Nurse #4 said the medication was not stored in the emergency drug kit. Nurse #4 said Resident #18 returned with a dressing on his/her leg but he did not remove the dressing.
Review of the facility emergency drug kit manifest, current at the time of the event, indicated there were 10 pills of Doxycycline 100 mg available for nursing to obtain.
During an interview on 5/2/23, at 8:34 A.M., Nurse #5 said on 4/29/23, he called the Nurse Practitioner (NP#2) with the hospital recommendations. Nurse #5 said that the NP #2 gave him orders to start the antibiotic and follow up labs. Nurse #5 said that he noticed the orders had not been implemented from the week before.
During an interview on 5/2/23, at 9:34 A.M., Nurse Practitioner #2 said that Resident #18 should have received the antibiotics because the nature of the injury. NP #2 said that with a laceration there is a high risk for infection. NP #2 said that when the wound specialty physician makes a recommendation he would expect the nursing staff to implement those recommendations.
During an interview on 5/2/23, at 2:09 P.M., the Physician said that on-call telemedicine coverage are credentialed providers. The Physician said that when a telemedicine physician makes a recommendation that he or his nurse practitioner do not need to be called because they are credentialed providers and said nursing should implement the recommendations.
During a follow up interview on 5/3/23, at 8:57 A.M., the Director of Nursing (DON) said nursing should have implemented the telehealth recommendations from 4/22/23. The DON said he was unable to find the hospital discharge paperwork from 4/22/23.
During a follow up interview on 5/3/23, at 9:20 A.M., the Assistant Director of Nursing (ADON) said there should be an order for wound care and monitoring. The ADON said she has not obtained the hospital paperwork from 4/22/23. The ADON and the surveyor went to Resident #18's room. The surveyor and the ADON observed sutures in Resident #18's leg. These were recommended to be removed on 5/2/23. The ADON said they should have been removed.
During a record review and interview on 5/3/23, at 10:07 A.M., the Regional Minimum Data Set Nurse said that the telemedicine recommendations and the wound physician's recommendations should have been implemented but were not.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0687
(Tag F0687)
Could have caused harm · This affected 1 resident
Based on observation, record review and interview the facility failed to ensure for one Resident (#63) foot care was provided to maintain good foot health, out of a total sample of 34 residents. Speci...
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Based on observation, record review and interview the facility failed to ensure for one Resident (#63) foot care was provided to maintain good foot health, out of a total sample of 34 residents. Specifically, for Resident #63 the facility failed to provide podiatry services for elongated toenails and failed to provide treatment for scaly, dry areas of the foot.
Findings include:
Review of the facility policy, entitled Diabetic Foot Care dated 9/16/16, indicated the following:
The purpose of this procedure is to ensure that all residents are provided appropriate foot care and are monitored routinely for alterations in skin integrity to their feet. It is the intention of this facility to monitor, identify, and resolve any issues with skin integrity timely. Diabetic foot care will be provided by a licensed nurse. Inspect all aspects of the feet, including the sole and heal (sic) Inspect for discolored areas, cracks or splits, calluses, peeling skin, swelling, blisters and ulcers. Apply lotion to feet, avoiding between toes.
Resident #63 was admitted to the facility in May 2022 with diagnoses including acute kidney failure, abnormalities of gait and mobility, and dementia with other behavioral disturbance.
Review of the most recent Minimum Data Set Assessment (MDS), with an Assessment Reference Date of 2/14/23, indicated a Brief Interview for Mental Status Exam score of 12 out of 15 indicating moderate cognitive impairment, required limited assistance with personal hygiene, bathing and dressing. Further review the MDS coded Resident #63 as not exhibiting behaviors of rejection or evaluation of care.
On 4/30/23, at 12:12 P.M., the surveyor observed Resident #63 lying on his/her bed with his/her feet exposed. Both his/her right and left feet were observed to have elongated toenails that extended beyond the toe. Both feet were observed to have whitish dry, scaly patches near the toes and around the foot.
During an interview on 4/30/23, at 12:12 P.M., Resident #63 said he/she has been here (at the facility) about ten months and has not seen a foot doctor and was waiting to see one.
On 4/30/23 at 1:17 P.M., review of the paper medical record indicated the following:
*A Podiatry Consent for Care and Treatment, dated 5/24/22, and signed by the Resident/or Personal representative.
*No documentation indicated that Resident #63 was treated by the podiatrist.
Review of Resident #63's electronic medical record indicated the following:
* A physician's order dated 8/5/22, diabetic foot checks daily, check feet toes, heels, report any redness or discolored area to the supervisor, every evening shift.
*A physician's order dated 5/25/22, podiatry evaluation and treatment as indicated.
On 5/1/23, at 8:09 A.M., the surveyor observed Resident #63 sitting up in his/her room, her/she was not wearing shoes. Resident #63's right and left feet were observed to have caked, dry, scaly skin around the area between his/her toes. His/her heels were observed calloused and had thick white dry skin.
During an interview on 5/1/23, at 8:09 A.M., Resident #63 said he/she has type 2 Diabetes's and said staff do not assist with putting lotion on his/her feet.
During an interview on 5/1/23, at 8:31 P.M., Certified Nursing Assistant #1 said the nurses provide foot care.
On 5/1/23, at 9:18 A.M. Nurse #2 and the surveyor went to Resident #63's room. Nurse #2 observed Resident #63's feet and said his/her toenails were long and feet and lower legs had dry skin. Nurse #2 said the Resident has an order for diabetic foot care. Resident #63 said he/she has not been seen by the podiatrist and needs a pedicure.
Review of the current Treatment Administration Record, with Nurse #2, indicated there was no treatment implemented for Resident #63's dry, scaly feet.
During an interview on 5/1/23, at 9:50 A.M., the Assistant Director of Nursing (ADON) said Resident #63 had refused the podiatrist visit. The ADON was asked to provide documentation of Resident #63 refusal. The ADON did not provide the surveyor with the documentation of the refusal for podiatry services.
During an interview with the Podiatrist on 5/1/23, at 10:17 A.M., he said he provided services to the facility up until 5 to 6 months ago said he had no record of Resident #63 being provided podiatry care.
On 5/43/23, at approximately at 3:00 P.M., the surveyor was provided a list for an upcoming visit with the new podiatrist for Resident #63 indicating priority/1st consult.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Tube Feeding
(Tag F0693)
Could have caused harm · This affected 1 resident
Based on observation, record review and interview the facility failed to ensure staff provided appropriate care and services for one Resident (#8) with a Gastrostomy tube (G-tube: a tube that is place...
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Based on observation, record review and interview the facility failed to ensure staff provided appropriate care and services for one Resident (#8) with a Gastrostomy tube (G-tube: a tube that is placed directly into the stomach through an abdominal incision for administration of nutrition, fluids, and medication), out of 34 sampled Residents. Specifically, the facility failed to have and accurate flow rate for feedings and accurate flush settings.
Findings included:
Review of the facility policy titled Enteral Nutrition dated 3/22/21, adequate nutritional support support through enteral feeding will be provided to residents as ordered.
- The dietician, with the input from the physician and the nurse, will calculate fluids to be provided (beyond free fluids in the formula)
- Enteral feedings will be scheduled to try to optimize resident independence whenever possible. The schedule will not be altered.
Resident #8 was admitted to the facility in April 2021 with diagnoses including respiratory failure, gastronomy tube placement, dysphagia, epilepsy, contracture, tracheostomy, quadriplegia, and a traumatic brain injury.
Review of the quarterly Minimum Data Set (MDS) assessment, dated 3/21/23, indicated Resident #8 was rarely/never understood and rarely/ never understands others. The MDS indicated his/her cognitive skills for daily decision making are severely impaired. The MDS further indicated he/she required a G-tube for feedings and required total dependence of staff for eating.
Review of the physician's order, dated 12/13/22, indicated:
- H20 [water] flush 200 milliliters (ml) every 4 hours
Review of the physician's order, dated 3/25/23, indicated:
- Free water flushes at 150 ml (milliliters) every 4 hours
Review of the physician's order, dated 4/4/23, indicated:
- Jevity 1.5 Cal/Fiber Oral Liquid (Nutritional Supplements) Give 60 ml via G-Tube every shift related to dysphagia, Jevity 1.5 at 55 ml/hr (hour) continuous to provide 1980 kcal, Hold feed for 2 hrs everyday between 9:00 A.M. - 11:00 A.M.
- Hold Tube feed for 2 hrs everyday from 9:00 A.M. - 11:00 A.M. in the morning Stop Feed
- Resume tube feed at 11:00 A.M., in the morning.
During an observation on 4/30/23, at 7:56 A.M. Resident #8's tube feeding pump was set and infusing at 60 ml/hour and the water flushes were set to 150 ml every 4 hours. The Jevity feeding bottle was dated 4/30/23, and had a written rate of 60 ml/hr.
During observations on 5/1/23, at 6:54 A.M., 5/1/23, at 1:44 P.M., and 5/1/23, at 4:45 P.M. , Resident #8's tube feeding pump was set and infusing at 60 ml/hour and the water flushes were set to 150 ml every 4 hours. The Jevity feeding bottle was dated 5/1/23, and had a written rate of 55 ml/hr, not the 60 ml/hr that the pump was set to.
During an interview on 5/2/23, at 10:45 A.M., Nurse #8 reviewed the physician's order with the surveyor. Nurse #8 first said the G-tube rate should be set to 55 ml/hour, she then re-read the order and said that it was unclear what the rate was. Nurse #8 said she would need to get the order clarified.
During an interview on 5/2/23, at 7:07 A.M., Nurse #7 said that the G-tube rates and flushes are set to the physician's order on the pump.
During an interview on 5/2/23, at 8:40 A.M., Nurse #5 said that the G-tube rates and flushes are set to the physician's order on the pump.
During an interview on 5/2/23, at 10:33 A.M., the Dietician reviewed the physician's orders with the surveyor. The Dietician said there should only be one rate and one flush order.
During an interview on 5/2/23, at 9:41 A.M., Nurse Practitioner (NP) #2 said that Resident #8's G-tube rates are managed by the dietician and the orders are implemented by nursing. NP #2 said that the order for the feeding should match.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Respiratory Care
(Tag F0695)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview the facility failed to maintain respiratory equipment according to professiona...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview the facility failed to maintain respiratory equipment according to professional standards of practice for 2 Residents (#22 and #8) out of a total sample of 34 Residents.
Findings include:
Review of the facility policy titled oxygen administration, dated 3/2021, indicated the purpose of the procedure is to provide guidelines for safe oxygen administration.
- verify there is a physician's order for oxygen administration.
- review the resident's care plan to assess for any special needs of the resident.
- document the oxygen flow rate, route, and rational.
1. For Resident #22 the facility failed to ensure that his/her oxygen flow rate was set according to the physician's order and failed to ensure that an oxygen tubing bag was not used for multiple residents.
Resident #22 was admitted to the facility in January 2023 with diagnosis including end stage renal disease, syncope, anxiety, major depressive disorder, panic disorder, hypotension, atrial fibrillation and weakness.
Review of Minimum Data Set (MDS) assessment dated [DATE], indicated Resident #22 is able to be understood and he/she had the ability to understand others. The MDS indicated Resident #22 does not have any behaviors and he/she requires assistance for activities of daily living. The MDS further indicated he/she received dialysis and did not require oxygen.
Review of the physician's order, dated 2/19/23, indicated:
-Oxygen therapy at 3L/m [3 liters per minute (LPM)] via nasal cannula. Further review of the order indicated the order was incomplete and did not include the frequency that the oxygen is needed.
Review of the plan of care on 4/30/23, indicated there was no documentation to support that Resident #22 required oxygen.
On 4/30/23, at 7:44 A.M., the Surveyor observed, attached to Resident #22's oxygen concentrator, an oxygen tubing bag that was dated 6/16/22. Further review indicated the bag did not have Resident #22's name but was labeled with another residents name. There were two sets of nasal cannula's sitting on Resident #22's night stand, the nasal cannula's were intertwined with a cup with tissues folded up in it, magazines, medicated powders and a personal radio. Resident #22 was observed in his/her chair, was wearing his/her nasal cannula and had oxygen on that was set at 10 liters per minute (LPM). The oxygen tank was out of reach.
During an observation on 4/30/23, at 7:52 A.M., Resident #22 was in his/her wheel chair in the dining room. The surveyor could hear Resident #22's oxygen whistling. The oxygen tank, hanging on the back of the chair, was set to 10 liters per minute.
During an observation on 4/30/23, at 10:41 A.M., Resident #22 was in his/her room. Resident #22 was connected to his/her oxygen concentrator in his/her room. The oxygen concentrator was set to 4 LPM. Resident #22 said that the oxygen tanks constantly run out and he/she needs to go back to his/her room to use the oxygen concentrator.
During an observation on 4/30/23, at 12:07 P.M., Resident #22 was in bed sleeping, the oxygen concentrator was set to 4 LPM. The oxygen concentrator was out of reach.
During an observation on 4/30/23, at 12:49 P.M., Resident #22 was in his/her wheel chair and his/her oxygen concentrator was set to 4 LPM. The oxygen tubing bag dated 6/16/22, with a another residents name on the bag was still in the room attached to the oxygen concentrator.
During an observation on 4/30/23, at 3:02 P.M., Resident #22 was in his/her room sitting in wheel chair the oxygen concentrator was set to 4 LPM.
During an observation on 5/1/23, at 11:44 A.M., Resident #22's oxygen tank was set to 4 LPM he/she had just returned from dialysis . The oxygen tank was empty.
During an observation on 5/2/23, at 6:37 A.M., Resident #22 was in his/her bed asleep. The oxygen concentrator was out of reach and the settings were at 3.5 LPM. The oxygen tubing bag dated 6/16/22, with a another residents name on the bag was still in the room.
During an interview on 5/2/23, at 6:55 A.M., the Regional Nurse and the surveyor observed Resident #22's oxygen concentrator. The surveyor showed the Regional Nurse photos of the surveyors observation on 4/30/23, and a photo of the bag dated 6/16/22, and she said that the bag should not have been in Resident #22's room.
During an interview on 5/2/23, at 2:34 P.M., Certified Nurse Assistant (CNA) #4 said that CNA's do not adjust oxygen settings. She said only the nurse can change oxygen setting.
During an interview on 5/2/23, at 8:43 A.M., Nurse #5 said that nursing should follow physician's orders for oxygen administration.
During an interview on 5/2/23, at 9:45 A.M., Nurse Practitioner #2 said that Resident #22 is dependent on oxygen. NP #2 said that nursing should implement the physician's order.
During an interview on 5/3/23, at 10:00 A.M., the Regional MDS Nurse said that the order for oxygen was not complete. The Regional MDS Nurse said there were no indications for when Resident #22 required the oxygen and said there was no care plan for oxygen developed.
2. For Resident #8, the facility failed to ensure that nursing changed oxygen tubing and an oxygen storage bag according to the physician's order.
Resident #8 was admitted to the facility in April 2021 with diagnoses including respiratory failure, gastronomy, dysphagia, epilepsy, contracture, tracheostomy, quadriplegia, and traumatic brain injury.
Review of the physician's order, dated 4/7/22, indicated:
- change 02 [oxygen] tubing, bag and date every Thursday 11-7 night shift [11:00 P.M. to 7:00 A.M.]
Review of the Treatment Administration Record (TAR), dated April 2023, indicated:
- 4/27/23, charted as completed for change 02 [oxygen] tubing, bag and date every Thursday 11 P.M.-7 A.M. night shift.
During observations on 4/30/23, at 7:56 A.M. and at 3:03 P.M., the oxygen tubing and oxygen bag was dated 4/24/23, not 4/27/23, as documented on the TAR
During observation on 5/1/23, at 6:54 AM 1:44 P.M., and 4:45 P.M., the oxygen tubing an oxygen bag was dated 4/24/23, not 4/27/23, as documented on the TAR.
During an observation on 5/2/23, at 6:55 A.M., the Corporate Nurse and the surveyor observed the the oxygen tubing an oxygen bag was dated 4/24/23, not 4/27/23, as documented on the TAR.
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 record review and interview the facility failed to provide care and services consistent with professional standards for...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to provide care and services consistent with professional standards for one Resident (#22), who required renal dialysis (a procedure to remove waste products and excess fluid from the body when the kidneys stop working), out of one applicable sampled resident, in a total sample of 34 residents. Specifically, the facility failed to ensure complete and accurate communication with the dialysis facility for the Resident's dialysis appointments.
Findings include:
Review of the facility policy titled, Dialysis Patients, dated 3/21, indicated a dialysis communication binder will be sent with the patient in case of documentation with the facility and the dialysis center.
Resident #22 was admitted to the facility in January 2023 with diagnosis including end stage renal disease, syncope, anxiety, major depressive disorder, panic disorder, hypotension, atrial fibrillation and weakness.
Review of Minimum Data Set (MDS) assessment dated [DATE], indicated Resident #22 is able to be understood and he/she had the ability to understand others. Further review of the MDS indicated Resident #22 does not have any behaviors and he/she requires assistance for activities of daily living. The MDS indicated he/she received dialysis.
Review of the physician's order, dated 1/27/23, indicated:
- Dialysis scheduled on Monday, Wednesday and Friday with a pick up time of 5:15 A.M.
Review of Resident #22's dialysis communication book on 4/30/23, at 8:27 A.M., indicated that the dialysis book included one communication note from 2/3/23. No other completed communication documents were in the book.
During an observation on 5/1/23, at 11:44 A.M., Resident #22 returned from dialysis. Resident #22 did not have a dialysis book with him/her. Resident #22 said he/she does not have a dialysis communication book but said he/she would use one if he/she had one.
The surveyor then observed the dialysis book on the bookshelf which only included the one communication note from 2/3/23.
During an interview on 5/2/23, at 2:26 P.M., the Director of Nursing (DON) reviewed the dialysis book with the surveyor. The DON said the dialysis communication book goes to dialysis with Resident #22 and the dialysis center removes the communication slips. The DON requested the Assistant Director of Nursing (ADON) to check to see if there was another dialysis communication book.
The ADON provided the surveyor with another dialysis communication book that included a communication notes from 12/31/22, 1/4/23, and 2/1/23.
During an interview on 5/2/23, at 7:07 A.M., Nurse #7 said that Resident #22 should bring his/her dialysis book with him/her to dialysis.
During an interview on 5/3/23, at 7:26 A.M., the Dialysis Center Registered Nurse said that Resident #22 does not come with a communication book to the dialysis center but he/she should. The Dialysis Center Registered Nurse said the dialysis center does not remove communication notes from a Resident's communication book.
During an observation on 5/3/23, at 12:00 P.M., Resident #22 was eating his/her lunch. Resident #22 said he/she did not return with any communication from dialysis.
The surveyor observed both dialysis books at the nursing station with no new communication forms.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0725
(Tag F0725)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review and interview, the facility failed to ensure that sufficient staffing levels were maintaine...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review and interview, the facility failed to ensure that sufficient staffing levels were maintained to safely and adequately meet each resident's personal care needs on 1 of 3 units.
Findings included:
1. Review of the facility assessment dated reviewed 1/16/23, indicated the following during a typical month:
1. The average daily census of the 3rd floor unit is 36.
2. The number of clinically complex residents in the facility is 10-15.
3. The number of residents with behavioral symptoms and cognitive performance issues is 40-70.
Further review indicated that the number of Certified Nurse's Aides (CNA) required to care for residents in the facility is 15-20. Further review failed to indicate how the CNA's were to be distributed through out the facility and shifts during the 24 hour period.
Review of the CNA daily assignment sheets and daily staffing schedules, indicated that on 4/13/23, 4/16/23, 4/18/23, 4/20/23, 4/25/23, 4/29/23, 4/30/23 and 5/1/23, 5/2/23, 2 CNA's were assigned to the 3rd floor on the 7:00 A.M.-3:00 P.M. shift, caring for 15 to 16 residents each.
2. Resident #6 was admitted to the facility in September 2013 with diagnoses including dementia, schizophrenia and bipolar disorder.
Review of the Minimum Data Set (MDS) dated [DATE], indicated that Resident #6 scored a 14 out of 15 on the Brief Interview for Mental Status (BIMS) indicating intact cognition. Further review indicated that Resident #6 is totally dependant for bathing.
During an interview on 4/30/23, at 9:52 A.M., Resident #6 said she/he wants a shower twice a week and only gets it maybe once a week. Resident #6 then said that they don't have enough people to help give showers.
Review of the shower schedule indicated that Resident #6 is scheduled for every Tuesday and Friday 7-3.
Review of the Certified Nurse's Aide (CNA) shower documentation indicated that Resident #6 received a shower one day (4/20/23) for the month of April 2023.
Review of the 3rd floor daily census indicated that on 5/1/23, the census was 31 residents.
During an interview on 5/01/23, at 9:35 A.M. CNA #2 said that the assignment he has today is 16 residents, this is to much and all scheduled showers are not given. CNA #2 then said that we need 2 more CNA's for the care to be given properly. CNA #2 said that there are a lot of heavy care residents on the unit.
During an interview on 5/01/23, at 9:46 A.M., CNA #9 said that she was assigned 15 residents. CNA #9 then said that when there are 2 CNA's all the showers and everything that is supposed to be done, isn't done. CNA #9 then said that it is much easier when there are 3 CNA's on the unit but even then it is hard to get all the showers done as well as all of the other care that needs to be done
During an interview with 2 surveyors, on 5/01/23, at 4:31 P.M., the Director of Nursing, when asked if a Certified Nurse's Aide could adequately care for 16 residents on the 7:00 A.M.-3:00 P.M. shift, with the current acuity level, getting the residents up, bathed, dressed, give 4 showers each, change the briefs of incontinent residents and reposition residents every 2 hours and serve 2 meals, nodded his head side to side and said no.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0726
(Tag F0726)
Could have caused harm · This affected 1 resident
Based on observation, record review and interview, the facility failed to ensure Nurse #2 was competent and had the required skill set to prepare and administer medications for one Resident (#15), tha...
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Based on observation, record review and interview, the facility failed to ensure Nurse #2 was competent and had the required skill set to prepare and administer medications for one Resident (#15), that met professional standards of quality, out of a total sample of 34 Residents.
-Nurse #2 crushed medications that should not have been crushed and Nurse #2 did not clean the rubber seal of an insulin pen and she did not prime the insulin pen prior to administering the injection. (removing the air from the needle and the cartridge that may collect during normal use. It is important to prime the pen before each injection so that the injection will work correctly. If a nurse does not prime before each injection, a nurse may give too much or too little insulin, resulting in the incorrect dose being administered.)
Finding include:
Review of the Humalog (short acting insulin) pen (insulin pen) manufacture's instructions, dated as reviewed 2023, indicated:
- Wipe the rubber seal with an alcohol swab.
- Push the capped needle straight onto the pen (rubber seal) and twist the needle on.
- Prime the needle
- To prime the pen, turn the dose knob to select 2 units.
- Hold the pen with the needle pointing up.
- Tap the cartridge holder gently to collect air bubbles at the top.
- Continue holding your pen with the needle pointing up.
- Push the dose knob in until it stops, and 0 is seen in the dose window.
- Hold the dose knob in and count to 5 slowly.
- You should see insulin at the tip of the needle, meaning the pen is primed and ready to use to ensure the correct dose.
- If you do not see insulin, repeat the priming steps.
During the medication pass observation on the 1st Floor on 5/1/23, at 8:20 A.M., Nurse #2 administered the following to Resident #15:
- Aspirin 81 milligrams (mg), 1 enteric coated tablet (review of manufactures guidelines indicated not to crush).
- Isosorbide Mononitrate ER (Extended Release) Tablet 24 Hour 30 MG, 1 tablet (review of manufactures' guidelines indicated not to crush).
- Levetiracetam Tablet 250 mg, Give 1 tablet (review of manufactures guidelines indicated not to crush).
- Humalog Solution 100 UNIT/ML (Insulin Lispro) subcutaneously, 2 units (Nurse #2 was observed to not prime insulin pen therefor unable to ensure dose accuracy and was observed to not clean the rubber stopper)
Review of the physician's order dated:
- 11/6/22: Levetiracetam Tablet 250 MG, Give 1 tablet by mouth two times a day for convulsion.
- 11/6/22: Isosorbide Mononitrate ER Tablet Extended Release 24 Hour 30 MG, Give 1 tablet by mouth one time a day for hypertension.
- 2/27/23: Aspirin Adult Oral Tablet (Aspirin), Give 81 mg by mouth one time a day for pain.
- 11/6/22: Humalog Solution 100 UNIT/ML (Insulin Lispro) Inject subcutaneously before meals and at bedtime for diabetes.
During an interview on 5/1/23, at 8:25 A.M., Nurse #2 said that she was not aware of which medications should not be crushed. Nurse #2 said that she did not clean the rubber stopper and she was not aware that insulin pen needed to be primed.
During an interview on 5/2/23, at 4:00 P.M., the Director of Nursing (DON) said that Nurse #2 should follow the facility policy for medication administration. The DON said that Nurse #2 should have primed the insulin pen prior to use.
Review of Nurse #2's education file, indicated no documentation to support she was reviewed for medication administration competencies.
During a follow-up interview on 5/3/23, the Director of Nursing said that he provided the surveyor with Nurse #2's education file and the DON said there was no additional competencies for Nurse #2. The DON declined to participate in any further interviews regarding Nurse #2 competencies.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Dental Services
(Tag F0791)
Could have caused harm · This affected 1 resident
Based on observations, record review and interviews, the facility failed to provide dental services to one Resident (#34) out of a total sample of 34 residents.
Findings include:
Review of the facili...
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Based on observations, record review and interviews, the facility failed to provide dental services to one Resident (#34) out of a total sample of 34 residents.
Findings include:
Review of the facility policy titled Dental Services and dated last revised 11/2017 indicated that routine and emergency dental services are available to meet the resident's oral health services in accordance with the resident's assessment and plan of care. Further review indicated that all dental services provided are recorded in the resident's medical record.
Resident #34 was admitted to the facility in July 2021 with diagnoses including diabetes, heart disease and kidney disease.
During an interview on 4/30/23, at 10:07 A.M., Resident #34 said she/he has had a tooth ache for 3 weeks. Resident #34 then said that the pain is at an 8 out of 10, with 10 being the worst ever. Resident #34 then said that she/he had been telling the nurses about the pain for weeks.
During an interview on 5/1/23, at 11:39 A.M. Resident #34 said the tooth pain was a 3 out of 10. Resident #34 then said that the pain was not as bad as the day before but it was still bothering her/him.
Review of the medical record failed to indicate that Resident #34 had seen a dentist. Further review failed to indicate that a dental appointment had been made.
Review of the physician progress note dated 3/29/23, indicated that the reason for the visit was because of tooth pain. Further review indicated that Resident #34 was started on an antibiotic and instructions were given to follow up with the dentist.
Review of the facility document titled NSG: Oral Health Evaluation (Licensed Nurse)-V1 and dated 4/18/23, indicated that Resident #34 had broken teeth. Further review indicated that Resident #34 did not require a referral to the dentist.
During an interview on 5/01/23, at 11:07 A.M., the Director of Nursing (DON) said that he was not able to locate a dental appointment scheduled for Resident #34. The DON then said that he is the one to make the dental appointments for other than routine services. He then said that he was not aware that Resident #34 required dental services.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Antibiotic Stewardship
(Tag F0881)
Could have caused harm · This affected 1 resident
Based on record review and interviews the facility failed to implement an effective antibiotic stewardship program for one Resident (#18) out of a total sample of 34 Residents.
Findings include:
Rev...
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Based on record review and interviews the facility failed to implement an effective antibiotic stewardship program for one Resident (#18) out of a total sample of 34 Residents.
Findings include:
Review of the facility policy, titled Antibiotic Stewardship - Review and Surveillance of Antibiotic Use and Outcomes, dated as revised 12/19, indicated:
- antibiotic usage and outcome will be collected and documented using a facility- approved antibiotic surveillance tracking form.
- the infection preventionist will review all antibiotic starts within 48 hours to determine if continued therapy is justified, justified with needed intervention, or not justified.
- at the conclusion of the review, the provider will be notified of the review findings and recommendations. The provider will documented if he/she agrees to make the change.
Resident #18 was admitted to the facility in January 2022 with a diagnoses including venous insufficiency, muscle weakness, abnormalities of the gait and mobility, dysphagia, anxiety, legal blindness and lack of coordination.
Review of Resident #18's telemedicine note, dated 4/22/23, indicated to administer Doxycycline (antibiotic).
Review of Resident #18's telemedicine note, dated 4/22/23, (addendum), indicated Resident #18 returned from the ER [Emergency Room] with an order for Doxycycline 100 mg po bid x 5 days [by mouth twice a day for 5 days].
Review of the nursing progress note, dated 4/22/23, and timed 22:23, indicated Resident #18 was sent out due laceration on the left leg, was readmitted with new order for antibiotic Doxycycline 100 mg bid x 5 days.
Review of the Medication Administration Record, dated April 2023, indicated that the Doxycycline was not implemented until 4/29/23, 7 days later.
Review of the Revised McGreer Criteria for Infection Surveillance Checklist indicated the following:
- Date of infection 4/22/23
- Date of Review: left blank
- Skin and Soft Tissue Infection (SSTI) surveillance (cellulitis, soft tissue, or wound infection)
- Did not meet criteria
Review of the nursing note dated 4/29/23, indicated that the provider was made aware of the hospital recommendations and there was an order obtained for a CBC with diff [complete blood count with differential, test used to check labs values] and Doxycycline 100 mg BID [twice a day] for 5 days.
Review of the late entry progress note written by the Assistant Director of Nursing, dated as entered on 5/1/23, and back dated to 4/23/23, indicated that Resident #18 did not start Doxycycline; as it did not meet criteria. MD [physician] aware and gave directive.
During an interview on 5/1/23, at 1:33 P.M., the Assistant Director of Nursing (ADON) said she worked on the McGreer form with Director of Nursing yesterday (4/30/23). The ADON said it was the first day she had reviewed the use of the antibiotic (8 days after the recommendation).
During an interview on 5/2/23, at 9:34 A.M., Nurse Practitioner (NP) #2 said that Resident #18 should have received the antibiotic because the nature of the injury. NP #2 said that with a laceration there is a high risk for infection.
During an interview on 5/2/23, at 2:09 P.M., the Physician said on-call coverage are credentialed providers. The Physician said that when a telemedicine physician makes a recommendation that neither him nor his nurse practitioner need to be called because they are credentialed providers and nursing should implement the orders given.
During an interview on 5/3/23, at 8:57 A.M., the Director of Nursing (DON) said he was not going to review any antibiotic stewardship information with the surveyor. The DON said he had already reviewed the antibiotic stewardship program with another surveyor.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0947
(Tag F0947)
Could have caused harm · This affected 1 resident
Based on interview and review of personnel files and training documentation, the facility failed to ensure 2 of 2 certified nurse aides (CNA) and 1 of 1 nurses' were provided with training on dementia...
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Based on interview and review of personnel files and training documentation, the facility failed to ensure 2 of 2 certified nurse aides (CNA) and 1 of 1 nurses' were provided with training on dementia management in accordance with State and Federal requirements.
Findings include:
Review of the 4 hour Hand-in Hand dementia care training certificate indicated that CNA #1 and #13 and Nurse #2 successfully completed the 4 hour Hand-in Hand dementia care training on 2/27/23.
Review of the facility documents titled Dementia Care Education Test For 4 hr Training, indicated that CNA #1 and #13 and Nurse #2 took the test on 4/22/23, nearly 2 months later. Further review indicated that the dementia training test was not signed by any of the employees whose name was on the test.
The surveyor requested to see the time card punches for the dates of 2/27/23 and 4/22/23 for CNA #1, #13 and nurse #2. The surveyor was presented with time card punches for 2/22/23.
During an interview on 5/1/23, at 2:42 P.M., the Director of Nursing (DON) was unable to explain why the date of the dementia training certificate was not the same date as the payroll time punch provided. The DON then said that the test was given and dated for today but when the surveyor pointed out that the date was for 4/22/23, and not today (5/1/23) he was not able to say why. The DON said that he was not able to locate the dementia training tests for the 3 employees that were administered immediately following the 4 hour yearly training requirement.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Comprehensive Care Plan
(Tag F0656)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview the facility failed to implement the plan of care for 2 Residents (#6, #50) an...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview the facility failed to implement the plan of care for 2 Residents (#6, #50) and failed to develop a person-centered care plan with individualized interventions for 2 Residents (#67 and #23) out of a total sample of 34 residents.
Findings include:
Review of the facility policy titled Shower/Tub Bath and not dated, failed to indicate that the resident has the choice of a shower or tub bath. Further review failed to indicate how often a shower is to be offered to a resident.
1. Resident #6 was admitted to the facility in September 2013 with diagnoses including dementia, schizophrenia and bipolar disorder.
Review of the Minimum Data Set (MDS) dated [DATE], indicated that Resident #6 scored a 14 out of 15 on the Brief Interview for Mental Status (BIMS) indicating intact cognition. Further review indicated that Resident #6 is totally dependant for bathing.
During an interview on 4/30/23, at 9:52 A.M., Resident #6 said she/he wants a shower twice a week and only gets one maybe once a week. Resident #6 then said that they don't have enough people to help give showers.
Review of the shower schedule indicated that Resident #6 is scheduled for a shower every Tuesday and Friday on the 7:00 A.M.-3:00 P.M. shift.
Review of the Certified Nurse's Aide (CNA) shower documentation indicated that Resident #6 received a shower one day (4/20/23) for the month of April 2023.
During an interview on 5/01/23, at 9:35 A.M. CNA #2 said that the assignment he has today is 16 residents. This is to much and all scheduled showers are not given. CNA #2 then said that we need 2 more CNA's for the care to be given properly and showers to be given as scheduled.
During an interview on 5/01/23, at 9:46 A.M., CNA #9 said that when there are 2 CNA's, all the showers and everything that is supposed to be done, isn't done. CNA #9 then said that it is much easier when there are 3 CNA's on the unit but even then, it is hard to get all the showers done.
2. Resident #50 was admitted to the facility in July 2022 with diagnoses including Alzheimer's, heart disease and chronic obstructive pulmonary disease.
Review of the care plan dated as reviewed 4/5/23, indicated that Resident #50 had problem behaviors including throwing her/his food tray on the floor.
Review of the care plan dated as reviewed 4/5/23, indicated an intervention for food to be presented one item at a time. Further review indicated to provide an extra sandwich twice a day on her/his food trays.
On 4/30/23, at 9:11 A.M. the surveyor observed Resident #50 in bed, eating alone in her/his room. The surveyor also observed that no staff were in the room offering Resident #50 food items one at a time.
On 4/30/23, at 12:55 P.M., the surveyor observed Resident #50 asking where the food is and saying that she/he is starving. At 1:08 P.M., the surveyor observed Resident #50 eating alone in her/his room with all food items on the tray. The surveyor also observed that there was no extra sandwich on the tray.
On 5/01/23, at 8:34 A.M., the surveyor observed Resident #50 lying in bed awake, with a covered food tray, out of reach, on the bedside table and no staff in the room to present food items one at a time.
During an interview on 5/01/23, at 8:42 A.M., Resident #50 said she/he was hungry.
On 5/1/23, at 8:52 A.M., the surveyor observed Resident #50 in bed eating a corn bread muffin. The surveyor observed no staff in the room presenting one item at a time, and all items of food were on the tray.
On 5/1/23, at 1:00 P.M., the surveyor observed Resident #50 eating alone in her/his room. The surveyor observed no staff in the room presenting one item at a time, and all items of food were on the tray.
At 1:10 P.M. the surveyor observed food all over the floor next to Resident #50's bed.
During an interview on 5/2/23, at 1:15 P.M., CNA #2 said that Resident #50 had thrown the food tray on the floor.
On 5/2/23, at 12:45 P.M., the surveyor and Nurse #6 observed Resident #50 eating in her/his room alone. The surveyor also observed that there was no extra sandwich on the tray.
On 5/3/23, at 12:40 P.M., the surveyor and Certified Nurse's Aide (CNA) #10 observed Resident #50's food tray without an extra sandwich. CNA #10 then placed the food tray in front of Resident #50 and left the room.
During an interview on 5/3/23, when asked if a resident whose care plan indicated that food items should be presented one item at a time should be alone when eating with all food items in front of the resident. Nurse #1 said that she couldn't think and did not answer the question.
During an interview on 5/3/23, at 12:42 P.M., CNA #10 said that she was not aware that Resident #50 was to have food items given one at a time.
3. For Resident #67 the facility failed to develop and implement a person-centered care plan care plan for behavioral symptoms with individualized interventions.
Resident #67 was admitted to the facility in December 2022 with diagnoses that included Alzheimer's disease, dementia in other diseases classified elsewhere, mild, with other behavioral disturbance, dysphagia, glaucoma, and aphasia.
Review of the comprehensive Minimum Date Set (MDS) with an Assessment Reference Date (ARD) of 1/4/23, indicated Resident #67 had a Brief Interview for Mental Status exam score of 8, indicating moderate cognitive impairment and required supervision and limited assistance for daily care. Further review of the MDS indicated Resident #67 did not display any patterns of behaviors.
Review of the MDS with an ARD of 4/4/23, indicated Resident #67 had a staff cognitive assessment indicating severe cognitive impairment and did not display any patterns of behaviors.
On all days of survey from 4/30/23 through 5/3/23 Resident #63 displayed verbal behavioral symptoms including threatening others, screaming, and cursing at others.
Review of Resident #67's medical record indicted the following:
*A behavioral health progress note dated 12/29/23 target symptoms agitation. Resident being seen per staff request due to behaviors since arriving at the facility.
*Progress notes in the seven day look back period from 1/4/23 indicated Resident #67 displayed behaviors of wandering, cursing and combative with care.
*Progress notes in the seven day look back period from 4/4/23 indicated Resident #67 displayed behaviors daily including wandering, yelling cursing at self and others.
The surveyor made the following observations:
*On 4/30/23 at 7:41 A.M., Resident #67 was observed in his/her private room. The room was sparse, with only a television and no personal effects. Nurse #2 said to the surveyor be careful, he/she can be loud and swear and curse a lot and does not like people in his room.
*On 4/30/23 at 8:19 A.M., Resident #67 was screaming and cursing using explicit language at the housekeeping staff who were near his/her door.
*On 4/30/23 at 12:52 P.M., Resident #67 opened his/her door, yelled out then went back into the room and closed the door.
*On 5/1/23 at 8:50 A.M., Resident #67 was heard calling out, swearing, repetitively.
On 5/1/23 at 11:22 A.M. Resident #67 was screaming/yelling and using explicit language at housekeeping staff in the hall. Resident #67 then retreated to his/her room and shut the door.
*On 5/1/23 at 11:38 A.M., Resident #67 came out into the hall, repetitively yelling out explicit language. A Certified Nursing Assistant (CNA) was walking in front nearby the resident and not respond, assist, alter or engage Resident #67.
* On 5/1/23 at 3:03 P.M., Resident # 67 was up walking in his/he room, yelling out at no one in particular.
During an interview on 5/1/23 at 8:50 A.M., Nurse #2 was asked by the surveyor about Resident #67's behavioral plan. Nurse #2 said she would need to check and get back to the surveyor. Nurse #2 said Resident #67 recently moved rooms so he/she could be in a private room because of displayed behaviors.
During an interview on 5/1/23, at 11:40 A.M., CNA #1 said Resident #67 had verbal behaviors and staff are to meet his/her needs and reapproach if needed. CNA #1 said Resident #67 will allow care when he/she is calm.
Review of Resident #67's care plan indicted: Focus:
Resident had a behavior problem wanders, verbal abuse to staff, refuses care r/t (related to) diagnosis of Alzheimer's dementia, refuses lab draws, dated 1/11/23, with a revision date of 4/18/23.
Goal: Resident will have fewer episodes of wandering by review date, 7/17/2023.
Interventions: All dated 1/11/2023:
-Administer medications as ordered, monitor/document for side effects and effectiveness.
-Anticipate and meet the resident's needs.
-Assist the resident in develop more appropriate methods of coping and interacting.
-Encourage the resident to express feeling appropriately
-Caregivers to provide opportunity for positive interaction, attention. Stop and talk with him/her as passing by.
Review of the care plan failed to have goals to support the behaviors as stated under the focus, including, verbal abuse to staff and refusing care. Further, the care plan failed to have individualized interventions.
During an interview on 5/1/23, at 2:17 P.M., the Social Worker (SW) said Resident #67 has displayed behaviors from admission, is followed by behavioral health provider and required a room change about a month ago because his/her roommate was intimidated by his/her behaviors. The SW said there are times the Resident does not make a peep and others when his/her behaviors are pronounced. The SW said both she and the nurses develop care plans. The SW reviewed Resident #67's care plan and said the interventions are very general and not patient specific.
During an interview on 5/01/23, at 4:23 P.M., the Director of Nursing (DON) said Resident #67 was displaying behaviors right from admission. The DON said the care plan interventions are not specific to Resident #67 and do not indicate risks or interventions related to behaviors, which could increase his/her quality of life.
4. For Resident #23 the facility failed to develop a person-centered care plan with individualized interventions for scratching at his/her skin, resulting in open areas and non-hygienic fingernails.
Resident #23 was admitted to the facility in February 2023 with diagnoses including sepsis, unsteadiness on feet, asthma, type 2 diabetes mellitus, unspecified dementia, and schizophrenia.
Review of the Minimum Data Set Assessment (MDS) with an Assessment Reference Date (ARD) of 2/28/23, indicated Resident #23 had a primary language of Spanish, scored 7 out of 15 on the Brief Interview of Mental Status Exam (BIMS) indicating severe cognitive impairment and required extensive assistance from staff for bed mobility, dressing, hygiene and was dependent on staff for bathing. Further, the MDS did not indicate Resident #23 displayed behaviors and did not indicate, under section M skin, that Resident #23 had any skin areas, that were not pressure areas.
Observations made by the surveyor of Resident #23 on 4/30/23, 5/1/23 and 5/2/23 indicated Resident #23 had dark colored debris underneath his/her fingernails.
Further surveyor observations included:
-On 4/30/23, at 8:23 A.M., Resident #23 was observed with reddened linear and small scabbed areas, consistent with scratches on both his/her right and left arms.
-On 5/1/23, at 12:42 P.M., Resident #23 was in his/her room all morning. Resident #23 was picking at his/her skin on his/her leg. His/her right leg had an area of blood coming from a scabbed area. Both his/her arms and upper shoulder area was observed with reddened scabbed spots.
During an interview on 5/2/23, at 8:45 A.M., Certified Nursing Assistant (CNA) #1 said Resident #23's scratches his/her skin and his/her nails should be kept clean.
Review of Resident #23's medical record indicted the following:
-Nursing: Skin check dated 4/18/23, skin condition: intact
-A care plan: Diabetes Mellitus, with an intervention dated 3/1/23, to check all of body for breaks in skin and treat promptly as ordered by the doctor.
-A Care summary document, dated as of 5/3/23, failed to indicate interventions related to Resident #23's behavior of scratching.
-A Nurse Practitioner/Doctor progress note with an encounter date 4/24/23, indicated Pruritus unspecified (a medical term for itchy skin), continue with Benadryl as indicted.
During an interview on 5/02/23, at 8:55 A.M., Nurse #2 said Resident #23 had scattered scabs all over his/her body and has the behavior of picking his/her skin since admission to the facility. Nurse #2 said visitors of Resident #23's said this was not a new issue and he/she had always picked/scratch his/her skin. Nurse #2 said the treatment for Resident #23 was Benadryl. Nurse #2 said the sheets are changed daily due to blood spotting from the scabs and staff should apply moisturizing cream during care. Nurse #2 reviewed Resident #23's care plans and said there was no care plan for the Resident's behavior of scratching his/her skin.
On 5/02/23, at 9:30 A.M. Resident #23 was observed with Nurse #2. Nurse #2 described Resident #23's skin as scattered scabs on both arms and legs. Resident #23's shoulder area, was observed with circular bright red spots.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0679
(Tag F0679)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview the facility failed to 1.) provide meaningful and person-centered activity pro...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview the facility failed to 1.) provide meaningful and person-centered activity programming on one resident care unit out of three resident care units and 2.) failed to provide activities to three Residents (#23, #370, and #67.) out of a total sample of 34 residents.
Findings include:
Review of the facility's policy entitled, Programming for Residents, dated as revised 4/21/17, indicated the following:
Activity programs are relevant and valuable to resident's quality of life. Activities are provided for maintenance and enhancement of each resident' quality of life while promoting physical, cognitive, and psychosocial well being.
1 The focus should be on the resident's abilities, not disabilities.
2 Activity programs are to be meaningful and reflect the resident's interests.
and lifestyles and choices
a Lifestyle and choices
b Help the resident to develop new relationships
c Resident to feel independent and helpful
d Provide a sense of belonging
3. During the resident's assessment process and comprehensive care plan, they will be identified for any physical, mental challenges, emotional deficits and or personal interests.
6. Activity programs are to be modified to fit each individual resident's needs.
7. Activities are offered with interaction from members of the community as well as participation inside and outside the facility.
8. Activities are provided on a one to one basis for residents who will not or cannot join out of room programs
9. Activities are offered throughout the day by the facilities (sic) staff.
10. All activity participation is documented on a daily attendance form.
11. Activities are developed round resident's likes and dislikes through the facilities resident council program who meet on a monthly basis.
Review of the 1st floor census sheet indicated 19 residents resided on the 1st floor resident care unit.
1. On 4/30/23. at 7:36 A.M., during the initial screening of the fist floor resident care unit, many residents' rooms were sparse and did not have materials/items used for activity.
The April Activity Calendar was posted on a board and was at approximately 12-point font, and not easy to see. At no time during observations from 4/30/23, through 5/3/23, were residents observed looking at the calendar.
The 4/30/23, activities were listed as follows:
10:30 Coffee Social
11:00 Board Games
2:00 Prayer Service/communion with [NAME].
On 4/30/23, during an observation of the first-floor resident care unit at 2:02 P.M., One resident was sitting in the dining room with no activity material/or programming in front of him/her. Nine residents were observed in their rooms either resting or sitting in a chair, not engaged in any activity, 2 residents were walking in the hall. One resident was asleep in his/her wheelchair with his/her head hanging forward towards his/her tray table.
On 5/1/23, at 10:38 A.M., the May Activity Calendar was up and indicted the following:
10:30 Coffee Social
11:00 Drum Exercises
2:00 Start Movie
The calendar failed to indicate what movie was playing.
On 5/1/23, at 10: 30 A.M., one resident was walking in the hallway, one resident was asleep at his/her tray table, and several residents remained in their rooms. At no time was anyone observed engaged in an arranged activity or individual pursuit except for one resident who had his/her own computer and a puzzle table.
During an interview on 5/2/23, at 10:10 A.M., Activity Aide #1 (AA#1) said he has been working part time (32 hours) in the activities department for nearly a year, starting out in supplies then moving to activities. He said activity participation is low compared to how many people are in the building. He said 13-14 residents participate in activities, which he said is okay because honestly that is all they have room for in the activity room. AA #1 said only 3 or 4 from the first floor come up for coffee, although he invites others they don't want to come. He said it has been months since an activity was held on the first floor. He said other than getting a few residents on the first floor to go up to activity room he does not spend time on the first floor. He said he did give a recent new admission a word search and a pencil recently. AA #1 said they do not take participation attendance and do not document in resident records, and said that is something an activity director would do. AA #1 then said currently it is only him and one other AA and they try the best they can with limited resources. He said they have been without an activity director since last September. AA #1 said the Administrator in training (AIT) has been the interim manager.
During an interview on 5/2/23, at 11:17 A.M., the Ombudsman who visits the building routinely, said there have been no activity programming observed for the first-floor residents and very little for the other 2 floors as well. The ombudsman said there are many residents who display agitation, and nothing is going on for them.
On 5/2/23, at 11:57 A.M., Certified Nursing Assistant (CNA) #2 said the AA will take a few residents up to the third floor for activities and on the first floor we do not have any activities.
On 5/3/23, the May Activity Calendar indicated the following:
10:30 Coffee Social
11:00 Word games/chair exercises
2:00 Music Videos
On 5/3/23, at 10:13 A.M., the following was observed on the first-floor resident care unit:
One Resident was behind a closed door to a private room and was intermittently yelling out.
One resident was walking in the hallway.
One room occupied by 2 residents; one was sitting in a chair the other was sitting in a wheelchair at a tray table with a television on.
One resident in his/her bed was repetitively calling out. Nurse #2 asked a certified nursing aid to get him/her some water.
One resident who AA #1 identified as one of 3-4 residents who leave the unit to go to the activity room for coffee social was in bed with his/her eyes closed.
One resident identified by the Nurse as being on hospice care, was sitting up in his/her chair with nothing in front of him or her, nor was there music.
One resident on his/her bed with eyes closed, the other resident in the room was watching television.
A resident in a shared room was asleep on his/her bed and the other resident in the room was lying in bed awake.
One resident was in his/her room and talking, with no other person present.
At 10:22 A.M., AA #2 came off the elevator, took one resident onto the elevator and left the floor.
At no time did any staff offer any activity programming, meaningful conversation or engagement.
2. a) For Resident #23 the facility failed to develop and implement a plan of care for person-centered activities.
Resident #23 was admitted to the facility in 2/2023 with diagnoses including unspecified type 2 diabetes's mellitus, dementia, and schizophrenia.
Review of the Minimum Data Set Assessment (MDS) with an Assessment Reference Date (ARD) of 2/28/23, indicated Resident #23 had a primary language of Spanish, scored 7 out of 15 on the Brief Interview of Mental Status Exam (BIMS) indicating severe cognitive impairment and required extensive assistance from staff for bed mobility, dressing, hygiene and was dependent on staff for bathing. Further review of the MDS indicated under section F, interview for activity preferences indicated the following:
How important is it to you to have books, newspapers, and magazines to read?
How important is it to you to listen to music you like?
How important is it to you to be around animals such as pets?
How important is it to you to do things with groups of people?
How important is it to you to do your favorite activities?
How important is it to you to go outside and get fresh air when the weather is good?
How important is it to you to participate in religious services or practices?
The response from Resident #23 to all the questions was very important.
How important is it to keep up with the news? Resident #23's response was Somewhat important.
Review of Resident #23's medical record failed to indicate any activities assessment or progress notes from activities. Review of the [NAME] (a document used to guide staff in giving care and other information) failed to indicate any quality of life activities, or interventions for engagement. Further review of Resident #23's medical record failed to indicate an activity care plan was developed to enhance Resident #23's quality of life.
During all days of survey Resident #23 was not observed to be engaged with any individual or group activity programming. The surveyor made the following observations:
*On 4/30/23, at 8:23 A.M., Resident #23 was observed in his/her room. The room was sparse and only a television was in the room.
*On 5/1/23, at 12:42 P.M., Resident #23 was observed several times in the morning sitting up in his/her wheelchair in his/her room. Resident #23 was observed intermittently picking at his/her skin and was not observed in any meaningful activities or engagement.
On 5/2/23, at 9:34 A.M., Resident #23 was observed in his/her room, sitting up in his/her wheelchair. The television was on a channel airing cartoons.
During an interview on 5/2/23, at 9:51 A.M., The Administrator in Training (AIT) reviewed the medical record and acknowledged that there was no facility activities assessment completed per facility policy.
2. b) For Resident #67 the facility failed to develop and implement an individualized care plan for activities.
Resident #67 was admitted to the facility in December 2022 with diagnoses including Alzheimer's disease, dementia in other diseases classified elsewhere, mild, with other behavioral disturbance, dysphagia, glaucoma, and aphasia.
Review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 1/4/23, indicated Resident #67 had a Brief Interview of Mental Status Exam (BIMS) score of 8, indicating moderate cognitive impairment and required supervision and limited assistance for daily care. Further review of the MDS indicated under section F, interview for activity preferences the following:
How important is it to you to do your favorite activities?
How important is it to you to listen to music you like?
Resident #67's response to the above questions: very important.
How important is it to you to have books, newspapers, and magazines to read?
How important is it to you to be around animals such as pets?
How important is it to you to do things with groups of people?
How important is it to you to go outside and get fresh air when the weather is good?
How important is it to you to participate in religious services or practices?
Resident #67's response to the above questions: Somewhat important
Review of Resident #67 the medical record failed to indicate an activities assessment was completed, nor any activity progress notes. Further review failed to indicate an activities care plan was developed or implemented to maintain residents' well being and enhance his/her quality of life.
During all days of survey from 4/30/23, through 5/3/23, Resident #67 was not observed in engaging in any individual or group programming. The surveyor made the following observations:
*On 4/30/23, at 7:41 A.M., Resident #67 was observed in his/her private room. The room was sparse, with only a television and no personal effects. Nurse #2 said to the surveyor be careful, he/she can be loud and swear and curse a lot and does not like people in his/her room.
*On 4/30/23, at 8:19 A.M., Resident #67 was screaming and cursing using explicit language at the housekeeping staff who were near his/her door.
*On 4/30/23, at 12:52 P.M., Resident #67 opened his/her door, yelled out then went back into the room and closed the door.
*On 5/1/23, at 8:50 A.M., Resident #67 was heard calling out, swearing, repetitively.
On 5/1/23, at 11:22 A.M. Resident #67 was screaming/yelling and using explicit language at housekeeping staff in the hall. Resident #67 then retreated to his/her room and shut the door.
*On 5/1/23, at 11:38 A.M., Resident #67 came out into the hall, repetitively yelling out explicit language. A CNA, was walking in front nearby the resident and did not respond, assist, alter or engage Resident #67.
* On 5/1/23, at 3:03 P.M., Resident # 67 was up walking in his/her room, yelling out at no one in particular.
During an interview on 5/1/23, at 11:40 A.M., CNA #1 said Resident #67 had behaviors and staff are to meet his/her needs and re-approach if needed. CNA #1 said Resident #67 will allow care when he/she is calm. CAN #1 said Resident #67 does not participate in activities.
During an interview on 5/3/23, the Minimum Data Nurse, said she has been completing the section F activity preference interviews for the MDS, because there was no one in the activity department that could do the interviews. The MDS nurse said she did not develop an activity care plan for Resident #67. The MDS nurse said residents with dementia and or behaviors could benefit from activity programming with specific interventions and that a care plan for activities should be developed for Resident #67.
2. c.) For Resident #370 the facility failed to develop an individualized activity plan.
Resident #370 was admitted in March 2023 with diagnoses including schizoaffective disorder, type 2 diabetes with unspecified complications. adjustment disorder with
mixed anxiety and depressed mood, and chronic atrial fibrillation.
Review of the Minimum Data Set Assessment (MDS) with an Assessment Reference Date of 4/5/23, indicated Resident #370 had a Brief Interview of Mental Status exam, score of 13 out of 15 indicating intact cognition. Further review of the MDS indicated that Resident #370 required extensive assistance with bed mobility, hygiene, dressing and supervision with walking. Further review of the MDS indicated Resident #370's responses to Section F, activity preference interview as follows:
-How important to you to have books, newspapers, and magazines to read?
-How important is it to you to have music to listen to music you like?
-How important is it to you to be around animals such as pets?
-How important is it to you to do things with groups of people?
-How important is it to you to do your favorite activity?
-How important is it to you to go outside to get fresh air when the weather is good?
-How important is it to you to participate in religious services or practices?
Resident #370's response to all questions was very important.
-How important is it to you to keep up with the news? Resident #370's response was somewhat important.
Review of Section V of the MDS indicated Activities triggered and to see Social Service care plans.
Review of the Social Service care plans failed to indicate any goals, preferences, or personalized intervention for activity involvement for Resident #370. One intervention dated 3/31/23, indicated review routines, and activity calendars with the resident or resident representative.
Review of Resident #370's medical record indicated the following:
-An Activities admission Assessment, in progress and all areas left blank.
-A second Activities Assessment, dated 4/5/23, was in progress and was blank.
Review of Resident #370's care plans failed to indicate a care plan for activities was developed.
On 4/30/23, at 8:06 A.M., 8:20 A.M., and 10:20 A.M., the surveyor observed Resident #370 resting in his/her bed and displayed intermittent crying out.
On 5/1/23, at 9:03 A.M., the surveyor observed Resident # 370 resting on his/her bed. His/her bedside chair had a plush animal and a [NAME] Steele book.
During an interview on 5/2/23, at 10:10 A.M., Activity Assistant #1 said he did provide a word search and a pencil for Resident #370 but did not have any further contact for activities.
During an interview on 5/2/23, at 12:11 P.M., the Social Worker said that when Resident #370 was admitted he/she was alert and oriented and wanted magazines to read.
On 5/3/23, at 8:07 A.M. Resident #370 greeted the surveyor. Resident #370 said he/she like magazines and said when he/she was younger he/she liked playing games with his/her brother. Resident #370 said he/she did not have any magazines here. He/she had one book and a plush animal.
On 5/3/23, at 9:07 A.M., the surveyor observed Resident #370 resting on his/her bed. The television was airing cartoons
On 5/3/23, at 12:30 P.M., the surveyor Resident # 370 lying on his/her bed crying out. Nurse #2 said he/she is crying for water and food, and she told Resident #370 that lunch will be coming soon.
During an interview on 5/2/23, at 4:08 P.M., the Administrator in Training (AIT) provided the Activity Assessments for Resident #23, #67 and #370 completed, but not locked. The AIT said they have not had full staff for activities. The AIT said nails, painting and music has been provided to the first-floor unit and she could not comment on the activity policy.
See F835.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Unnecessary Medications
(Tag F0759)
Could have caused harm · This affected multiple residents
Based on observation, record review and interview, the facility failed to ensure it was free from a medication error rate of greater than 5% when 3 out of 3 nurses observed made 7 errors out of 28 opp...
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Based on observation, record review and interview, the facility failed to ensure it was free from a medication error rate of greater than 5% when 3 out of 3 nurses observed made 7 errors out of 28 opportunities resulting in a medication error rate of 25%. Those errors impacted 4 Residents (#15, #30, #57, and #272) out of 5 residents observed.
Findings include:
Review of the facility policy titled, Administering Medications, undated, indicated:
- medications must be administered in accordance with the orders, including any required time frame.
- the individual administering the medication must check the label three times to verify the right resident, right medication, right dosage, right time and right method (route) of administration before giving the medication.
1. For Resident #15, Nurse #2 crushed medications that were not crushable and failed to prime an insulin pen prior to use resulting in the incorrect dose of insulin being administered.
During the medication pass observation on the 1st Floor on 5/1/23, at 8:20 A.M., Nurse #2 administered the following to Resident #15:
- Aspirin 81 milligrams (mg), 1 enteric coated tablet (review of manufactures guidelines indicated not to crush).
- Isosorbide Mononitrate ER Tablet (Extended Release) 24 Hour 30 MG, 1 tablet (review of manufactures' guidelines indicated not to crush).
- Levetiracetam Tablet 250 mg Give 1 tablet (review of manufactures' guidelines indicated not to crush).
- Humalog Solution 100 UNIT/ML (Insulin Lispro) subcutaneously, 2 units (nurse did prime insulin pen therefor unable to ensure dose accuracy)
Review of the physician's order dated:
- 11/6/22: Levetiracetam Tablet 250 MG, Give 1 tablet by mouth two times a day for convulsions.
- 11/6/22: Isosorbide Mononitrate ER Tablet Extended Release 24 Hour 30 MG, Give 1 tablet by mouth one time a day for hypertension.
- 2/27/23: Aspirin Adult Oral Tablet (Aspirin), Give 81 mg by mouth one time a day for pain.
- 11/6/22: Humalog Solution 100 UNIT/ML (Insulin Lispro) Inject subcutaneously before meals and at bedtime for diabetes.
During an interview on 5/1/23, at 8:25 A.M., Nurse #2 said that she was not aware of which medications should not be crushed. Nurse #2 said that she was not sure how much insulin was administered.
2. For Resident #30, Nurse #3 failed to administer the correct form a aspirin.
During an medication observation on the 2nd Floor on 5/1/23, at 9:37 A.M., Nurse #3 administered the following medications:
- aspirin 81 milligrams safety coated, 1 tablet
Review of the physician's order dated 4/18/23, indicated:
- Aspirin 81 Oral Tablet Chewable (Aspirin) Give 1 tablet by mouth in the morning for cardio protector [sic]
During an interview on 5/1/23, at 9:45 A.M., Nurse #3 said he was not aware that he administered Resident #30 the incorrect form of aspirin.
3. For Resident #57, Nurse #3 failed to administer medications at the correct time and failed to apply a medicated patch to the correct location.
During an medication observation on the 2nd Floor on 5/1/23, at 9:24 A.M., Nurse #3 administered the following medications:
- Lidocaine 4% patch, one patch was applied to the left shoulder.
- Methadone 5 mg, one tablet by mouth (1 hour and 24 minutes after the scheduled time)
Review of the physician's order, dated 2/17/23, indicated:
- Lidocaine External Patch 4 % (Lidocaine) Apply to lower back topically one time a day for back pain.
Review of the physician's order, dated 3/9/23, indicated:
- Methadone HCl Oral Tablet 5 MG (Methadone HCl)- Give 1 tablet by mouth every 12 hours related to low back pain (scheduled at 8:00 A.M. and 8:00 P.M.)
During an interview on 5/1/23, at 9:35 A.M., Nurse #3 said he was late on administering Resident #57's medications and said he has a 1 hour window. Nurse #3 said he should have applied the Lidocaine patch to Resident #57's back as ordered.
4. For Resident #272, Nurse #1 administered the incorrect dose of vitamin C, incorrect dose of calcium and incorrect dose of vitamin D.
During an observation on the 3rd Floor on 5/1/23, at 7:57 A.M., Nurse #1 prepared medications for Resident #272.
- vitamin C 250 milligrams (mg), 1 tablet
- calcium with vitamin D 600 mg/ 5 micrograms, 1 tablet
Review of the physician's order dated, 4/4/23, indicated:
- Ascorbic Acid Oral Tablet 250 MG (Vitamin C), Give 0.5 tablet by mouth in the morning for Vitamin C deficiency
- Calcium Carbonate-Vitamin D Oral Tablet 500-5 MG-MCG (Calcium Carbonate-Vitamin D), Give 1 tablet by mouth one time a day for Vitamin D deficiency
During an interview on 5/1/23, at 8:16 A.M., Nurse #1 said she administered the incorrect dose of vitamin C and calcium and vitamin D.
During an interview on 5/2/23, at 4:00 P.M., the Director of Nursing said that Nurse #2, Nurse #3 and Nurse #1 should have followed the medication administration policy.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0804
(Tag F0804)
Could have caused harm · This affected multiple residents
Based on observation, interview, and test trays, the facility failed to ensure food was served at safe and appetizing temperatures.
Findings include:
During the initial screening process on 4/30/23, ...
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Based on observation, interview, and test trays, the facility failed to ensure food was served at safe and appetizing temperatures.
Findings include:
During the initial screening process on 4/30/23, at approximately 8:00 A.M., multiple residents interviewed on the 3rd floor unit complained of poor food quality.
On 5/3/23 at 8:17 A.M., the third-floor food truck arrived at the resident care unit. After all resident trays were served the surveyor received the test tray at 8:38 A.M., the following was recorded:
-Scrambled eggs, 100 degrees Fahrenheit, tasted warm but not hot
-Breakfast Pastry, 90 degrees Fahrenheit, palatable
-Hot cereal, 120 degrees Fahrenheit, watery and without flavor
-Orange Juice, 60 degrees Fahrenheit, slightly cool, not cold
-Milk, 58 degrees Fahrenheit, slightly cool, not cold
On 5/3/23 at 8:27 A.M., the first-floor food truck arrived at the resident care unit. After all resident trays were served the surveyor received the test tray at 8:48 A.M., and the following was recorded:
-Scrambled eggs registered at 90 degrees Fahrenheit, were warm to taste and had a buttery flavor.
-Hot Cereal registered 120 degrees Fahrenheit, had water separated on top, and were hot, bland and watery to taste.
-Buttered toast, only one side visibly toasted, warm to taste.
-Orange juice, registered 63 degrees Fahrenheit, tart, cool, not cold to taste.
-Milk, registered 60 degrees Fahrenheit, cool not cold to taste.
Coffee/tea were not on the tray.
On 5/3/23 at 12:44 P.M., the third-floor food truck arrived at the resident care unit. After all resident trays were served the surveyor received the test tray at 1:05 P.M., the following was recorded:
-Rice, 128 degrees Fahrenheit, tasted warm, not hot, and without flavor
-Taco, 98 degrees Fahrenheit tasted room temperature, not hot
-Beans, 118 degrees Fahrenheit tasted warm not hot
-Milk - 65 degrees Fahrenheit, tasted room temperature, not cold
On 5/03/23 at 12:56 P.M., the food truck arrived at the first-floor resident care unit. After all trays were served to residents the surveyor received the test tray at 1:12 P.M., and the following was recorded:
-Beef taco meat, registered at 110 degrees Fahrenheit, was warm and salty to taste.
-Mexican rice, registered at 120 degrees Fahrenheit, was warm/hot and had dull/bland flavor.
-Mashed potato, registered 110 degrees Fahrenheit, warm and pasty to taste.
-Soft taco shell, unable to take temperature, soft, dry, grainy texture to taste.
-Milk, 62 registered at 62 degrees Fahrenheit, cool not cold to taste.
-one plastic wrapped soft cookie. Not tasted.
-Coffee, black, registered 150 degrees Fahrenheit, hot and tasted like coffee.
The tray lacked condiments that could enhance the meal experience, such as sour cream and salsa.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Food Safety
(Tag F0812)
Could have caused harm · This affected multiple residents
Based on observations and interview the facility failed to maintain proper sanitation practices related to food storage, food labeling, and food handling.
Findings include:
Review of the undated faci...
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Based on observations and interview the facility failed to maintain proper sanitation practices related to food storage, food labeling, and food handling.
Findings include:
Review of the undated facility policy, titled Preventing Food borne Illness - Food Handling, indicated the following:
*Food will be stored, prepared, handled and served so that the risk of food borne illness is minimized.
During the initial kitchen walk through on 4/30/23, at 7:09 A.M., the following produce was observed with significant visible signs of decomposition:
*Tomatoes
*Celery
*Potatoes
*Cabbages
During an observation on 4/30/23, at approximately 7:45 A.M., the following was observed:
*4 unlabeled and undated sandwiches in the refrigerator on the 1st floor kitchenette.
*An unlabeled and undated container of food in the refrigerator of the 2nd floor kitchenette.
During a tray line observation on 4/30/23, at 12:27 P.M., the surveyor observed the cook contaminating his gloves by touching the handles of serving utensils, a knife, and the microwave door. The cook then used the same contaminated gloves to grab a ready-to-eat grilled cheese sandwich, and prepare a chicken salad sandwich, both of which he placed directly on to residents plates.
During a tray line observation on 5/3/23, at 7:49 A.M., the surveyor observed the cook contaminating his gloves by touching utensil handles, bottoms of plates, and plate lids. The cook then used the same contaminated gloves to grab ready-to-eat breakfast pastries and toast which he placed directly on to 8 out of 10 observed resident plates.
During an interview on 5/3/23, at 7:55 A.M. the Food Service Director acknowledged the cooks improper food handling practices.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Medical Records
(Tag F0842)
Could have caused harm · This affected multiple residents
Based on interview and observations the facility A) failed to maintain complete medical records for 1 Resident (#3) and B) failed to maintain accurate medical records for 4 Residents (#3, #26, #23 and...
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Based on interview and observations the facility A) failed to maintain complete medical records for 1 Resident (#3) and B) failed to maintain accurate medical records for 4 Residents (#3, #26, #23 and #40) out of a total sample of 34 residents.
Findings include:
1) For Resident #3 the facility failed to A) maintain complete and B) maintain accurate medical records.
Resident #3 was admitted to the facility in September 2019 with diagnoses including psychosis.
A) Review of the Minimum Data Set (MDS) quarterly assessment, dated 4/11/23, indicated that Resident #3 scored a 13 out of 15 on the Brief Interview for Mental Status (BIMS), which indicates the Resident is cognitively intact.
Review of a Pharmacy Consultant Note, dated 4/7/23, indicated the following:
*Note Text: Medication Regimen Reviewed. Recommendations Made to Prescriber: See Medication Regimen Review Report.
Review of Resident #3's medical record failed to contain the pharmacy recommendation made on 4/7/23.
During an interview on 5/2/23, at 1:28 P.M., the Assistant Director of Nursing said she was not able to locate the pharmacy recommendation made by the pharmacy consultant on 4/7/23.
B) Review of the Dental Evaluation, dated 4/12/23, indicated Resident #3 has dentures.
Review of the Nursing Oral evaluation, dated 4/18/23, indicated the Resident does not have dentures.
During an interview on 5/2/23, at 1:24 P.M., Nurse #1 said she evaluated Resident #3 today and the Resident has partial dentures. Nurse #1 also said the nursing oral evaluation, dated 4/18/23, was not accurate as it should have indicated the Resident has dentures.
2. Resident #26 was admitted to the facility in June 2015 with diagnoses including Dementia.
Review of the Minimum Data Set (MDS) quarterly assessment, dated 3/28/23, indicated that Resident #26 was unable to complete a Brief Interview for Mental Status (BIMS) as the Resident is rarely/never understood.
Review of the physician Wound Evaluation & Management Summary, dated 9/26/22, indicated a recommendation to add a Gauze Island with boarder dressing.
Review of the physician Wound Evaluation & Management Summary, dated 5/1/23, indicated the recommendation to continue applying a Gauze Island with boarder dressing.
Review of Resident #26's physician orders indicated the following order, initiated 1/10/23:
Normal Saline wash to coccyx wound, pat dry, apply Alginate Calcium w/silver daily
During an interview on 5/2/23, at 1:30 P.M., the Assistant Director of Nursing said the wound dressing order is not complete as it does not include a boarder dressing.
3. Resident #40 was admitted to the facility in October 2018 with diagnoses including paranoid schizophrenia, major depressive disorder and diabetes.
Review of the doctor's orders indicated an order dated 12/17/20, for Clozapine give 150 milligrams (mg) by mouth one time a day at 8:00 A.M Further review indicated an order dated 12/11/20, for Clozapine give 200 milligrams (mg) by mouth at bedtime.
Review of the Medication Administration Record (MAR) dated January 2023 indicated that Clozapine, give 150 milligrams (mg) by mouth one time a day 0800 was held on 1/23/23, 1/24/23 and 1/25/23. Further review indicated that Clozapine, give 200 milligrams (mg) by mouth at bedtime was held on 1/21/23, 1/22/23, 1/23/23 and 1/24/23. Further review indicated that on 1/25/23 at 8 P.M. and 1/26/23 at 8:00 A.M. and 8:00 P.M. the medication was administered as ordered however, the medication had not been delivered to the facility, by the pharmacy, until 1/28/23.
During an interview on 5/01/23, at 8:25 A.M., the Director of Nursing said that if the medication wasn't here then it couldn't have been given.
3. For Resident #23 the facility failed to accurately document Resident #23's skin assessment and progress notes related to his/her skin status.
Resident #23 was admitted to the facility in February 2023 with diagnoses including sepsis, unsteadiness on feet, asthma, type 2 diabetes mellitus, unspecified dementia, and schizophrenia.
Review of the Minimum Data Set Assessment (MDS) with an Assessment Reference Date (ARD) of 2/28/23, indicated Resident #23 had a primary language of Spanish, scored 7 out of 15 on the Brief Interview of Mental Status Exam (BIMS) indicating severe cognitive impairment and required extensive assistance from staff for bed mobility, dressing, hygiene and was dependent on staff for bathing. Further, the MDS did not indicate Resident #23 displayed behaviors and did not indicate under section M skin, that Resident #23 had any open skin areas, that were not pressure areas.
The surveyor made the following observations:
-On 4/30/23, at 8:23 A.M., Resident #23 was observed with multiple reddened, circular scabbed areas on both his/her upper right and left arms.
-On 5/1/23, at 12:42 P.M., Resident #23 was in his/her room all morning. Resident #23 was picking at his/her skin on his/her leg. His/her right leg had an area of blood coming from a scabbed area. Both his/her arms and extended towards his/her shoulder area was observed with multiple, red, pencil eraser size spots and scabs.
Review of Resident #23's medical record indicted the following:
-Nursing: Skin check, dated 2/25/23, describe and document any skin issues: right shoulder (front) description left blank, further down indicated generalized scabs.
-Nursing skin check, dated 3/21/23, skin condition, dry fragile, irritation/redness.
-Nursing skin check, dated 3/28/23, skin condition: intact.
-Nursing skin check, dated 4/4/23, skin condition: intact.
-Nursing skin check, dated 4/11/23, skin condition: intact
-Nursing skin check, dated 4/18/23, skin condition: intact.
-Nursing skin check, dated 4/26/23, skin condition: intact.
-A Nurse Practitioner/Doctor progress note with an encounter date 4/24/23, indicted Pruritus unspecified (a medical term for itchy skin), continue with Benadryl as indicted. Further, the note indicated under physical exam Skin: no rash, warm and dry.
-A Nurse Practitioner/Doctor progress note with an encounter date 4/20/23 indicated under physical exam: skin: no rash, warm and dry.
Further review of the NP/Doctor progress notes with encounter dates 4/18/23, 4/13/23, 4/10/23, 4/7/23, 4/5/23, 4/3/23, 3/29/23, 3/13/23, 3/6/23, 3/6/23, 3/3/23, 3/1/23, and 2/28/23 all indicated Resident #23's skin: No rash, warm and dry.
During an interview on 5/02/23, at 8:55 A.M., Nurse #2 reviewed the weekly Nursing skin checks and said they do not accurately reflect Resident #23's actual scabbing and skin areas that Resident #23 had since admission.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Safe Environment
(Tag F0584)
Could have caused harm · This affected most or all residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, the facility failed to ensure the building had a home-like environment on 3 of 3 nursing units evidenced b...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, the facility failed to ensure the building had a home-like environment on 3 of 3 nursing units evidenced by, gouged walls, various stains on the ceilings and walls, broken tiles, rusted toilet paper holders, and rusty detached baseboard covers on 3 of 3 nursing units.
Findings include:
During an environmental rounds on 5/2/23, and 5/3/23, the surveyor observed the following:
room [ROOM NUMBER]- gouges on the wall behind bed A and B.
room [ROOM NUMBER]- gouges on the wall behind bed A and B. The baseboard heating cover was detached and protruding out.
room [ROOM NUMBER]- gouges on the wall behind bed A and B.
room [ROOM NUMBER]- gouges on the wall behind bed A and B. room [ROOM NUMBER]'s shared bathroom had missing tiles on the wall and floor.
room [ROOM NUMBER]- gouges on the wall behind bed A and B.
room [ROOM NUMBER]- the shared bathroom with a rusted paper towel holder.
room [ROOM NUMBER]- the shared bathroom with rusted paper towel holders. The bathroom doors were scuffed with white marks.
room [ROOM NUMBER]- gouges on the wall behind bed A and B.
room [ROOM NUMBER]- gouges on the wall behind bed A and B. The baseboard heating cover was rusted, detached and protruding out.
room [ROOM NUMBER]- gouges on the wall behind bed A and B. room [ROOM NUMBER]'s toilet seat and cover was broken.
room [ROOM NUMBER]- The shared bathroom with a rusted toilet paper holder.
The 3rd floor storage room across from room [ROOM NUMBER] with roughly 10 square feet of wallpaper with water stains.
The 3rd floor shower room with multiple broken and missing tiles (approximately 27 tiles) and a water damaged back board.
room [ROOM NUMBER]- multiple spots of dry white paint on the floor by the bathroom door. The baseboard heating cover is detached and protruding out.
The Window frames across from room [ROOM NUMBER] had gouges and the surrounding wall paper was peeling away from the wall.
room [ROOM NUMBER]- scattered brown stains on the ceiling. room [ROOM NUMBER]'s bathroom had large brown stains on the ceiling. The toilet paper holder was broken, there was a roll of toilet paper on top of the toilet tank cover.
room [ROOM NUMBER]- gouges on the wall behind bed B. The baseboard heating cover was detached and protruding out.
room [ROOM NUMBER]- gouges on the wall behind bed B. The baseboard heating cover is detached and protruding out. room [ROOM NUMBER]'s shared bathroom had a rusted toilet paper holder and the bathroom doors were scuffed with white marks.
room [ROOM NUMBER]- gouges on the wall behind bed A and B. room [ROOM NUMBER]'s shared bathroom had a rusted toilet paper holder.
room [ROOM NUMBER]- gouges on the wall behind bed A and B. room [ROOM NUMBER]'s shared bathroom did not have a toilet paper holder. There was a roll of toilet paper that was partially wet placed on the sink.
room [ROOM NUMBER]- gouges on the wall behind bed A and B.
room [ROOM NUMBER]- gouges on the wall behind bed A and B. There were brown stains/patches on the ceiling above bed B.
room [ROOM NUMBER]- Bed B had dry, crusted yellow stains all over the oxygen concentrator and the IV poll stand. There were dry/crusted stains on the wall by the window next to bed B.
room [ROOM NUMBER] - The shared bathroom did not have a toilet paper holder. There was a roll of toilet paper on top of the toilet tank cover.
room [ROOM NUMBER]- gouges on the wall behind bed A and B. There were large brown stains in the ceiling above bed A and a hole in the wall in front of the bathroom door. room [ROOM NUMBER]'s shared bathroom had a rusted toilet paper holder. The bathroom doors were scuffed with white marks.
room [ROOM NUMBER]- gouges on the wall behind bed A and B.
room [ROOM NUMBER]- unfinished patches of primer paints on the wall and large brown stains on the ceiling above bed B.
room [ROOM NUMBER]- gouges on the wall behind bed A and B. The room had an unfinished paint job, with 3 different paint colors (green, bright green, and yellow).
The 2nd floor eye wash station area had wallpaper peeling off the wall.
The 2nd floor whirlpool room had floor tiles that were patched with a [NAME] board and sealed with tape.
The Whirlpool tub surface had yellow particles, dry matted hair and was visibly dusty.
room [ROOM NUMBER]- the window blinds were broken. The door frame was scuffed with white marks. The bathroom had rusted toilet paper holder.
room [ROOM NUMBER]- the door frame was scuffed with white marks.
room [ROOM NUMBER]- the door and door frame were scuffed with white marks. room [ROOM NUMBER]'s bathroom door was scuffed with white marks.
room [ROOM NUMBER]- the door frame was scuffed with white marks.
room [ROOM NUMBER]- the door frame was scuffed with white marks. room [ROOM NUMBER]'s bathroom door was scuffed with white marks.
room [ROOM NUMBER]- the baseboard heating cover was detached and protruding out. room [ROOM NUMBER]'s bathroom had a large brown stain on the ceiling. The toilet paper holder was broken, and there was a roll of toilet paper on top of the toilet tank cover.
room [ROOM NUMBER]- the bathroom had a large stain on the ceiling. The toilet paper holder was broken and there was a roll of toilet paper on top of the toilet tank cover.
room [ROOM NUMBER]- there were brown stains on the ceiling. The baseboard heating cover was detached and protruded out.
The 1st floor family room the baseboard heating cover was rusted. The walls had not been fully painted with multiple prime paint spots on the wall.
The 1st floor hallway had multiple ceiling hatch doors (in front of room [ROOM NUMBER] and #114) that were not closed tight and rusted on edges.
In the 1st floor shower room, the surveyor observed the following:
-large water stains on the ceiling with paint and plaster failing and presenting as a falling object hazard.
-a wheelchair scale with large debris and a Hoyer lift on top of the scale.
-a folded wheelchair covered with debris and spots of dry paint on the handle and the wheel next to the wheelchair scale.
-floor tiles with large, scattered debris
-a whirlpool tub that stored laundry baskets, and 5 large hoses.
-below the whirlpool tub multiple missing tiles approximately 3 square feet exposing dark, moist board with a black fuzzy substance consistent with mold growth.
-in the corner of the room was a broom and dirty used blue disposable gloves, and matted hair with damp flooring.
During an interview on 5/3/23 at 10: 15 A.M., the Maintenance Director acknowledged the surveyor's findings during the environmental rounds. He said that the facility had a painter but they left in November 2022. He told the surveyor that he had patched and painted some of the gouges in some of the rooms. The surveyor requested a work tracking log to check which rooms and resident care areas were done but he was unable to provide any tracking or documentation.
See F835.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Comprehensive Assessments
(Tag F0636)
Could have caused harm · This affected most or all residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to complete Comprehensive (Annual and Admission) Minimum Data Set (MDS)...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to complete Comprehensive (Annual and Admission) Minimum Data Set (MDS) Assessments in a timely manner for 2 Residents (#59 and #33) and failed to complete a discharge MDS in a timely manner for 1 Resident (#59) out of a total sample of 34 residents.
Findings include:
Review of the Resident Assessment Instrument (RAI) Manual 3.0 indicated the following:
1. An admission Data Set (MDS) assessment must be completed no later than the 14th day from admission and must be transmitted to the Centers for Medicare and Medicaid (CMS) no later than 35 days from the Assessment Reference Date (ARD).
2. The Annual and Quarterly MDS must be completed no later than 14 days from the ARD.
3. A discharge MDS must be completed no later than 14 days after discharge and transmitted to CMS no later than 14 days of completion of the MDS.
1. For Resident #59 review of the MDS's indicated the admission MDS had an ARD of 12/27/22, and was transmitted to CMS on 3/6/23, 80 days after the ARD. Further review indicated a discharge MDS dated [DATE], was completed 4/11/23, 20 days late.
2. For Resident #33 review of the MDS's indicated an Annual comprehensive assessment with an ARD of 10/4/22, was completed on 1/11/23, 84 days late.
During an interview on 5/01/23, at 3:45 P.M., the MDS Coordinator said that the problem was insufficient staffing to get all of the MDS's done timely. She then said that she simply didn't have any help.
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 record review and interview, the facility failed to complete annual Certified Nurse Aide (CNA) performance reviews for 5 of 5 sampled CNAs.
Findings include:
Review of the facility policy ti...
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Based on record review and interview, the facility failed to complete annual Certified Nurse Aide (CNA) performance reviews for 5 of 5 sampled CNAs.
Findings include:
Review of the facility policy titled Performance Assessments and dated as last reviewed 12/2020, indicated that the Executive Director and the Director of Nursing Services and location leaders with direct reports in a job that requires annual skills evaluation, are responsible to ensure a Performance assessment related to skills is completed annually.
Review of the facility document titled Evaluation Form failed to indicate that the CNA's individual skills required to perform their jobs were evaluated to ensure that nurse aides are able to demonstrate competency in skills and techniques necessary to care for residents' needs, as identified through resident assessments, and described in the plan of care
During review of 5 CNA employee records, the Surveyor was unable to locate annual performance reviews for all 5 CNAs.
During an interview on 5/01/23, at 3:16 P.M., the DON said that a skills performance review is not completed yearly on Certified Nurse's Aides with education that is directed towards their weaknesses.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0761
(Tag F0761)
Could have caused harm · This affected most or all residents
Based on observations, policy review and interviews the facility failed to ensure medication carts were clean, had medications that were stored according to manufacturer's guidelines (refrigerated), a...
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Based on observations, policy review and interviews the facility failed to ensure medication carts were clean, had medications that were stored according to manufacturer's guidelines (refrigerated), and that medications once opened were dated according to manufacturer's guidelines on 3 out of 3 sampled medication carts.
Findings include:
Review of the facility policy titled, Storage of Medications, undated, indicated the facility shall store all drugs and biological's in a safe, secure, and orderly manner.
- drugs and biological's shall be stored in the packaging, containers or the dispensing systems in which they are received.
- nursing staff are responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner.
- the facility shall not use discontinued, outdated, or deteriorated drugs or biological's.
- medications requiring refrigeration must be stored in the refrigerator.
Review of the facility policy titled, Administering Medications, undated, indicated:
- the expiration/beyond use date on the medication label must be checked prior to administering. When opening a multi-dose container, the date open shall be recorded on the container.
1. During the Morning hours on 5/1/23, between 6:50 A.M., and 7:15 A.M., surveyors made observations of Nurse #3 preparing medications and then placing these medications in the 2nd floor medication cart top drawer.
2. On 5/1/23 at 7:24 A.M., The surveyor observed the following in the 2nd floor medication cart:
- two cups of prepared medications that Nurse #3 identified as medications for two residents whom he prepared medications for but had not yet administered.
- multiple loose medications and debris from medication cards scattered through the drawers.
- one bottle of liquid protein, opened and undated (good for 3 months once opened)
- one Breo Ellipta inhaler, opened and undated (good for 6 weeks once opened)
- one Humalog insulin pen, opened 3/30/23, no expiration date. (good for 28 days once open)
- one Humalog insulin pen, dated opened 4/ unknown the label had been smudged off and not legible (good 28 days once open)
- one bottle of Lantus insulin, opened and undated
- one bottle of Novolog insulin, opened and undated
- one bottle of Xalatan eye drops, opened and undated
During an interview on 5/1/23, at 7:30 A.M., Nurse #2 said nursing is responsible to clean the medication carts. Nurse #2 said the items should be dated once opened.
3. On 5/1/23 at 7:34 A.M., Nurse #3 and surveyor made the following observations in the 1st floor medication cart:
- one Anoro Ellipta inhaler, opened and undated (good for 6 weeks once opened)
- one bottle of Novolog insulin, not open (marked refrigerate until open)
- one bottle Novolog insulin, open undated
- one carton of fortified nutritional shake, opened undated, warm to touch in a drawer (refrigerate prior to opening, after open, consume product within 4 days if properly refrigerated, after open consume product within 4 hours if not refrigerated)
- dentures in a plastic bag, unlabeled for whom the dentures belonged to, next to a bottle of milk of magnesia, one bottle of Miralax, and one bottle of ibuprofen.
During an interview on 5/1/23, at 7:40 A.M., Nurse #3 said that medications should be dated once opened, the Novolog insulin should be stored in the refrigerator, and the dentures should not be stored with medications.
3. On 5/1/23, at 7:41 A.M., the surveyor went to conduct the medication administration task with Nurse #1. Nurse #1 opened the medication cart and the surveyor observed a medication cup with 3 white pills in the cup. Nurse #3 said she did not know what these medications were and Nurse #3 said that they should not have been there. The surveyor then initiated the medication storage task on the 3rd floor medication cart.
The surveyor made the following observations:
- one Novolog insulin pen with two dates opened on it. One label dated 4/2/23 and another label dated 4/12/22.
- one Novolog insulin pen, opened and undated
- one bottle of Lantus insulin, dated with two dates 3/17 and 4/17.
- two Serevent diskus inhalers, opened and undated (good for 6 weeks once opened)
- two Fluticasone and Salmeterol inhaler, opened and undated
During an interview on 5/1/23, at 7:49 A.M., Nurse #3 said that insulin pens and inhalers should be dated once opened.
During an interview on 5/2/23, at 4:55 P.M., the Director of Nursing said that nursing should follow the policy for medication storage.
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 observations and interviews, the facility failed to ensure it was administered in a manner that enables it to use resources effectively to attain the highest practicable physical, mental, and...
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Based on observations and interviews, the facility failed to ensure it was administered in a manner that enables it to use resources effectively to attain the highest practicable physical, mental, and psychosocial well-being of each resident.
Findings include:
During the recertification survey conducted on 4/30/23, through 5/3/23, the survey team observed concerns with a lack of activities programming for all residents, an unclean and non-homelike environment in resident rooms and bathing areas and a lack of sufficient staffing.
On 4/30/23, the survey team identified a lack of activities program for all residents living in the facility.
On 4/30/23, the surveyors identified the building did not have a home-like environment on 3 of 3 nursing units evidenced by, gouged walls, various stains on the ceilings and walls, broken tiles, rusted toilet paper holders, and rusty detached baseboard covers on 3 or 3 nursing units.
During an interview with 2 surveyors, on 5/01/23, at 4:31 P.M., the Director of nursing, when asked if a Certified Nurse's Aide could adequately care for 16 residents on the 7:00 A.M.-3:00 P.M. shift, with the current acuity level, getting the residents up, bathed, dressed, give 4 showers, change briefs of incontinent residents and reposition residents every 2 hours and serve 2 meals, nodded his head side to side and said no.
During an interview on 5/3 /23, at 3:12 P.M. the Administrator said that he was aware of the condition of the building and thought the maintenance department was working on it. The Administrator then said that he does not do rounds to check to see what building improvements have been completed. The Administrator also said that the activities director position has been open for more than a year and activities for the residents have been directly impacted by the lack of an activity director.
Despite having the knowledge of the aforementioned concerns, the facility's administrative team and governing body did not provide the services necessary to provide for the needs of residents.
See F925
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0865
(Tag F0865)
Could have caused harm · This affected most or all residents
Based on record review and interview the facility failed to ensure they implemented and maintained an effective, comprehensive and data driven Quality Assurance and Performance Improvement (QAPI) prog...
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Based on record review and interview the facility failed to ensure they implemented and maintained an effective, comprehensive and data driven Quality Assurance and Performance Improvement (QAPI) program. The facility also failed to make a good faith effort to establish a quality assurance and improvement plan to maintain the quality of life and well-being for residents by failing to offer meaningful, person-centered activities and failing to maintain the building in a homelike manner.
Findings include:
Review of the facility policy titled Quality Assurance and Performance Improvement (QAPI) Program and dated as revised February 2020, indicated that the facility shall develop, implement and maintain an ongoing, facility wide, data driven QAPI program that is focused on indicators of the outcomes of care and quality of life for our residents. Further review indicated that the QAPI plan includes tracking and measuring performance, establishing goals and thresholds for performance measurement, identifying and prioritizing quality deficiencies, systematically analyzing underlying causes of systemic quality deficiencies, developing and implementing corrective action or performance improvement activities and monitoring and evaluating the effectiveness of corrective action/performance improvement activities and revising as needed.
During an interview on 5/03/23, at 3:12 P.M. with the Administrator and the the Administrator In Training (AIT), the Administrator said that the biggest focus has been staffing. He said that the facility is struggling with staffing challenges, we use agency. The Administrator acknowledged that the building was in disrepair. The Administrator was unable to discuss key components of their program such as tracking, and measurement of their performance improvement projects as well as how the facility systematically analyzed underlying causes of systemic quality deficiencies or corrective actions. The Administrator said that projects were ongoing but could not provide the surveyor with analysis of the attempts at improvement objectives. The Administrator also said that in regard to nursing compliance for medication administration with late administration, we have talked about it. When asked if there was a QAPI in place the Administrator said no because it was all related to staffing. The Administrator and the Administrator in Training also said a project he has been working on was hiring an Activity Director. He said it has been an open position for over a year. He said he recently hired a third activity assistant. He said it has been a challenge to meet all the activity needs for the residents. The Administrator said he did not establish a plan he could share for the activity department but communicated to staff to assist when they could. The Administrator acknowledged that with the staffing challenges it would be difficult for staff to engage residents in activities.
Review of the QAPI plan failed to indicate a plan for attaining in-house staff other than listing agency use as a problem. Further review indicated an ongoing performance improvement plan for maintaining painting of the building but without analysis of the effectiveness of the plan. No other QAPI for the repair of the walls, floors, tiles, ceiling etcetera was included in the QAPI minutes.
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 observation, review of the Quality Assurance Performance Improvement (QAPI) plan, and interview, the facility failed to ensure that the Quality Assurance Committee met quarterly, identified q...
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Based on observation, review of the Quality Assurance Performance Improvement (QAPI) plan, and interview, the facility failed to ensure that the Quality Assurance Committee met quarterly, identified quality deficient areas to develop and implement an appropriate corrective action plans, to ensure satisfactory outcomes.
Findings Include:
Review of the sign-in sheets for the quarterly QAPI meetings indicated 2 sign-in sheets for the quarterly QAPI meeting held on 1/19/23. The sign-in sheets had signatures of some of the same people but in different ink. One of the sheets indicated the signature of the Medical Director while the other sheet indicated that he attended by phone. Further review failed to indicate a scheduled quarterly QAPI review had taken place.
During an interview on 5/03/23, at 3:12 P.M. with the Administrator and the the Administrator In Training (AIT), the AIT said that she was not able to locate the sign in sheet for the quarterly QAPI meeting in April 2023. The Administrator acknowledged the 2 sign-in sheets for 1/19/23, but could not account for why there were 2 sheets with conflicting signatures.
The Administrator then then said he did not establish a plan he could share for the activity department but communicated to staff to assist when they could. The Administrator acknowledged that with the staffing challenges it would be difficult for staff to engage residents in activities. The Administrator also said he regularly speaks with the residents, family members, and staff to identify improvements. However, he was unable to provide documentation to indicate the QAPI data was measurable and evaluated to determine and track the progress and outcome of each project.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0925
(Tag F0925)
Could have caused harm · This affected most or all residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interviews, the facility failed to implement effective pest control management by not following pest co...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interviews, the facility failed to implement effective pest control management by not following pest control recommendations as evidenced by mouse activities, droppings on multiple resident rooms, including the kitchen.
Findings include:
During an environmental tour on the 3rd floor on 5/2/23, at 7:50 A.M., the surveyor observed multiple mouse traps below the radiator base board in room [ROOM NUMBER]. Resident #33 told the surveyor that a pest control service installed those mouse traps after he/she reported mouse sightings. Resident #33 told the surveyor that he/she can still hear mouse activity such as walking/chewing at night every now and then. Resident #33 told the surveyor that all rooms have mouse traps.
The surveyor observed mouse traps in resident rooms, dining areas, and family rooms on all three nursing units on 5/3/23.
Review of the facility grievance logs indicated residents had reported mouse sightings on 3/28/23, and 4/10/23.
Review of the pest control reports and recommendations indicated the following:
The pest control report dated 1/3/23, indicated the technician recommended going through each room within the building and properly sealing up all gaps around the heating pipes: These access points create highways of travel for mice to freely roam around the building.
Review of a pest control report dated 2/7/23, indicated the main kitchen was inspected and one mouse was captured in the storage room area. The report also indicated shredded Styrofoam was found on the floor against the back wall of the kitchen: the back wall of the kitchen consists of Styrofoam, making it easy for the mice to chew their way through and have access to food supplies. The report indicated the technician recommended repairing holes with solid and permanent materials that will seal mice out:
The interior condition of the building indicates holes in the wall allowing pest entry. Holes around heating pipes throughout all resident rooms create easy access highways and allow rodent entry. The technician recommends repairing walls throughout resident rooms.
Review of the pest control report dated 3/3/23, indicated there were multiple mouse activities within the facility. The report indicated recommendations including:
- Clean out services.
-Any holes over the size of a quarter will be up to the facility maintenance to repair as steel wool (used to repel mice) will not hold tightly in place.
-Plugging the holes in walls that are too large for the steel wool around the heating units in the following rooms: room [ROOM NUMBER], #302, #306, #310, and #316.
Review of the pest control report dated 3/28/23, indicated: clean out services were provided, all rooms were accessed and multiple glue boards and one bait station were placed within each room. Placed traps within common areas such as linen closets, activity rooms and dining rooms.
During an interview with the Maintenance Director on 5/3/23, at 9:00 A.M., he told the surveyor that the facility started to have mouse issues a few months ago after a building that is not that far from the facility was torn down. He told the surveyor that pest control comes every month for services and that pest control technicians recommended plugging the holes in the walls an in the heating pipes in all resident rooms. He told the surveyor that he used the steel wool to plug the holes in the heating pipes as recommended. The surveyor requested a work tracking log to check which rooms were done but he was unable to provide any tracking or documentation. He told the surveyor that he already plugged all the holes in the walls and the heating pipes.
A rooms inspection was conducted with the Maintenance Director to checks for holes in the wall and heating pipes on 5/3/23, at 9:15 A.M., the following observations were made by the surveyor:
-room [ROOM NUMBER], heating pipe holes not plugged as recommended by pest control, mouse droppings were observed near the hole.
-room [ROOM NUMBER], heating pipe hole not plugged as recommended by pest control, mouse droppings were observed near the hole.
-room [ROOM NUMBER], heating pipe hole not plugged as recommended by pest control, mouse droppings were observed near the hole.
-room [ROOM NUMBER], heating pipe hole not plugged as recommended by pest control, mouse droppings were observed near the hole.
-room [ROOM NUMBER], heating pipe hole not plugged as recommended by pest control, mouse droppings were observed near the hole.
During an interview with the Maintenance Director on 5/3/23, at 9:50 A.M., he acknowledged that in the 5 resident rooms observed the heating pipe holes were not plugged and there were mouse droppings near the hole.
On 5/3/23, at 10:40 A.M. the following observations were made by the surveyor in the kitchen while accompanied by the maintenance director and regional director:
-shredded Styrofoam on the floor against the back wall. The surveyor observed the holes were not covered with solid materials as recommended.
During an interview with the Maintenance Director on 5/3/23, at 10:50 A.M., he acknowledged that the holes in the back of the kitchen are not covered with solid materials as recommended by the technician.
The facility failed to implement the pest control recommendations that would provide effective pest control management within the facility.
Feb 2023
1 deficiency
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Abuse Prevention Policies
(Tag F0607)
Could have caused harm · This affected 1 resident
Based on records reviewed and interviews for one of three sampled Employee Personnel Records (Certified Nurse Aide (CNA) #1), the Facility failed to ensure that the Facility or Staffing Agency they co...
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Based on records reviewed and interviews for one of three sampled Employee Personnel Records (Certified Nurse Aide (CNA) #1), the Facility failed to ensure that the Facility or Staffing Agency they contracted with conducted a Massachusetts Nurse Aide Registry (NAR) background check upon hire, in accordance with the Facility Policy and Facility's Staffing Agency Agreement.
Findings include:
Review of the Facility Policy titled, Abuse and Neglect, dated April 2017, indicated all prospective employees of this Facility submit to a background check and licensure verification as a part of the hiring process.
Review of the Facility's Staffing Agency Agreement with CNA #1's Staffing Agency, dated 12/19/22, indicated their duties and responsibilities included to screen their employees.
Review of CNA #1's Personnel File indicated she was hired on 07/20/22.
There was no documentation in CNA #1's Personnel File to indicate a Massachusetts NAR background check was completed upon hire.
During an interview on 02/01/23 at 1:15 P.M., the Director of Nurses and Assistant Administrator said the Facility was unable to provide any documentation to support that CNA #1 had a Massachusetts NAR background check completed upon hire by the Facility or by the Staffing Agency.
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
- • Licensed and certified facility. Meets minimum state requirements.
Concerns
- • Multiple safety concerns identified: 4 harm violation(s), $141,733 in fines. Review inspection reports carefully.
- • 59 deficiencies on record, including 4 serious (caused harm) violations. Ask about corrective actions taken.
- • $141,733 in fines. Extremely high, among the most fined facilities in Massachusetts. Major compliance failures.
- • Grade F (5/100). Below average facility with significant concerns.
Bottom line: Trust Score of 5/100 indicates significant concerns. Thoroughly evaluate alternatives.
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About This Facility
What is Twin Oaks Center's CMS Rating?
CMS assigns TWIN OAKS CENTER an overall rating of 1 out of 5 stars, which is considered much below average nationally. Within Massachusetts, 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 Twin Oaks Center Staffed?
CMS rates TWIN OAKS CENTER's staffing level at 1 out of 5 stars, which is much below average compared to other nursing homes.
What Have Inspectors Found at Twin Oaks Center?
State health inspectors documented 59 deficiencies at TWIN OAKS CENTER during 2023 to 2025. These included: 4 that caused actual resident harm and 55 with potential for harm. Deficiencies causing actual harm indicate documented cases where residents experienced negative health consequences.
Who Owns and Operates Twin Oaks Center?
TWIN OAKS CENTER is owned by a for-profit company. For-profit facilities operate as businesses with obligations to shareholders or private owners. The facility operates independently rather than as part of a larger chain. With 101 certified beds and approximately 71 residents (about 70% occupancy), it is a mid-sized facility located in DANVERS, Massachusetts.
How Does Twin Oaks Center Compare to Other Massachusetts Nursing Homes?
Compared to the 100 nursing homes in Massachusetts, TWIN OAKS CENTER's overall rating (1 stars) is below the state average of 2.9 and health inspection rating (1 stars) is much below the national benchmark.
What Should Families Ask When Visiting Twin Oaks Center?
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 Twin Oaks Center Safe?
Based on CMS inspection data, TWIN OAKS 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 Massachusetts. While no facility is perfect, families should still ask about staff-to-resident ratios and recent inspection results during their visit.
Do Nurses at Twin Oaks Center Stick Around?
TWIN OAKS CENTER has not reported staff turnover data to CMS. Staff turnover matters because consistent caregivers learn residents' individual needs, medications, and preferences. When staff frequently change, this institutional knowledge is lost. Families should ask the facility directly about their staff retention rates and average employee tenure.
Was Twin Oaks Center Ever Fined?
TWIN OAKS CENTER has been fined $141,733 across 2 penalty actions. This is 4.1x the Massachusetts average of $34,496. Fines at this level are uncommon and typically indicate a pattern of serious deficiencies, repeated violations, or failure to correct problems promptly. CMS reserves penalties of this magnitude for facilities that pose significant, documented risk to resident health or safety. Families should request specific documentation of what issues led to these fines and what systemic changes have been implemented.
Is Twin Oaks Center on Any Federal Watch List?
TWIN OAKS 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.