How many inspection deficiencies does REGALCARE AT HOLYOKE have?

REGALCARE AT HOLYOKE has 46 deficiencies from recent inspections. None are at the Immediate Jeopardy level.

What are the staffing levels at REGALCARE AT HOLYOKE?

REGALCARE AT HOLYOKE has a two-star staffing rating from CMS with 0.30 RN hours per resident per day. This rating is based on registered nurse (RN), licensed practical nurse (LPN), and nurse aide staffing hours.

Where is REGALCARE AT HOLYOKE located?

REGALCARE AT HOLYOKE is located in HOLYOKE, MA. It is a Medicare and Medicaid certified skilled nursing facility.

How many beds does REGALCARE AT HOLYOKE have?

REGALCARE AT HOLYOKE has 102 certified beds.

Who owns REGALCARE AT HOLYOKE?

REGALCARE AT HOLYOKE is a for profit - limited liability company facility and is part of the REGALCARE chain.

What questions should families ask when visiting REGALCARE AT HOLYOKE?

Families visiting REGALCARE AT HOLYOKE should ask about daily routines, communication with families, how they handle medical emergencies. Also ask to speak with current residents or families, tour during mealtime, and request a copy of the most recent inspection report.

How does REGALCARE AT HOLYOKE compare to other nursing homes?

REGALCARE AT HOLYOKE has a 1-star overall rating, which is below average compared to other nursing homes in MA. Families should carefully review inspection findings and consider alternatives.

REGALCARE AT HOLYOKE

Name: REGALCARE AT HOLYOKE
Address: 282 CABOT STREET, HOLYOKE, MA, 01040, US
Telephone: (413) 538-7470
Rating: 1.0

282 CABOT STREET, HOLYOKE, MA 01040 · (413) 538-7470

For profit - Limited Liability company 102 Beds REGALCARE Data: November 2025

Trust Grade

25/100

#316 of 338 in MA

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Last Inspection: June 2025

Inspected within the last 6 months. Data reflects current conditions.

Overview

RegalCare at Holyoke has received a Trust Grade of F, indicating significant concerns about the quality of care provided. Ranking #316 out of 338 facilities in Massachusetts places it in the bottom half, and #24 out of 25 in Hampden County shows that only one local option is better. While the facility is improving its inspection issues, having decreased from 18 to 10 problems over the last year, it still faces serious staffing challenges, with a concerning 51% turnover rate that exceeds the state average. Additionally, the facility has incurred $26,071 in fines, suggesting some compliance issues, and it provides less RN coverage than 94% of facilities in the state, which could impact resident care. Specific incidents include a resident's pressure wound deteriorating due to inadequate care planning and treatment, as well as failures to ensure timely response to call bells, indicating potential gaps in staff support and care. Overall, while there are some signs of improvement, families should weigh these significant weaknesses when considering this nursing home.

Trust Score: F
In Massachusetts: #316/338
Safety Record: Moderate
Inspections: Getting Better
Staff Stability: 51% turnover. Above average. Higher turnover means staff may not know residents' routines.
Penalties: $26,071 in fines. Lower than most Massachusetts facilities. Relatively clean record.
Skilled Nurses: Each resident gets only 18 minutes of Registered Nurse (RN) attention daily — below average for Massachusetts. Fewer RN minutes means fewer trained eyes watching for problems.
Violations: 46 deficiencies on record. Higher than average. Multiple issues found across inspections.

★☆☆☆☆

1.0

Overall Rating

★★☆☆☆

2.0

Staff Levels

★☆☆☆☆

1.0

Care Quality

★★☆☆☆

2.0

Inspection Score

↔

Stable

2024: 18 issues

2025: 10 issues

The Good

Full Sprinkler Coverage · Fire safety systems throughout facility
No fines on record

Facility shows strength in fire safety.

The Bad

1-Star Overall Rating

Below Massachusetts average (2.9)

Significant quality concerns identified by CMS

Staff Turnover: 51%

Near Massachusetts avg (46%)

Higher turnover may affect care consistency

Federal Fines: $26,071

Below median ($33,413)

Moderate penalties - review what triggered them

Chain: REGALCARE

Part of a multi-facility chain

Ask about local staffing decisions and management

The Ugly 46 deficiencies on record

2 actual harm

Jun 2025 10 deficiencies

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0638 (Tag F0638)

Could have caused harm · This affected 1 resident

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Based on record review and interview, the facility failed to ensure that a quarterly review assessment was completed as required to ensure critical indicators of gradual status change were monitored for one Resident (#58) out of a total sample of 19 residents. Specifically, for Resident #58, the facility failed to ensure that the Resident was reviewed between comprehensive assessments with respect to the Minimum Data Set (MDS) items specified in the quarterly assessment. Findings include: Review of the RAI (Resident Assessment Instrument) Version 1.19.1 dated October 2024, indicated the following: -The Quarterly assessment is an OBRA (Federal law, known as the Omnibus Budget Reconciliation Act of 1987) non-comprehensive assessment for a resident that must be completed at least every 92 days following the previous OBRA assessment of any type. -It is used to track a resident's status between comprehensive assessments to ensure critical indicators of gradual change in a resident's status are monitored. -The ARD (Assessment Reference Date) must not be more than 92 days after the ARD of the most recent OBRA assessment of any type. Resident #58 was admitted to the facility in February 2023. Review of the clinical record indicated an MDS assessment was submitted for the Resident on 2/5/25. Further review of the clinical record failed to indicate that any other subsequent quarterly assessment was completed. During an interview on 6/20/25 at 12:20 P.M., the MDS Nurse said a quarterly MDS assessment should have been completed in May 2025 for Resident #58, but one was not completed. The MDS Nurse said she refers to the RAI Manual for timeliness of MDS assessments.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0645 (Tag F0645)

Could have caused harm · This affected 1 resident

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Based on record review and interview, the facility failed to ensure a Preadmission Screening and Resident Review (PASRR - preadmission screening to identify residents with mental health disorders or intellectual disabilities) was accurately completed prior to admission for one Resident (#46), out of a total sample of 19 residents. Findings include: Review of the facility's policy titled admission Criteria, revised 4/22, indicated the following: -All new admissions and readmissions are screened for mental disorders (MD), intellectual disabilities (ID), or related disorders (RD) per the Medicaid Pre-admission Screening and Resident Review (PASARR) process. [sic] Resident #46 was admitted to the facility in March 2025 with a diagnoses including Schizoaffective Disorder and a history of alcohol use. Review of the Hospital Discharge/Transfer Note, dated 3/13/25, indicated Resident #46 had a diagnosis of Schizoaffective Disorder and had medication changes in the hospital relative to his/her antipsychotic medication. Review of the Medical Doctor's (MD) History and Physical, completed on 3/18/25, indicated Resident #46 had a diagnosis of Schizoaffective Disorder. Review of Resident #46's PASRR, dated 3/19/25 (completed post admission to the facility), indicated the following: -Resident #46 had no diagnosis of serious mental illness (SMI). During an interview on 6/17/25 at 2:45 P.M., the Social Worker (SW) said prior to being admitted to the facility all residents needed to have a PASRR completed. The SW said for Resident #46, his/her PASRR was not completed until after he/she had been admitted to the facility. The SW said Resident #46's PASRR was also completed inaccurately and did not indicate he/she had a diagnosis of Schizoaffective Disorder and a new PASRR needed to be submitted with the accurate diagnosis. The SW further said she was aware there were issues with PASRR completion and PASRR accuracy, but no audit had been completed to see which residents in the facility did not have PASRRs completed at admission and/or if their PASRRs had been completed accurately. During an interview on 6/18/25 at 7:33 A.M., the Ombudsman said the facility was not ensuring PASRRs were being completed accurately and when the Nurses from the local Elder Services Agency were reviewing resident PASRRs during Medicaid Screenings, the PASRRs were often missing mental health diagnoses and other information.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0658 (Tag F0658)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews, and interview, the facility failed to provide services that meet professional standards of quality for one Resident (#34), out of a total sample of 19 residents. Specifically, for Resident #34, the facility failed to administer the medication Ingrezza (Valbenazine Tosylate - medication used to treat tardive dyskinesia (TD) and help reduce uncontrolled body movements) as prescribed: -for increased involuntary movement symptoms when the medication was ordered to be administered daily. -when the medication was discontinued by facility staff, and was being administered without current Physician orders. Findings include: Review of [NAME], Manual of Nursing Practice 11th ed, dated 2019, indicated the following: -The professional nurse's scope of practice is defined and outlined by the State Board of Nursing that governs practice. 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 prescriber's 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 error. -In any situation where an order is unclear, or a nurse questions the appropriateness, accuracy, or completeness of an order, the nurse may not implement the order until it is verified for accuracy with a duly authorized prescriber. Review of the facility's policy titled Change of Condition in a Resident Status, dated 3/17, indicated the following: -the facility shall notify the resident, his or her attending physician, and representative (sponsor of changes in the resident's medical mental condition). -The nurse will notify the resident's Attending Physician or On-call Physician when there has been a need to alter the resident's medical treatment significantly. Resident #34 was admitted to the facility in June 2024 with diagnoses including malignant neoplasm of the brain (brain tumor), adult failure to thrive, Parkinson's Disease, epilepsy, drug induced subacute dyskinesia, and a history of falling. Review of Resident #34's May 2025 Medication Administration Record (MAR) indicated the following: -Valbenazine Tosylate Oral Capsule 40 milligrams (mg). Give one capsule via G-tube (gastrostomy tube - a feeding tube inserted into the stomach through the abdomen) in the morning for TD (tardive dyskinesia) - start date 5/9/25, discontinue date 5/15/25. >5/9/25 - initialed by the Nurse as a 9 (other/see progress notes) indicating the medication was not administered. -Valbenazine Tosylate Oral Capsule 40 mg. Give two capsules via G-tube at bedtime for TD - start date 5/15/25, discontinue date 6/13/25. >5/21/25, 5/22/25 and 5/30/25 were left blank and not initialed by the Nurse as being administered. >5/25/25-initialed by the Nurse as a 9. >Valbenazine Tosylate Oral Capsule was not administered on 5/9/25, 5/21/25, 5/22/25, 5/25/25, and 5/30/25. Review of Resident #34's June 2025 MAR indicated the following: -Valbenazine Tosylate Oral Capsule 40 mg. Give two capsules via G-tube at bedtime for TD -start date 5/15/25, discontinue date 6/13/25. >6/2/25 - initialed by the Nurse as a 9. Review of Resident #34's Provider's Progress Note, dated 6/4/25, indicated the following: -Resident had been off the Ingrezza per nursing for several days, now receiving 80 mg and movements improving. He/she remains with notable involuntary movements but able to stay in bed. It seems he/she is getting his/her Ingrezza per Medication Administration Record (MAR) but missed a dose the other day. -Tardive Dyskinesia - continue Ingrezza 80 mg via G-tube (gastrostomy tube - a feeding tube inserted into the stomach through the abdomen) qhs (every night at bedtime) for significant TD. Involuntary movements likely contributing to falls. Review of Resident #34's Provider's Progress Note, dated 6/12/25, indicated the following: -Resident remains with notable involuntary [sic], but able to stay in bed -Tardive Dyskinesia, continue Ingrezza 80 mg via G-tube qhs for significant TD. Involuntary movements likely contribute to falls, Ingrezza seems to be helping. Review of Resident #34's Provider's Progress Note, dated 6/16/25, indicated the following: -Resident had a notable increase in movements so significant he/she had fallen out of the bed and the chair. -Tardive Dyskinesia, continue Ingrezza 80 mg via G-tube qhs for significant TD. Involuntary movements likely contribute to falls, Ingrezza seems to be helping. Review of Resident #34's June 2025 MAR indicated the following: -Valbenazine Tosylate Oral Capsule 40 mg. Give two capsules via G-tube at bedtime for TD - start date 5/15/25, discontinue date 6/13/25. >6/2/25 - initialed by the Nurse as a 9. -Valbenazine Tosylate was discontinued on 6/13/25 and not administered on 6/13/25, 6/14/25, 6/15/25 or 6/17/25. -A one-time order for Ingrezza 80 mg capsule to be given on 6/16/25 was administered and initialed by the nurse. Further review of Resident #34's medical record failed to indicate any evidence or correlating progress notes relative to why the Valbenazine Tosylate medication was not administered or Provider communication that the medication had not been administered on 5/9/25, 5/21/25, 5/22/25, 5/25/25, 5/30/25, 6/2/25, 6/13/15, 6/14/25, 6/15/25 or 6/17/25 (10 occasions). During an interview on 6/18/25 at 5:22 P.M., Nurse #2 said Resident #34 was prescribed Ingrezza and currently received it in the evening. The surveyor and Nurse #2 reviewed the current Physician's orders and Nurse #2 said there was no current order for the Valbenazine Tosylate/Ingrezza. Nurse #2 said it appeared the medication was discontinued and she was not sure why. Nurse #2 said there had been adjustments made to the medication to be administered in the evening at bedtime instead of in the morning, but the medication had not been discontinued to the best of her knowledge. On 6/18/25 at 5:25 P.M., the surveyor and Nurse #2 observed multiple blister packs that held the Valbenazine Tosylate/Ingrezza, located in the nurses' medication cart. Nurse #2 was unable to determine the last time Resident #34 received the Ingrezza medication based on what medication was left in the blister packs. During an interview on 6/23/25 at 11:06 A.M., the Nurse Practitioner (NP) said Resident # 34 was prescribed Ingrezza because the NP felt he/she was benefiting from it and had noted less (involuntary) movement. The NP said she had not discontinued the Ingrezza medication since re-starting it in May 2025. The surveyor and the NP reviewed the dates that indicated the Resident did not receive the Ingrezza. The NP said she was not made aware Resident #34 had not received the medication that many times. The NP said that the staff had notified her about some missed doses, but not that many. The NP further said that she would not expect the staff to call her for one missed dose but to notify her when she came in the following morning. The NP said she did not recall the facility staff notifying her that the Resident had not received the Ingrezza medication on the ten missed occasions noted and should have. Please Refer to F760

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Accident Prevention (Tag F0689)

Could have caused harm · This affected 1 resident

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Based on record reviews, and interviews, the facility failed to ensure the environment remained free of accidental hazards and was safe for one Resident (#27), out of a total sample of 19 residents. Specifically, for Resident #27, the facility failed to ensure that the call bell was placed within reach for the Resident's use and that fall mats were appropriately implemented after the Resident sustained an unwitnessed fall. Findings include: Review of the facility's policy titled Fall and Fall Risk Managing, revised on 3/2022, indicated the following: -Based on previous evaluations and current data, the staff will identify interventions related to the residents' specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling. -The staff, with the input of the attending physician, will implement a resident centered fall prevention plan to reduce the specific risk factor(s) of falls for each resident at risk or with a history of falls. Resident #27 was admitted to the facility in March 2025 with diagnoses including paraplegia, spinal stenosis, contracture of muscles, blindness in the left eye, and indwelling urinary catheter. On 6/18/25 at 5:06 P.M., the surveyor heard a muffled, groaning sound from Resident #27's room. The surveyor did not observe a Resident from the room doorway but heard a muffled, groaning sound and observed a urinary catheter attached to the right side of the bed which stretched across the bed. The surveyor further observed Resident #27 lying on the floor on the left side of his/her bed. The surveyor immediately notified staff that Resident #27 was heard by the surveyor from the hallway groaning and making muffled sounds and was found lying on the floor, on the left side of his/her bed. The surveyor observed that Resident #27's call bell had not been activated as it was not lit up in the hallway. During an interview on 6/18/25 at 5:11 P.M., the Unit Manager (UM) said the Resident had experienced an unwitnessed fall out of bed but was thankfully okay. During an interview on 6/18/25 at 5:14 P.M., Certified Nurses Aide (CNA) #1 said Resident #27 was alert and orientated to him/herself and able to use a call bell. CNA #1 said he was not sure why the Resident did not use his/her call bell to ask for help as he/she usually does. CNA #1 said sometimes Resident #27 will roll side-to-side putting him/her at risk of rolling out of the bed. During an interview on 6/18/25 at 5:34 P.M., Nurse #6 said she and two CNAs had assessed Resident #27 after his/her fall and then placed him/her back into the bed using a Hoyer Lift (a mechanical lift used to move residents who are dependent on staff to be transferred from one space to another). Nurse #6 further said the Resident was able to use the call bell to ask for help. The surveyor and Nurse #6 entered the room and observed Resident #27 lying in bed. The surveyor observed the Resident's call bell was located on the floor on the left side of the Resident's bed, partially under the bed, and out of reach for the Resident. Nurse #6 said the call bell should be within reach and was not. The surveyor observed that three staff members (Nurse #6 and 2 - CNA's) had exited the Resident's room after assisting with getting him/her into bed after the unwitnessed fall, and failed to place the call bell within reach to ensure the Resident could call for assistance as needed before exiting the room. Review of the At Risk for Falls Care Plan, initiated on 6/3/25 and updated on 6/19/25, indicated the following: -Place mats on both sides of the bed, initiated on 6/19/25. On 6/23/25 at 4:27 P.M., the surveyor and Nurse #2 observed the following: -Resident #27 was lying in bed with the bed in the low position. -the Resident was alert and leaning slightly to the left. -the call bell was within reach. -there were no bilateral mats on the floor next to the Resident's bed. During an interview immediately following the observation, Nurse #2 looked throughout the Resident's room and said she did not see any fall mats available in the room that could be placed on the floor. The surveyor and Nurse #2 reviewed Resident #27's Care Plan and observed the following intervention was updated on 6/19/25: -place mats on both sides of the bed. Nurse #2 said the intervention had not been implemented and should have been. During an interview on 6/23/25 at 4:46 P.M., the Assistant Director of Nursing (ADON) said Resident #27 had been provided the fall mats as a new intervention for safety relative to falls, however the housekeeping staff removed the mats to clean the floors and had placed them in the shower room while the Resident was out at an appointment. The ADON said the housekeeping staff had not replaced the fall mats on each side of the Resident's bed prior to the Resident returning to the facility.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0698 (Tag F0698)

Could have caused harm · This affected 1 resident

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Based on observation, interview, and record review, the facility failed to provide care and services consistent with professional standards of practice for one Resident (#22), of one applicable resident receiving dialysis (process that filters wastes, salts and fluid from your blood when the kidneys are unable to work adequately) services, out of a total sample of 19 residents. Specifically, for Resident #22, the facility failed to ensure: -timely medication administration on the Resident's dialysis scheduled days, when scheduled morning medications were delayed in being administered until after the Resident's return to the facility in the early afternoon on Mondays, Wednesdays, and Fridays. -that Sevelamer (medication to lower phosphorus levels in the blood) medication was administered as ordered by the Physician with meals, when the Resident's blood phosphorus level was elevated, and the Resident was missing the breakfast Sevelamer medication dosage on Mondays, Wednesdays, and Fridays. Findings include: Review of the facility's policy titled Care of a Resident with End-Stage Renal Disease, revised 4/2022, indicated the following: -Residents with End-Stage Renal Disease (ESRD) will be cared for according to currently recognized standards of care -staff caring for residents with ESRD, including residents receiving dialysis care outside of the facility, shall be trained in the care and special needs of these residents -education and training of staff include, specifically: >timing and administration of medications, particularly those before and after dialysis . Review of the facility's policy titled Administering Medications, revised 1/2025, indicated: -medications are administered in a safe and timely manner, and as prescribed. -medications are administered in accordance with prescriber orders, including any required time frame -medication administration times are determined by resident need and benefit, not staff convenience. Factors that are covered include: >enhancing optimal therapeutic effect of the medication >preventing potential medication or food interactions; and >honoring resident choices and preferences, consistent with his or her care plan -medications are administered within one (1) hour of their prescribed time, . Resident #22 was admitted to the facility in April 2025 with diagnoses including Chronic Kidney Disease. Review of the Minimum Data Set (MDS) Assessment, dated 5/17/25, indicated Resident #22 was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) score of 15 out of 15 and received dialysis while in the facility. Review of the Renal/Dialysis Care Plan, initiated 5/21/25, indicated Resident #22 had a potential for complications related to hemodialysis (use of a machine to conduct dialysis) and included the following interventions also initiated 5/21/25: -administer and monitor effectiveness of medications as ordered (see Physician's orders/Medication Administration Record [MAR]) -communicate with dialysis center regarding medication, diet, and lab results -dialysis days: Mondays, Wednesdays, Fridays Review of Resident #22's lab work, dated 4/21/25, indicated a Phosphorus level of 5.4 mg/dL (High) (hyperphosphatemia = level greater than 4.5 milligrams (mg) per deciliter (dL); Normal phosphorus level = 2.5 to 4.5 mg/dL). Review of Resident #22's Nutrition Evaluation, dated 5/14/25, indicated: -phosphorus level obtained on 4/21/25 was 5.4 mg/dL . communicated to Nurse Practitioner (NP) Review of the Resident #22's lab work, dated 6/4/25, indicated the Phosphorus level remained at 5.4 mg/dL (High). During an interview on 6/17/25 at 9:01 A.M., Resident #22 said he/she received dialysis on Mondays, Wednesdays, and Fridays at an outside clinic. Resident #22 said he/she was picked up by transportation services at 6:15 A.M. and returned around 1:30 P.M. Resident #22 said he/she received a bagged breakfast prior to leaving the facility and did not have medications from the facility sent with him/her. Resident #22 further said a dialysis communication book was sent with him/her from the facility to dialysis. Review of Resident #22's June 2025 Physician's orders indicated the following: -Folic Acid 1 milligram (mg) daily, initiated 4/9/25 -Oxybutynin Chloride ER 24 hour (medication for overactive bladder), 10 mg daily, initiated 4/9/25 -Pantoprazole Sodium Delayed Release (medication to reduce stomach acid), 40 mg daily initiated 4/10/25 -Fluticasone Propionate Nasal Spray (allergy medication), 50 micrograms (mcg) per actuation (ACT), 2 spray in each nostril daily, initiated 4/10/25 -Potassium 20 milliequivalents (mEq) daily, initiated 4/10/25 -Cholecalciferol (Vitamin D supplement) 50000 international units (IU) every Monday, initiated 4/14/25 -Dialysis on Mondays, Wednesdays, and Fridays initiated 4/18/25 -Torsemide (diuretic medication), 20 mg twice daily, initiated 4/20/25 -Selevamer HCL (phosphate binder) 800 mg, one tablet with meals (TID: three times daily), initiated 5/14/25 -Apixaban (anticoagulant) 5 mg every 12 hours (twice daily), initiated 5/15/25 -Carvedilol (blood pressure medication) 25 mg twice daily, initiated 5/15/25 -Losartan Potassium (blood pressure medication), 25 mg daily, may hold on dialysis days, initiated 5/22/25 -Fluticasone Furoate-Vilanterol 50-25 mcg/ACT, 1 puff inhale orally in the morning . initiated 6/6/25 Review of Resident #22's June 2025 Medication Administration Record (MAR), indicated the following medications were documented as administered at the prescribed morning times from 6/1/25 through 6/19/25 (exception of Wednesday 6/4/25 when the Resident was documented to be out of the facility): -Folic Acid 1 mg, scheduled to be administered daily at 8:00 A.M., -Oxybutynin Chloride ER 10 mg, scheduled to be administered daily at 8:00 A.M., -Pantoprazole 40 mg, scheduled to be administered daily at 9:00 A.M., -Fluticasone Propionate 50 mcg/ACT, scheduled to be administered daily at 9:00 A.M., -Potassium 20 mEq, scheduled to be administered daily at 9:00 A.M., -Cholecalciferol 50000 IU, scheduled to be administered on Mondays at 9:00 A.M., was documented as administered on 6/2/25, 6/9/25 and 6/16/25 -Torsemide 20 mg, scheduled to be administered at 8:00 A.M., -Sevelamer HCL 800 mg, scheduled to be administered at 8:30 A.M., -Apixaban 5 mg, scheduled to be administered at 8:00 A.M., -Carvedilol 25 mg, scheduled to be administered at 8:00 A.M., -Losartan Potassium 25 mg, scheduled to be administered daily at 8:00 A.M., -Fluticasone Furoate-Vilanterol 50-25 mcg/ACT, scheduled to be administered daily at 8:00 A.M., During an interview on 6/18/25 at 2:13 P.M., Nurse #2 said Resident #22 left the facility for dialysis on Mondays, Wednesdays and Fridays around 6:00 A.M. and returned to the facility around 1:00 - 1:30 P.M. Nurse #2 said no medications from the facility were sent to dialysis with Resident #22, and the medications scheduled to be administered in the morning (8:00 A.M., 8:30 A.M., and 9:00 A.M.) when the Resident was out at dialysis, would be administered when he/she returned from dialysis treatment at 1:00 P.M. - 1:30 P.M. Nurse #2 further said the Resident's MAR should reflect the times that the Resident's medications were administered and currently the MAR was not accurate relative to the medication administration times. During an interview on 6/18/25 at 2:30 P.M., Unit Manager (UM) #2 said no medications were sent from the facility with Resident #22 to dialysis, and that he/she received a bagged breakfast prior to leaving the facility and that he/she would receive the lunch meal when he/she returned from dialysis. The surveyor and UM #2 reviewed Resident #22's June 2025 MAR which indicated the Resident was receiving morning medications (scheduled for 8:00, 8:30 and 9:00 A.M.) on Mondays, Wednesdays and Fridays,when he/she was not in the facility and UM #2 said she would have to look into this. UM #2 further said she would also look into the Sevelamer medication which was scheduled to be given with the Resident's meals. Review of the Nutritional Evaluation Note, dated 6/18/25, indicated: -Resident was evaluated for monthly high nutrition risk related to hemodialysis and ESRD. -Phosphorus level obtained on 6/4/25 was 5.4 mg/dL . -Phosphorus binder initiated on 5/14/25 . During an interview on 6/18/25 at 4:45 P.M., the Director of Nursing (DON) said Resident #22 started dialysis treatments after admission to the facility, and that his/her medication administration times should have been adjusted based on his/her dialysis schedule. The DON further said she would have to look into the Sevelamer medication administration. During a follow-up interview on 6/25/25 at 8:23 A.M., the DON said Resident #22's orders were adjusted after the surveyor brought the concerns about the medication administration times. The DON further said she was unsure if the Provider was made aware that morning medications scheduled for 8:00 A.M. and 9:00 A.M. on dialysis days were given after the Resident's return from dialysis prior to this adjustment or that the Sevelamer medication (scheduled for 8:30 A.M. with breakfast) was not being administered as ordered for the breakfast meal on the days (Mondays, Wednesdays, and Fridays) Resident #22 was at dialysis. During an interview on 6/25/25 at 9:37 A.M., the Registered Dietitian (RD) said Resident #22 was considered high nutritional risk due to hemodialysis treatments and was followed monthly and as needed (PRN). The RD said when he completed his assessments, he contacted the Resident's dialysis clinic to coordinate the Resident's plan of care, which included a review of the Resident's weights, intake and lab work. The RD said he noted the Resident's elevated phosphorus level on 5/14/25 and relayed this information to the NP, who added a phosphorus binder medication (Sevelamer). The RD said the Sevelamer medication would need to be administered with the Resident's meals so that it could bind to the phosphorus in the food, and that the medication would not be effective if administered after the meal as the medication would not serve its purpose. The RD further said he was unaware that the Sevelemar was not being administered with the Resident's breakfast meal on dialysis days. During an interview on 6/25/25 at 10:41 A.M., the NP said she was made aware of the issue with Resident #22's medications administration times the previous week (week of 6/17/25) by UM #2, and the medication times have been adjusted based on his/her dialysis schedule. The NP said prior to last week, she was unaware that the Resident's morning medications were administered after (he/she returned from) dialysis, and she was not made aware that the Sevelemar medication was not being administered on dialysis days for the breakfast meal. The NP said she would have expected the facility staff to review the Resident's medication times and coordinate theses times based on his/her dialysis schedule to ensure the medications were administered as ordered. The NP said Resident #22's medications would have needed to be adjusted once the dialysis schedule was determined since dialysis treatments started after his/her admission. The NP said relative to the Sevelamer medication, some dialysis clinics administer this medication to the resident while at dialysis. The NP further said she was made aware by UM #2 that the Sevelemar medication was not administered to Resident #22 at dialysis and that it would now be sent with him/her on dialysis days from the facility. During an interview on 6/25/25 at 11:49 A.M., the Regional Nurse said the facility policy should have been followed relative to dialysis and medication timing for Resident #22. The Regional Nurse said the facility should have coordinated with the Resident's dialysis clinic relative to his/her medications and should have made adjustments to the medication administration times on dialysis days. Please refer to F842

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Medical Records (Tag F0842)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record reviews, the facility failed to ensure complete and accurate medical records were maintained for two Residents (#22, and #91), out of a total sample of 19 residents. Specifically, 1. For Resident #22, the facility failed to ensure accurate documentation of medications scheduled at 8:00 A.M., 8:30 A.M. and 9:00 A.M., were administered, when the Resident was out of the facility receiving dialysis services on Mondays, Wednesdays, and Fridays, and the medications were documented as being administered during the time the Resident was away at dialysis. 2. For Resident #91, the facility failed to ensure accurate documentation on the Skin Observation/ Assessment Tools and Nursing Evaluations when the Resident had a Stage 3 pressure area present on his/her coccyx. Findings include: 1. Resident #22 was admitted to the facility in April 2025 with diagnoses including Chronic Kidney Disease. Review of the facility policy titled Administering Medications, revised 1/2025, indicated: -medications are administered in a safe and timely manner, and as prescribed. -medications are administered in accordance with prescriber orders, including any required time frame -medication administration times are determined by resident need and benefit, not staff convenience. Factors that are covered include: >honoring resident choices and preferences, consistent with his or her care plan -medications are administered within one (1) hour of their prescribed time, Review of the Minimum Data Set (MDS) Assessment, dated 5/17/25, indicated Resident #22: -was cognitively intact as evidenced by a Brief Interview of Mental Status (BIMS) score of 15 out of 15 possible points -received dialysis while in the facility. Review of the Renal/Dialysis Care Plan, initiated 5/21/25, indicated Resident #22 had a potential for complications related to hemodialysis (use of a machine to conduct dialysis) and included the following interventions: -administer and monitor effectiveness of medications as ordered (see Physician's orders/Medication Administration Record [MAR]) -communicate with dialysis center regarding medication, diet, and lab results -dialysis days: Mondays, Wednesday, Fridays During an interview on 6/17/25 at 9:01 A.M., Resident #22 said he/she received dialysis on Mondays, Wednesdays, and Fridays at an outside clinic. Resident #22 said he/she was picked up by transportation services at 6:15 A.M. and returned to the facility around 1:30 P.M. Resident #22 said he/she received a bagged breakfast prior to leaving the facility and did not have medications from the facility sent with him/her to dialysis. Review of the June 2025 Physician's orders indicated the following: -Folic Acid 1 milligram (mg) daily, initiated 4/9/25 -Oxybutynin Chloride ER 24 hour (medication for overactive bladder), 10 mg daily, initiated 4/9/25 -Pantoprazole Sodium Delayed Release (medication to reduce stomach acid), 40 mg daily initiated 4/10/25 -Fluticasone Propionate Nasal Spray (medication for allergies), 50 micrograms (mcg) per actuation (ACT), 2 spray in each nostril daily, initiated 4/10/25 -Potassium 20 milliequivalents (mEq) daily, initiated 4/10/25 -Cholecalciferol (Vitamin D supplement) 50000 international units (IU) every Monday, initiated 4/14/25 -Dialysis on Mondays, Wednesdays, and Fridays initiated 4/18/25 -Resident may receive, as per Medical Doctor (MD) order, while at dialysis, initiated 4/18/25 -Torsemide (diuretic medication), 20 mg twice daily, intimated 4/20/25 -Selevamer HCL (phosphate binder), 800 mg, one tablet with meals, initiated 5/14/25 -Apixaban (anticoagulant) 5 mg every 12 hours (twice daily), initiated 5/15/25 -Carvedilol (blood pressure medication) 25 mg twice daily, initiated 5/15/25 -Losartan Potassium (blood pressure medication), 25 mg daily, may hold on dialysis days, initiated 5/22/25 -Fluticasone Furoate-Vilanterol 50-25 mcg/ACT, 1 puff inhale orally in the morning . initiated 6/6/25 Review of Resident #22's June 2025 Medication Administration Record (MAR), indicated the following medications were documented as administered at the prescribed morning times from 6/1/25 through 6/19/25 (except Wednesday 6/4/25 when the Resident was documented to be out of the facility): -Folic Acid 1 mg, scheduled to be administered daily at 8:00 A.M., -Oxybutynin Chloride ER 10 mg, scheduled to be administered daily at 8:00 A.M., -Pantoprazole 40 mg, scheduled to be administered daily at 9:00 A.M., -Fluticasone Propionate 50 mcg/ACT, scheduled to be administered daily at 9:00 A.M., -Potassium 20 mEq, scheduled to be administered daily at 9:00 A.M., -Cholecalciferol 50000 IU, scheduled to be administered on Mondays at 9:00 A.M., was documented as administered on 6/2/25, 6/9/25 and 6/16/25 -Torsemide 20 mg, scheduled to be administered at 8:00 A.M., -Sevelamer HCL 800 mg, scheduled to be administered at 8:30 A.M., -Apixaban 5 mg, scheduled to be administered at 8:00 A.M., -Carvedilol 25 mg, scheduled to be administered at 8:00 A.M., -Losartan Potassium 25 mg, scheduled to be administered daily at 8:00 A.M., -Fluticasone Furoate-Vilanterol 50-25 mcg/ACT, scheduled to be administered daily at 8:00 A.M., During an interview on 6/18/25 at 2:13 P.M., Nurse #2 said Resident #22 left the facility for dialysis on Mondays, Wednesdays and Fridays around 6:00 A.M. and returned to the facility around 1:00 -1:30 P.M. Nurse #2 said no medications from the facility were sent with Resident #22, and that the medications scheduled to be administered in the morning (8:00 A.M., 8:30 A.M., and 9:00 A.M.), when the Resident was out at dialysis, would be administered when he/she returned from dialysis treatment at 1:00 P.M.-1:30 P.M. Nurse #2 further said the Resident's MAR should reflect the times that the Resident's medications were administered and currently the MAR was not accurate relative to the time the medications were administered. During an interview on 6/18/25 at 2:30 P.M., Unit Manager (UM) #2 said no medications were sent from the facility with Resident #22 to dialysis. The surveyor and UM #2 reviewed Resident #22's June 2025 MAR which indicated the Resident was being administered morning medications at scheduled times (scheduled for 8:00, 8:30 and 9:00 A.M.), when he/she was not in the facility and UM #2 said she would have to look into this. During an interview on 6/25/25 at 11:49 A.M., the Regional Nurse said the facility policy should have been followed relative to dialysis and medication timing for Resident #22. The Regional Nurse said the facility should have coordinated with the Resident's dialysis clinic relative to his/her medications and should have made adjustments to the medication administration times on dialysis days. 2. Resident #91 was admitted to the facility in May 2025 with diagnoses of Type 2 Diabetes, Essential Hypertension, and Unspecified Fall. Review of the facility policy titled Comprehensive Assessments and the Care Delivery System, effective 4/17 revised 2/2025, included but was not limited to: -Assessment and information collection includes (what, where, and when). The objective of the information collection (assessment) phase is to obtain, organize, and subsequently analyze information about a patient. -Assess the individual: observation; physical assessment; consultant reports. Review of Resident 91's Nursing Evaluation, dated 5/12/25, indicated that the Resident had no pressure injury and the goal would be for the Resident's skin to remain intact. Review of the Resident's MDS Assessment, dated 5/18/25, indicated that the Resident was severely impaired cognitively as evidenced by a BIMS score of two out 15 possible points and that the Resident did not have any pressure injuries noted on his/her skin. Review of the Resident's clinical record included a Nursing Progress Note, dated 5/22/25, which noted .one cm (centimeter) open area observed on coccyx, uneven borders, red, 0 (no) s/sx (signs and symptoms) infection, triad (a cream that creates a moist wound healing environment) applied, nsg (nursing) and cna (Certified Nursing Assistant) to inform colleagues to monitor. Note left in dr (Doctor) book for evaluation and tx (treatment) . Review of Resident #91's May 2025 Physician's orders and Treatment Administration Record (TAR) included: -apply zinc paste to coccyx 2x day, two times a day for skin integrity, Start Date 5/23/25, D/C (discontinue) 5/27/25. The treatment was noted as done daily 5/23/25 through 5/27/25. -coccyx, cleanse with N/S (normal saline) pat dry gently, apply silver alginate (a dressing that is absorbent with antimicrobial silver) to wound bed f/b (followed by) dcd (dry clean dressing) daily and prn (as needed). Start Date 5/28/25. The treatment was noted as done daily 5/28/25 through 5/31/25. Review of the Resident's June 2025 TAR indicated that the treatment to the coccyx started on 5/28/25 was still in place and noted as done daily on the TAR through 6/23/25. Review of the Resident's Care Plan included: -Alteration in skin integrity on the coccyx, Stage 3, initiated 5/27/25 revised 6/9/25, Review of the Wound Consultant Initial Progress Note, dated 5/27/25, indicated the Resident was seen for a Stage 3 pressure ulcer to the coccyx. Review of the clinical record included Skin Observation Tools, skin assessments completed by nursing, which indicated the following: -5/28/25 skin intact -5/30/25 skin intact -6/3/25 noted skin tear on right elbow, no other open areas Review of the Nursing Evaluation Skin Assessment, dated 6/9/25, indicated the Resident had no pressure injuries present. During an interview on 6/23/25 at 9:16 A.M., the Assistant Director of Nursing (ADON) said the Skin Observation Tools, dated 5/28/25, 5/30/25, and 6/3/25, and the Nursing Evaluation Skin assessment dated [DATE], which were completed by the Nurses, were inaccurate. The ADON said that the Resident continued to have an open pressure area on his/her coccyx, which was first identified on 5/23/25. The ADON said that the Resident was still evaluated weekly by the Wound Consultant, and was receiving a daily treatment for the ongoing open area on his/her coccyx. The ADON said that the pressure area on the Resident's coccyx should have been noted on the Skin Assessments dated 5/28/25, 5/30/25, and 6/3/25, as well as the Nursing Evaluation completed on 6/9/25, but they had not been.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Infection Control (Tag F0880)

Could have caused harm · This affected 1 resident

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Based on observations, record reviews, and interviews, the facility failed to 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 on one unit (Unit Four), out of three units and for two Residents (#37 and #70) residing on Unit Four. Specifically, the facility failed to implement Enhanced Barrier Precautions (EBP) when providing care on Unit Four: 1. For Resident #37, when the facility staff failed to wear the appropriate Personal Protective Equipment (PPE) when providing direct care for the Resident on EBP due to foot wound and a recent amputation. 2. For Resident #70, when the facility staff failed to don the appropriate PPE while providing high contact care for the Resident on EBP related to an indwelling urinary catheter. Findings include: Review of the facility's policy titled Enhanced Barrier Precautions (EBP), revised 9/2022, indicated the following: -Enhanced Barrier Precautions are an infection prevention intervention designed to reduce the transmission of multi-drug-resistant organisms (MDROs) in the facility. The precautions involve gown and glove use during high contact resident care activities for residents known to be colonized or infected with MDROs as well as those with an increased risk of contracting MDROs. -Use of EBP includes but was not limited to residents with indwelling medical devices or wounds (regardless of MDRO colonization or infection status in addition) . 1. Resident #37 was admitted to the facility in January 2025 with diagnoses including chronic ulcer of the right heel and mid foot, Type 2 Diabetes with diabetic peripheral angiopathy, infection following a procedure deep incisional surgical site, Type 2 Diabetes with foot ulcers, osteomyelitis of the right ankle and foot. Review of Resident #37's June 2025 Physician orders indicated the following in part: -4th and 5th toe amputation and surgical site to the left foot . -Right foot distal plantar surgical wound . On 6/17/25 at 9:46 A.M., the surveyor observed the following from the doorway of Resident #37's room, located on Unit Four: -An EBP sign posted at the entrance of the Resident's doorway to the room. -A three drawer PPE bin with the necessary PPE required located in the hallway directly outside of the Resident's room. -Resident #37 had bilateral bandages on his/her feet. -A Certified Nurses Aide (CNA), wearing a surgical mask and gloves was bent down assisting Resident #37 with putting on his/her shoes. -The CNA was observed assisting the Resident from the bed into the wheelchair and then from the wheelchair into the bathroom. -The CNA exited the bathroom with an empty wheelchair and doffed (took off the gloves, exited the room, and performed hand hygiene). -The CNA was not observed to don (put on) a gown while putting on the Resident's shoes and while assisting with the Resident transfers. During an interview on 6/18/25 at 3:51 P.M., the Assistant Director of Nursing (ADON) said Resident #37 was on EBP due to his/her foot wound and recent amputation. The ADON said a gown and gloves should be worn when providing care for Resident #37. 2. Resident #70 was admitted to the facility in February 2025 with diagnoses including BPH with lower urinary tract symptoms and obstructive and reflux uropathy requiring the use of an indwelling catheter. Review of Resident #70's June 2025 Physician's orders indicated the following in part: -Foley catheter (a medical device that helps drain urine from your bladder) care, initiated 5/7/25 -Change Foley catheter as needed, initiated 5/7/25 On 6/17/25 from 10:08 A.M. until 10:19 A.M., the surveyor observed the following from the doorway of Resident #70's room, located on Unit Four: -An EBP sign posted at the entrance of the Resident's doorway to the room -A three drawer PPE bin with the necessary PPE required located in the hallway directly outside of the Resident's room. -A CNA provided care to Resident #70 behind the closed curtain. -The CNA came out from behind the curtain to gather supplies and was observed donning a surgical mask and gloves. The CNA did not don a gown. During an interview on 6/17/25 at 10:19 A.M., while standing outside of Resident #70's room, the ADON said the Resident was on EBP due to his/her urinary catheter and that staff were required to don full PPE when providing high contact care such as toileting and changing a resident. The surveyor discussed the CNA observation with the ADON, who entered the room to observe the CNA providing care. When the ADON exited the room, she said the CNA providing care worked with Hospice Services and was providing patient care. The ADON further said the CNA donned gloves and a surgical mask but did not don a gown as required, when providing high contact care.

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Assessment Accuracy (Tag F0641)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4. Resident #44 was admitted to the facility in August 2023 with diagnoses including Peripheral Vascular Disease, Type 2 Diabetes, and Chronic Kidney Disease. Review of the MDS Assessment, dated 3/19/25, indicated Resident #44 utilized an anticoagulant (blood thinner) medication within the seven day look back period (3/13/25 through 3/19/25). Review of Resident #44's March 2025 Physician's orders failed to indicate any orders for an anticoagulant medication. Review of Resident #44's March 2025 Medication Administration Record (MAR) failed to indicate any documentation that Resident #44 was administered an anticoagulant medication during the month of March 2025. During an interview on 6/20/25 at 10:05 A.M., the MDS Nurse said Resident #44 was not on an anticoagulant medication during the look back period for the MDS assessment dated [DATE], and the use of anticoagulant medication was coded incorrectly. 5. Resident #65 was admitted to the facility in March 2025 with diagnoses including Chronic Obstructive Pulmonary Disease (COPD), Pneumonia, and Asthma. On 6/17/25 at 9:18 A.M., and 6/20/25 at 8:04 A.M., the surveyor observed Resident #65 with a nasal cannula in place and a portable oxygen tank delivering Oxygen via the nasal cannula at 2 liters per minute (LPM). Review of Resident #65's June 2025 Physician's orders indicated the following orders: -Oxygen at 0-4 LPM continuous to keep oxygen saturations above 90%, start date 3/28/25. Review of Resident #65's care plan titled Resident #65 had altered respiratory status/difficulty breathing .initiated 3/6/25, indicated the following interventions: -Oxygen Settings: Oxygen 1-4 via nasal cannula .initiated 4/17/25 Review of the MDS Assessment, dated 6/3/25, indicated Resident #65 had not utilized oxygen while a Resident at the facility. During an interview on 6/20/25 at 2:50 P.M., the MDS Nurse said Resident #65 had been utilizing Oxygen since his/her admission to the facility and the MDS Assessment, dated 6/3/25, was coded inaccurately and should have indicated Resident #65 had utilized Oxygen while a Resident at the facility. Based on observation, interview, and record review, the facility failed to accurately code Minimum Data Set (MDS) Assessments for six Residents (#83, #55, #91, #44, #65, and #93), out of a total sample of 19 residents. Specifically, the facility failed: 1. For Resident #83, to accurately code medications administered when the Resident received Insulin daily. 2. For Resident #55, to accurately code a pressure injury that was present upon admission to the facility. 3. For Resident #91, to accurately code a pressure injury that was present during the MDS observation look back time period. 4. For Resident #44, to accurately code medications administered while in the facility when the Resident was coded as utilized an anticoagulant (blood thinner) medication but was not ordered for an anticoagulant. 5. For Resident #65, to accurately code the use of oxygen therapy while in the facility when the Resident was coded as had not utilized oxygen, and was ordered for continuous oxygen and using oxygen. 6. For Resident #93, to accurately complete a Discharge MDS Assessment, when the Resident was coded as discharged to an acute hospital and the Resident was discharged to home. Findings include: 1. Resident #83 was admitted to the facility in October 2024 with diagnoses including Type 2 Diabetes Mellitus (DM) without complications. Review of the Resident's MDS Assessment, dated 5/28/25, indicated that the Resident had not been administered any Insulin or had any injections during the MDS observation period. Review of Resident #83's June 2025 Physician's orders included: -Insulin Glargine Subcutaneous Solution 100 UNIT/ML (milliliter), Inject 18 units subcutaneously (under the skin) at bedtime for diabetes. (Start date 12/18/24) Review of the Resident's May 2025 Medication Administration Record (MAR) indicated that the Insulin Glargine injection was administered to the Resident each evening as ordered by the Physician. During an interview on 6/24/25 at 11:20 A.M., the MDS Nurse said that the Resident did receive Insulin injections each evening during the MDS lookback observation period and the correct response on the MDS dated [DATE] should have been 7 days of injections and 7 days of Insulin administration. The MDS Nurse said the MDS dated [DATE] was coded inaccurately for injections and Insulin. 2. Resident #55 was admitted to the facility in September 2024 with diagnoses including corns and callosities, muscle weakness, and Dementia. Review of the Physician's Progress Note, dated 10/21/24, included . left foot has a large callous to the base of foot which has been there for years per pt (patient). He/she has a new open area towards the base of the mid foot/ankle that is open and bleeding. Pt states his/her callous was taken off and it is attached to his/her sock. Foot was placed in a soapy bath of warm water and will have a dressing placed daily. Wound Consult to see in the near future. Review of the Initial Progress Note by the Wound Care Physician, dated 10/23/24, indicated that the pressure ulcer to the left plantar heel began as a callous which was present when the Resident was admitted to the facility and was considered community acquired. The Wound Care Physician continued to evaluate and treat the Resident's left plantar heel. The follow-up progress note, dated 4/22/25, noted that the open area on the left plantar heel was the result of a callous falling off that was present upon admission to the facility. Review of the facility Weekly Wound Rounds Report, dated 4/22/25, indicated that the Left heel plantar Stage 3 pressure ulcer was present upon admission to the facility. Review of the MDS Assessment, dated 4/23/25, indicated that the Stage 3 pressure area was not present upon admission to the facility. During an interview on 6/25/25 at 12:22 P.M., the Assistant Director of Nursing (ADON) said the open area on the Resident's left plantar heel was a result of a callous falling off. The ADON said that the callous was present upon the Resident's admission to the facility. During an interview on 6/25/25 at 2:20 P.M., the MDS Regional Nurse said that the MDS Assessment, dated 4/23/25, was coded incorrectly and the Stage 3 pressure area noted in Section M of the MDS Assessment should have also indicated that the pressure area was present upon admission to the facility. 3. Resident #91 was admitted to the facility in May 2025 with diagnoses of Type 2 Diabetes, Essential Hypertension, and Unspecified Fall. Review of the Resident's clinical record included a Nursing Progress Note, dated 5/22/25, which noted .one cm (centimeter) open area observed on coccyx, uneven borders, red, 0 (no) s/sx (signs and symptoms) infection, triad (a cream that creates a moist wound healing environment) applied, nsg (nursing) and cna (Certified Nursing Assistant) to inform colleagues to monitor. Note left in dr (Doctor) book for evaluation and tx (treatment) . Review of Resident #91's May 2025 Physician's orders and Treatment Administration Record (TAR) included: -apply zinc paste to coccyx 2x day, two times a day for skin integrity, Start Date 5/23/25, D/C (discontinue) 5/27/25. The zinc paste treatment was noted as done daily 5/23/25 through 5/27/25. -coccyx, cleanse with N/S (normal saline) pat dry gently, apply Silver Alginate (a dressing that is absorbent with antimicrobial silver) to wound bed f/b (followed by) dcd (dry clean dressing) daily and prn (as needed). Start Date 5/28/25. The treatment was noted on the TAR as done daily 5/28/25 through 5/31/25. Review of the Resident's June 2025 TAR indicated that the treatment to the coccyx started on 5/28/25 was still in place and noted as done daily on the TAR from 6/1/25 through 6/23/25, except for four days when the Resident was in the hospital (from 6/5/25 through 6/8/25). Review of the MDS Assessment, dated 6/5/25, failed to indicate the Resident had any pressure areas present. During an interview on 6/23/25 at 9:34 A.M., the MDS Nurse said that the MDS Assessment, dated 6/5/25, was coded inaccurately. The MDS Nurse said that the Resident had a Stage 3 pressure area present during the MDS observation period and it should have been coded on the MDS Assessment but it had not been. 6. Review of the RAI (Resident Assessment Instrument) Manual, dated October 2024, indicated the following for MDS item A2105: -This item documents the location to which the resident is being discharged at the time of discharge. -Knowing the setting to which the individual was discharged helps to inform discharge planning. -Code 01, Home/Community: if the resident was discharged to a private home, apartment, board and care, assisted living facility, group home, transitional living, or adult foster care. Resident #93 was admitted to the facility in May 2025. Review of Resident #93's MDS Assessment, dated 5/23/25, indicated the following: -the Resident was discharged to a Short-term General Hospital (acute hospital .) Review of Resident #93's Clinical Nurse Progress Note, dated 5/23/25, indicated the Resident was discharged home. During an interview on 6/20/25 at 1:02 P.M., the MDS Nurse said she had incorrectly coded the Resident's Discharge MDS Assessment regarding the Resident's discharge location. The MDS Nurse said that she refers to the RAI Manual for accuracy of Assessments completed.

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0760 (Tag F0760)

Could have caused harm · This affected multiple residents

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Based on interview and record review, the facility failed to ensure that one Resident (#34), out of a total sample of 19 residents, was free from significant medication errors. Specifically, for Resident #34, the facility failed to ensure that the medication Ingrezza (Valbenazine Tosylate- a medication to treat Tardive Dyskinesia (TD) used to help reduce uncontrolled body movements) was transcribed accurately as prescribed by the Provider, resulting in missed medication administration for a total of ten occasions out of 47 opportunities, for May 2025 and June 2025, putting the Resident at risk for involuntary movements not being managed appropriately. Findings include: Resident #34 was admitted to the facility in June 2024 with diagnoses including malignant neoplasm of the brain (brain tumor), adult failure to thrive, Parkinson's Disease, Epilepsy, drug induced subacute dyskinesia, and a history of falling. Review of Resident #34's June 2025 Physician orders on 6/17/25 at 5:22 P.M., indicated no current order for Valbenazine Tosylate/Ingrezza medication. Review of Resident #34's Provider's Progress Note, dated 6/4/25, indicated the following: -Resident had been off the Ingrezza per nursing for several days, now receiving 80 mg and movements improving. He/she remains with notable involuntary movements but able to stay in bed. It seems he/she is getting his/her Ingrezza per Medication Administration Record (MAR) but missed a dose the other day. -Assessment and Plan: >Tardive Dyskinesia- continue Ingrezza 80 mg via G-tube (gastrostomy tube - a feeding tube inserted into the stomach through the abdomen) qhs (every night at bedtime) for significant TD. Involuntary movements likely contributing to falls. Review of Resident #34's Provider's Progress Note, dated 6/12/25, indicated the following: -Resident remains with notable involuntary[sic], but able to stay in bed -Assessment and Plan: >Tardive Dyskinesia, continue Ingrezza 80 mg via G-tube qhs for significant TD. Involuntary movements likely contribute to falls, Ingrezza seems to be helping. Review of Resident #34's Provider's Progress Note, dated 6/16/25, indicated the following: -Resident had a notable increase in movements so significant he/she had fallen out of the bed and the chair. -Per nursing today Ingrezza is in stock in the nursing cart but unclear if the Resident received the medication over the weekend as it was not indicated on the MAR and it was not charted as given consistently. Ingrezza has helped with TD symptoms and involuntary movements are likely contributing to falls. -Assessment and Plan: >Tardive Dyskinesia, continue Ingrezza 80 mg via G-tube qhs for significant TD. Involuntary movements likely contribute to falls, Ingrezza seems to be helping. Review of Resident #34's Provider's Progress Note, dated 6/17/25, indicated the following: -Assessment and Plan: >Tardive Dyskinesia, continue Ingrezza 80 mg via G-tube qhs for significant TD. Involuntary movements likely contribute to falls, Ingrezza seems to be helping. Review of Resident #34's May 2025 MAR indicated the following: -Valbenazine Tosylate Oral Capsule 40 milligrams (mg). Give one capsule via G-tube in the morning for TD -start date 5/9/25, discontinue date 5/15/25. >5/9/25 -initialed by the nurse as a 9 (other/see progress notes) indicating the medication was not administered. -Valbenazine Tosylate Oral Capsule 40 mg. Give two capsules (total dose of 80 mg) via G-tube at bedtime for TD -start date 5/15/25, discontinue date 6/13/25. >5/21/25, 5/22/25 and 5/30/25 were left blank and not initialed by the nurse as being administered. >5/25/25-initialed by the nurse as a 9. Review of Resident #34's June 2025 MAR indicated the following: -Valbenazine Tosylate Oral Capsule 40 mg. Give two capsules (total dose 80 mg) via G-tube at bedtime for TD -start date 5/15/25, discontinue date 6/13/25. >6/2/25 -initialed by the nurse as a 9. -Valbenazine Tosylate was discontinued on 6/13/25 and not administered on 6/13/25 6/14/25, 6/15/25 or 6/17/25. -A one-time order for Ingrezza 80 mg capsule to be given on 6/16/25 was administered and initialed by the Nurse. Further review of the medical record indicated no documented evidence, or correlating progress notes relative to why the Valbenazine Tosylate was not administered or that the provider had been notified that the medication had not been administered on 5/9/25, 5/21/25, 5/22/25, 5/25/25, 5/30/25, 6/2/25, 6/13/15, 6/14/25, 6/15/25 and 6/17/25 (10 occasions). During an interview on 6/18/25 at 5:22 P.M. Nurse #2 said Resident #34 was prescribed Ingrezza and currently received it in the evening. The surveyor and Nurse #2 reviewed the current order Physician orders and Nurse #2 said there was no current order for the Valbenazine Tosylate/Ingrezza. Nurse #2 said it appeared the medication was discontinued and was not sure why. Nurse #2 said there had been adjustments made to the medication to be administered in the evening at bedtime instead of in the morning, but the medication had not been discontinued to the best of her knowledge. During an interview on 6/23/25 at 11:06 A.M., the Nurse Practitioner (NP) said Resident #34 was prescribed Ingrezza because the NP felt the Resident was benefiting from it and had noted less (involuntary) movement. The NP further said she had not discontinued the Ingrezza medication since re-starting it in May 2025. During an interview on 6/23/25 at 12:01 P.M., with the Regional Nurse Consultant and the Director of Nursing (DON), the DON said there were dates that the medication was not available but would have to go back and research that information. The DON and Regional Nurse Consultant reviewed the May 2025 and June 2025 MARs and said it appeared the Resident did not receive the medication five times in May and once in June. The DON was unsure why the medication had been discontinued on 6/13/25, administered once on 6/16/25 and not administered again on 6/17/25. The DON said that the Resident missed an additional four doses of Ingrezza due to the medication being accidentally discontinued.

MINOR (B)

Minor Issue - procedural, no safety impact

MDS Data Transmission (Tag F0640)

Minor procedural issue · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure Minimum Data Set (MDS) Assessments were completed and transmitted within 14 days of completion for two Residents (#26, #45) reviewed, out of a total of three residents reviewed for MDS records over 120 days, and for one Resident (#25) reviewed, out of a total of three resident reviewed for closed records. Specifically, the facility failed: 1. For Resident #26, to complete a Discharge MDS Assessment. 2. For Residents #45 and #25, to complete Death in the Facility Tracking Records resulting in inaccurate resident tracking. Findings include: Review of the Resident Assessment Instrument (RAI) Version 1.19.1 dated [DATE] indicated the following: -Must be completed when the resident is discharged from the facility and the resident is not expected to return to the facility within 30 days. -Must be completed .within 14 days after the discharge date . -Must be submitted within 14 days after the MDS completion date . Review of the RAI Manual Version 1.19.1 dated [DATE] indicated the following: -A Death in Facility Tracking Record must be completed when the resident dies in the facility. -Must be completed within 7 days after the resident's death -Must be submitted within 14 days after the resident's death. 1. Resident #26 was admitted to the facility in February 2024 with a diagnosis of Sepsis. Review of the Nursing Progress Note, dated [DATE], indicated Resident #26 was discharged from the facility back to his/her home in the community. Review of Resident #26's MDS Assessments failed to indicate that a Discharge MDS Assessment had been completed at the time of Resident #26's discharge. During an interview on [DATE] at 8:43 A.M., the MDS Nurse said a Discharge MDS Assessment for Resident #26 should have been completed but was not. 2A. Resident #45 was admitted to the facility in [DATE] with a diagnosis of Malignant Neoplasm of the skin (skin cancer). Review of Resident #45's Registered Nurse (RN)/Physician Assistant (PA)/Nurse Practitioner (NP) Pronouncement of Death, dated [DATE], indicated he/she expired in the facility on [DATE]. Review of Resident #45's MDS Assessments failed to indicate a Death in the Facility Tracking Record had been completed when Resident #45 expired on [DATE]. During an interview on [DATE] at 8:43 A.M., the MDS Nurse said a Death in the Facility Tracking Record for Resident #45 should have been completed but was not. B. Resident #25 was admitted to the facility in [DATE]. Review of Resident #25's nursing progress notes indicated the following: -the Resident expired in the facility on [DATE]. Review of the MDS Assessments failed to indicate a Death in the Facility Tracking Record had been completed when the Resident expired on [DATE]. During an interview on [DATE] at 1:03 P.M., the MDS Nurse said that a Death in the Facility Tracking Record should have been completed for Resident #25, but one was not. The MDS Nurse said that she refers to the RAI Manual for accuracy and timeliness of MDS Assessment completion.

Oct 2024 1 deficiency

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Report Alleged Abuse (Tag F0609)

Could have caused harm · This affected 1 resident

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Based on interviews and records reviewed for one of three sampled residents (Resident #1), who back in June 2024, alleged that during care by a staff member, he/she was physically abused, the Facility failed to ensure they reported the final results of their abuse investigation to the Department of Public Health (DPH) within five working days, when although an allegation of abuse, involving Resident #1 and Certified Nurse Aide (CNA) #1, was reported on 06/06/24, the final results of the investigation however, were not reported to the DPH until 10/01/24, almost four months later. Findings include: Review of the Agency Policy titled Abuse: Identification and Reporting, dated as revised March 2022, indicated the results of all investigations must be reported to the administrator and to other officials in accordance with state law within five working days of the incident and if the alleged violation is verified, appropriate corrective action must be taken. Review of Reports submitted to the DPH by the facility via the Health Care Facility Reporting System (HCFRS) indicated that on 06/06/24, the Facility submitted an initial report that indicated Resident #1 alleged that on 06/05/24, CNA #1 dropped his/her legs during care, resulting in severe pain. Further review of the Report from the Facility in HCFRS indicated, after submission of the initial report, the Facility was repeatedly contacted by the DPH Intake Department (on 06/11/24, 07/17/24, 08/29/24, 09/04/24, 09/17/24, and 09/20/24) requesting a final summary of the outcome of the Facility's Internal Investigation, and the summary was not received by DPH until 10/01/24. During an interview on 10/23/24 at 8:00 A.M., the Director of Nurses (DON) said that she was not working at the Facility at the time of the investigation, and that she was not sure why the final report was not submitted within the required time frame.

May 2024 17 deficiencies

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Grievances (Tag F0585)

Could have caused harm · This affected 1 resident

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Based on record review and interviews the facility failed to implement their grievance policy and assist one Resident (#56) to file a grievance out of a total sample of 21 residents. Specifically, the facility staff failed to follow up and investigate a report of a missing electric razor. Findings include: Review of the facility policy titled Grievances, dated 8/2019 indicated the following: -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. -Upon receipt of a grievance, complaint report or the missing items form, the Director of Social services will begin an investigation into the allegation. Resident #56 was admitted to the facility in August 2023 with diagnoses that include Parkinson's disease (a disorder of the central nervous system that affects movement, often including tremors). Review of the Minimum Date Set (MDS) Assessment, dated 3/29/24, indicated the Resident had moderate cognitive impairment as evidenced by a Brief Interview for Mental Status (BIMS) exam score of 10 out of a possible 15 and, and was dependent on staff for personal hygiene. Review of the Nurses Notes dated 12/10/23, indicated the Resident's family reported a missing electric razor. The charger was plugged into the wall in his room, but the razor could not be found. During an interview on 5/23/24 at 5:08 P.M., Social Worker (SW) #1 said she had not been aware of the missing razor until the surveyor had informed her of the Nurses Note dated 12/10/23. SW #1 said that since that time, she had talked with staff on the unit, and they remembered the razor going missing. SW #1 said she had reviewed the grievance log and said there was no evidence that a grievance form had been filled out or that an investigation into the missing razor had been initiated. SW #1 said the process for missing items is that facility staff should assist the resident or family to fill out a grievance form and the staff should give the form to a Unit Manager or anyone in management. She said an investigation should have been initiated and if the missing razor was not found the Resident should have been reimbursed.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Abuse Prevention Policies (Tag F0607)

Could have caused harm · This affected 1 resident

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Based on interviews, records review and policy review, the facility failed to implement their abuse policies and procedures. Specifically; 1) The facility failed to investigate an allegation of abuse according to policy and procedure for one Resident (#30), out of a total of 21 sampled residents resulting in potential for psychological harm. 2) The facility failed to implement their employee screening procedures to ensure new employees have no previous abuse, neglect or mistreatment findings for one staff member (CNA #4) out of 5 staff members reviewed. Findings include: Review of facility policy titled Abuse: Investigation, dated March 2022, indicated but was not limited to the following: -The nursing supervisor will coordinate the interview process during the shift in which the event was reported. Any individual who may have knowledge of the event should be interviewed. This includes the alleged victim, employees working during the shift when the event was discovered/reported, as well as visitors and other residents who may have witnessed something. -Documentation of the incident/alleged incident will be entered into the resident's medical record Review of the facility policy titled Abuse Screening, dated March 2022, indicated but was not limited to the following: -The Nurse Aide Registry is checked prior to employment for all facility employees. If applicant indicates employment in another state, that Nurse Aide Registry is checked. -The person responsible for hiring will ensure that the request for the required criminal background check (CORI) has been submitted no later than the date of initial orientation. -Documentation on all of the above information will be maintained as part of the employment record. 1) Resident # 30 was admitted to the facility in June 2023 with diagnoses of Anxiety Disorder (feelings of fear, dread, uneasiness) and Depression (a recurring feeling of sadness/hopelessness, loss of interest in activities). Review of Resident #30's Minimum Data Set (MDS) Assessment, dated 4/3/24, indicated a Brief Interview for Mental Status (BIMS) score of 14 (cognitively intact) out of 15. During an interview on 5/22/24 at 1:00 P.M., Resident #30 made an allegation of verbal abuse by staff to the surveyor. The Resident alleged the following: -Approximately 4 months ago the Resident asked a Certified Nurse Aide (CNA)for a ginger ale, and she told him/her no, she didn't feel like it. -The Resident reported the interaction relative to ginger ale to the Man Director. -The CNA returned the next day and made comments to the Resident that he/she likes to report people. The Resident felt afraid the CNA would hit her. -The Resident observed the CNA to eat off residents' tray and then pass the tray to those residents 4 separate times during a meal. -The Resident reported the tray incident to a staff member. -The CNA came into the Resident's room and said to the Resident if he/she kept reporting people he/she'd find him/herself on the floor with his/her head split open. -The Resident reported the CNA's threatening comments to the head nurse. -The CNA was moved to a different unit (fourth floor). The Resident still saw her when he/she would go upstairs to play bingo and the CNA would give him/her the middle finger. -The Resident reported the CNA's gestures to an activities assistant. -At the conclusion of the interview, the Resident said that he/she did not feel safe. Immediately after the Resident interview, the surveyor informed the Director of Nursing (DON) and Administrator of the allegation. The DON said an investigation of the allegation and a report to Department of Public Health (DPH) would be initiated immediately. A review of Resident #30's May 2024 interdisciplinary progress notes on 5/24/24 at 8:30 A.M. indicated no documentation of interview or follow-up on reported allegations. During an interview on 5/24/24 at 8:38 A.M., Social Worker (SW) #2 said that she had not been working on this investigation, but that SW #1 had been unable to interview the Resident because he/she had attended activities during the day on 5/22/24 and 5/23/24. SW #2 said the expectation for an allegation of abuse would be that the resident would be interviewed the same day as the allegation was received, and that the interview or attempted interview(s), (if unable to obtain the interview), would be documented in a social work progress note within the resident's clinical record. SW #2 further said that there would be an expectation of psychosocial follow-up for this type of allegation with a minimum of three visits over about a 3-week period with the first visit typically occurring the day after the allegation was made. Review of a typed, unsigned addendum to SW #2's summary of interview with Resident #30 dated 5/24/24 at 10:25 A.M. indicated the surveyor's reported allegation to SW #1 and that the Resident was unable to meet with the Social Worker when three attempts were made on 5/22/24 and three attempts were made on 5/23/24 due to his/her attendance in activities. During a review of Resident #30's Interdisciplinary Progress Notes on 5/24/24 at 11:00 A.M., a late entry Nursing Progress Note written by the DON for 5/22/24 at 1:30 P.M. was entered into the medical record on 5/24/24 at 10:30 A.M. that indicated the Resident was provided support by social services. During an interview on 5/24/24 at 11:00 A.M., Resident #30 said the first-time staff met with him/her to discuss the allegations reported to surveyor on 5/22/24, was that morning (two days later). When asked, Resident #30 said that no one had attempted to meet with him/her when he/she was at an activity. During an interview on 5/24/24 at 11:48 A.M., Activity Assistant (AA) #1 said she has worked at the facility for many years as an activities assistant and is familiar with Resident #30. AA #1 said that a couple months ago when the Resident resided on the second floor, he/she brought a concern about CNA #5 to her. AA #1 said the Resident would not specify the concern and only reported to her that he/she did not like CNA #5 at that time. AA #1 said she brought the Resident down to speak with the former administrator and former director of nursing who worked at the facility at the time the concern was brought to her, and CNA #5 was moved to the fourth floor. During an interview on 5/24/24 at 1:46 P.M., the Administrator said that the involved resident should be interviewed right away when allegations of abuse are made. The Administrator said any staff member can complete the interview and that evidence that the interview occurred or had been attempted should be documented in the resident's interdisciplinary progress notes. During an interview on 5/24/24 at 4:03 P.M. the DON said the expectation for investigating abuse means the involved resident would immediately be interviewed about the allegation. The DON said this process did not occur for Resident #30's allegation of abuse. Relative to the late entry Nursing Progress Note dated 5/22/24 at 1:30 P.M., the DON said she entered this progress note because she thought that someone would interview the Resident about the allegation of abuse but said that she did not verify the interview occurred before documenting the nursing progress note. 2) CNA #4 was hired to the facility in March 2023. Review of CNA #4's Human Resources (HR) file indicated no evidence of a CORI check or Nurse Aide Registry check being completed. During an interview on 5/24/24 at 3:20 P.M., Regional Consultant Nurse #1 said that the facility was unable to provide documentation of a CORI check or Nurse Aide Registry check for CNA #4.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Investigate Abuse (Tag F0610)

Could have caused harm · This affected 1 resident

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Based on observation, interviews, records review and policy review, the facility failed to prevent the potential for further abuse for one Resident (#30) out of a total of 21 sampled residents. Specifically, the facility failed to follow their policy and take steps to protect the Resident and prevent him/her from the potential of further abuse during an investigation of an allegation of abuse. Findings include: Review of the facility policy titled Abuse: Identification & Reporting dated March 2022 indicated but was not limited to the following: -All alleged violations are thoroughly investigated and must prevent further potential abuse while the investigation is in process Review of the facility policy titled Abuse: Investigation dated March 2022 indicated but was not limited to the following: -The nursing supervisor will take appropriate steps to protect the resident, if applicable, from further mistreatment and to ensure appropriate care is provided. Separate accused/suspected employee or resident from alleged victim and other residents. Suspension of employee pending investigation as indicated. -Interviews of appropriate individuals. The nursing supervisor will coordinate the interview process during the shift in which the event was reported. Any individuals who may have knowledge of the event should be interviewed. This includes the alleged victim, employees working during the shift when the event was discovered/reported, as well as visitors and other residents who may have witnessed something. Resident # 30 was admitted to the facility in June 2023 with diagnoses of Anxiety Disorder (feelings of fear, dread, uneasiness) and Depression (a recurring feeling of sadness/hopelessness, loss of interest in activities). Review of Resident #30's Minimum Data Set (MDS) Assessment, dated 4/3/24, indicated a Brief Interview for Mental Status (BIMS) score of 14 (cognitively intact) out of 15. During an interview on 5/22/24 at 1:00 P.M., Resident #30 made an allegation of verbal abuse by staff to the surveyor. The Resident alleged the following: -Approximately 4 months ago the Resident asked a Certified Nurse Aide (CNA)for a ginger ale, and she told him/her no, she didn't feel like it. -The Resident reported the interaction relative to ginger ale to the Man Director. -The CNA returned the next day and made comments to the Resident that he/she likes to report people. The Resident felt afraid the CNA would hit her. -The Resident observed the CNA to eat off residents' tray and then pass the tray to those residents 4 separate times during a meal. -The Resident reported the tray incident to a staff member. -The CNA came into the Resident's room and said to the Resident if he/she kept reporting people he/she'd find him/herself on the floor with his/her head split open. -The Resident reported the CNA's threatening comments to the head nurse. -The CNA was moved to a different unit (fourth floor). The Resident still saw her when he/she would go upstairs to play bingo and the CNA would give him/her the middle finger. -The Resident reported the CNA's gestures to an activities assistant. -At the conclusion of the interview, the Resident said that he/she did not feel safe. Immediately after the Resident interview, the surveyor informed the Director of Nursing (DON) and Administrator of the allegation. The DON said an investigation of the allegation and a report to Department of Public Health (DPH) would be initiated immediately. During an interview on 5/24/24 at 8:38 A.M., Social Worker (SW) #2 said that she had not been working on this investigation, but that SW #1 had been unable to interview the Resident because he/she had attended activities during the day on 5/22/24 and 5/23/24. SW #2 said the expectation for an allegation of abuse would be that the resident would be interviewed the same day as the allegation was received, and that the interview or attempted interview(s), (if unable to obtain the interview), would be documented in a social work progress note within the resident's clinical record. On 5/24/24 at 10:50 A.M., Resident #30 was observed exiting the elevator onto the third floor. The Resident said he/she had returned from an activity on the second floor where the accused CNA was currently working. The Resident said he/she left the activity because the CNA was giving him/her the finger while he/she was there. The Resident said that until that morning (5/24/24), no staff member had approached him/her to discuss the allegations made to the surveyor on 5/22/24. When asked, the Resident said specifically that no one had approached him/her to speak about his/her concerns with the CNA while at an activity. On 5/24/24 at 11:15 A.M. the surveyor observed an activity occurring in the dining room of the second floor. Review of the investigation data provided by the DON on 5/24/24 at 11:15 A.M. indicated one completed interview with Resident #30. There was no documented evidence of interviews with other residents, staff or visitors provided. During an interview on 5/24/24 at 11:48 A.M., Activity Assistant (AA) #1 said she has worked at the facility for many years as an activities assistant and was familiar with Resident #30. AA #1 said that a couple months ago, when the Resident resided on the second floor, he/she brought a concern about CNA #5 to her. AA #1 said the Resident would not specify the concern and only reported to her that he/she did not like CNA #5 at that time. AA #1 said she brought the Resident down to speak with the former Administrator and former DON and CNA #5 was moved to the fourth floor to work. During an interview on 5/24/24 at 1:46 P.M., the Administrator said that the involved resident should be interviewed right away when allegations of abuse are made. The Administrator further said that the expectation would be that social services would interview all alert and oriented residents on the same assignment about their care relative to the allegation. During an interview on 5/24/24 at 1:57 P.M., SW #2 said that she was given a name for the staff member today (5/24/24) during her interview with the Resident at 9:30 A.M. SW #2 further said the Resident also gave information about the CNA's car to assist in identifying the staff member. During an interview on 5/24/24 at 4:03 P.M., the DON said the Resident should have been interviewed immediately upon identification of the allegation. When asked, the DON said that interviews were being completed now, but that she could not provide any additional evidence of other interviews that had been completed. The DON said that efforts to identify the accused CNA should have been made so the facility could implement measures, such as removing the accused CNA from the schedule, to protect the Resident from the potential for further abuse while the investigation was ongoing.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

PASARR Coordination (Tag F0644)

Could have caused harm · This affected 1 resident

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Based on record review and interview, the facility failed to provide recommended specialized services from the Preadmission Screening and Resident Review (PASRR- a federal and state-required process that is designed to, among other things, identify evidence of serious mental illness (SMI) and/or intellectual or developmental disabilities (ID/DD) in all individuals (regardless of source of payment) seeking admission to Medicaid- or Medicare-certified nursing facilities) Level II Evaluation (an evaluation conducted to determine if an individual who screened positive for an SMI or ID/DD requires specialized services), for one Resident (#21) out of 21 total residents sampled. Specifically, the facility failed to provide Resident #21 with individual psychotherapy as recommended by the Department of Mental Health (DMH) based on the PASRR Level II Evaluation. Findings include: Resident #21 was admitted to the facility in January 2024 with multiple diagnoses that included Bipolar Disorder (a SMI that causes extreme mood swings, from high to low, that affect your energy, thinking, and behavior). Review of the PASRR Level II Evaluation Determination Summary, completed on 2/26/24, indicated that Resident #21 met SMI criteria for PASRR involvement, and it was recommenced that he/she received individual psychotherapy. Review of the Behavioral Health Group note dated 3/22/24 indicated that Resident #21 is now open to psychotherapy. Further review of the Resident's medical record indicated no documented evidence that Resident #21 received individualized psychotherapy as recommended in the PASRR Level II Evaluation Determination Summary. During an interview on 5/22/24 at 1:24 P.M. Social Worker (SW) #1 said that she was unable to find any notes at this time indicating that the Resident had been seen by anyone for talk therapy since he/she had agreed to receive this service on 3/22/24. SW #1 said that the process is that the team would review the psych recommendations provided by the Physician Assistant through the Behavioral Health Group, put the recommendations in the psych book that is located on each unit, so that the person who provided talk therapy would know to see this Resident. She further said that per the recommendations made by the PASRR Level II Evaluation, the Resident should have been seen by the therapist soon after he/she agreed to the services and was not as required.

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

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Based on observation, interview, and record review the facility failed to ensure an intervention was implemented as recommended by the Wound Physician's Assistant (PA) for one Resident (#48) out of a total sample of 21 residents. Specifically, the facility failed to ensure a protective boot was obtained for Resident #48 as recommended by the Wound PA to protect the Resident's foot where he/she had a transmetatarsal amputation (TMA-surgical removal of part of the foot). Findings include: Resident #48 was admitted to the facility in January 2023 with diagnoses including Type 2 Diabetes Mellitus, right TMA, and osteomyelitis (a bone infection). During an observation on 5/21/24 at 8:54 A.M., the surveyor observed Resident #48 seated in his/her wheelchair. He/She had a bandage to his/her right foot area, was dangling, and he/she was not wearing a protective boot. During an observation on 5/22/24 from 8:34 A.M. to 9:12 A.M., the surveyor observed Resident #48 to be seated in his/her wheelchair. He/She had a bandage to his/her right foot area and was not wearing a protective boot. During an observation on 5/22/24 at 9:26 A.M., the surveyor observed Resident #48 seated in his/her wheelchair and resting the bandaged area of his/her foot directly on the ground. During an observation on 5/22/24 at 12:43 P.M., the surveyor observed Resident #48 seated in his/her wheelchair and resting the bandaged area of his/her foot directly on the ground. Review of the care plan titled Resident has an actual alternation in skin integrity, right foot TMA, initiated 10/26/23 indicated the following interventions: -Follow Medical Doctor orders for skin care and treatment initiated 10/26/23 -Refer to rehab services as indicated initiated 10/26/23 -Refer to wound care doctor as needed initiated 10/26/23 Review of the 4/26/24, 5/2/24, 5/10/24, and 5/17/24 the facility's contract wound company's Progress notes indicated it had been recommended the Resident was fitted for a Darco Boot (a name brand orthotic boot that is commonly used for post surgical healing, the boot is designed to protect a surgical area from being bumped on surfaces and to reduce weight bearing pressure on a wound). During an interview on 5/22/24 at 12:26 P.M., Nurse #2 said Resident #48 did not have a boot for his/her right foot and nursing was only bandaging the foot daily. During an interview on 5/22/24 at 4:17 P.M., the Regional Rehabilitation Director said she was unaware of the recommendation for the Resident to be fitted with a Darco boot until the surveyor asked about the boot. She said she would expect that nursing would have let the rehabilitation department know of the recommendation for the boot so the rehabilitation staff could start the process of obtaining the boot for the Resident. During an interview on 5/23/24 at 2:45 P.M., with the Wound PA and Medical Director of the wound care company, the Wound PA said an associate from the wound care company made the recommendation for the Darco boot on 4/26/24. She said the Darco boot would provide a protective barrier for the Resident's right foot wound. She further said she would expect the facility would have started the process to obtain the Darco boot within a week of the wound care team's recommendation and the facility had not yet started the process of obtaining the Darco boot as recommended.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0685 (Tag F0685)

Could have caused harm · This affected 1 resident

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Based on record review an interview the facility failed to ensure one Resident (#12) out of a total of 21 residents sampled received proper treatment and assistive devices to maintain vision abilities. Specifically, for Resident #12 the facility failed to coordinate follow-up services relative to vision, after communicating his/her vision concerns. Findings include: Resident #12 was admitted to the facility in February 2022. Review of the 2/22/24 Minimum Data Set (MDS) Assessment indicated the Resident was cognitively intact as evidenced by a BIMS (Brief Interview for Mental Status) score of 15 out of 15. Review of the Request for Services signed by the Resident on 2/28/22, indicated Eye Care as one of the requested services provided by the mobile contracted agency. During an observation and interview on 5/21/24 at 12:07 P.M., Resident #12 said that he/she had been seen by the eye doctor sometime last July and has not been seen again since. He said that during this visit he/she understood that he/she would be obtaining new glasses to help with his/her worsening vision. The Resident said that he/she cannot see well and would like glasses. The Resident was observed to not be wearing glasses. Review of a Nursing Progress Note dated 12/24/23 indicated the following: -Son informed about need for new glasses and services provided here in that regard. Message left to contact facility after holiday to make arrangements for eye exam and new pair of glasses. Review of the care plan meeting note dated 3/12/24 indicated the following: -Son had concerns with eyeglasses, that he/she (the Resident) needed new ones. During an interview on 5/21/24 at 4:23 P.M. Nurse #3 said that she had never seen the Resident wearing glasses and is unaware of his/her need for new glasses. During a telephone interview on 5/22/24 at 11:06 A.M., Resident #12's son said that about one year ago someone came to the facility and assessed the Resident's eyes. He said that the company who completed the vision assessment said that they would be following up and providing new glasses. The glasses never came, and he said the Resident often talked about how his/her vision being poor and continued difficulty when watching television and reading. He said he and the Resident had both brought it up during care plan meetings and at different times in passing, however, nothing had been done about obtaining the new glasses or a follow up visit at this time. He said that he has even offered to take the Resident out to a provider to obtain the new glasses but was assured by the facility that they had a contract with a company who could see the Resident at the facility. During an interview on 5/22/24 at 2:04 P.M., Social Worker (SW) #1 said that she was unable to locate any documentation that the Resident had been seen by the contracted vision care agency for the Resident's vision concerns. SW #1 provided a copy of the signed Request for Service form and said that the Resident did wish to have vision care services provided and should have, as requested. During an interview on 5/23/24 at 1:21 P.M., Nurse #3 said that she reviewed the Nursing Progress Note dated 12/24/23 and said that the nurse who wrote the note was a per diem (worked only on an as-needed basis) nurse and did not follow up or do anything with the referral information. She said that nothing had been done and ball had been dropped. During an interview on 5/23/24 at 1:26 P.M., the eye doctor who worked for the contracted agency told the surveyor that he is at the facility monthly and sees the residents that are on the list he is provided.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0698 (Tag F0698)

Could have caused harm · This affected 1 resident

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Based on record review, policy review and interview, the facility failed to provide care and services consistent with professional standards for one Resident (#1) out of one applicable resident, out of a total sample of 21 residents. Specifically, the facility staff failed to coordinate delivery of medications with Resident #1's dialysis (procedure to remove waste products and excess fluid from the blood when the kidneys stop working properly) treatment schedule to ensure the Resident received all medication as ordered by the Physician. Findings include: Review of the facility's policy titled Care of a Resident with End Stage Renal Disease (ESRD-a permanent stage of chronic kidney disease that occurs when the kidneys can no longer function on their own requiring dialysis or a kidney transplant), dated 4/2022 indicated the following: -Staff caring for residents with End Stage Renal Disease, including residents receiving dialysis outside the facility, shall be trained in the care and special needs of these residents. -Education and training of staff includes, specifically: Timing and administration of medications, particularly those before and after dialysis. Resident #1 was admitted to the facility in August 2023 with a diagnosis of ESRD. Review of the medical record indicated the Resident received Dialysis treatments every Monday, Wednesday and Friday at an off-site Dialysis center. Review of the Physician's Orders dated May 2024 indicated the following orders: -Gabapentin (a medication used to treat seizures or nerve pain) 100 milligrams (mg) give one time daily related to diabetic neuropathy (a type of nerve damage), date initiated 10/5/23. -Acetaminophen (a medication used to treat mild or chronic pain) 975 mg by mouth every eight hours related to low back pain, date initiated, 3/3/23. -Hydralazine (a medication used to treat high blood pressure) 100 mg three times a day for hypertensive urgency (high blood pressure), date initiated 3/4/23. -Vistaril (a medication used to treat anxiety, nausea, allergies, and itching) 25 mg three times a day for itching, date initiated 4/26/24. Review of the Medication Administration Record (MAR) dated May 2024, indicated the following: -Gabapentin 100 mg was scheduled to be administered daily at 2:00 P.M. -Acetaminophen 975 mg was scheduled to be administered daily at 6:00 A.M., 2:00 P.M, and 10:00 P.M. -Hydralazine 100 mg was scheduled to be administered daily at 9:00 A.M., 1:00 P.M., and 5:00 P.M. -Vistaril 25 mg was scheduled to be administered daily at 9:00 A.M., 1:00 P.M., and 5:00 P.M. Review of the MAR dated 5/1/24 through 5/22/24 indicated the Resident did not receive the following medications on 5/1/24, 5/3/24, 5/6/24, 5/8/24, 5/10/24, 5/13/24, 5/15/24, 5/17/24, 5/20/24 and 5/22/24 due to the Resident being at dialysis: - Gabapentin 100 mg at 2:00 P.M, -Acetaminophen 975 mg at 2:00 P.M., -Hydralazine 100 mg at 1:00 P.M., and -Vistaril 25 mg at 1:00 P.M. During an interview on 5/22/24 at 9:50 A.M., Nurse #2 said the Resident goes to dialysis on Monday, Wednesday and Friday and on those days, he charts the 1:00 P.M. and 2:00 P.M. medications as not given-absent from building. He says he does not send any medication to the dialysis center with the Resident, but he believes that the medications were administered at the dialysis center. During an interview on 5/22/24 at 1:03 P.M., Nurse #2 said he had called the dialysis center and found out the dialysis center does not administer the Resident his/her scheduled medications prescribed at the facility, and that the Resident has not been getting his/her scheduled 1:00 P.M. and 2:00 P.M. medications as ordered by the Physician on dialysis days. During an interview on 5/22/24 at 3:33 P.M., the Director of Nurses says the prescribed medications should not have been omitted on dialysis days and the medication administration times should have been adjusted.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0730 (Tag F0730)

Could have caused harm · This affected 1 resident

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Based on interviews, record review and review of the Facility Assessment (an assessment completed by the facility to identify what resources are necessary for competent care of residents on a day-to-day or emergency basis), the facility failed to ensure annual performance appraisals for Certified Nurse Aides (CNAs) were completed every 12 months. Specifically, the facility failed to ensure that two CNAs (#4 and #5) out of 2 applicable CNAs reviewed had an annual performance appraisal completed and ensured regular in-service education was completed based on the result of the performance appraisals. Findings include: Review of the Facility Assessment, dated 4/17/24, indicated no documented evidence the facility addressed the need for annual performance appraisals of CNAs. CNA #4 was hired to the facility on 3/15/23. A review of CNA #4's Human Resource (HR) record indicated no documented evidence that performance appraisal(s) had occurred. CNA #5 was hired to the facility on 1/21/20. A review of CNA #5's HR record indicated no documented evidence that performance appraisal(s) had occurred. During an interview on 5/24/24 at 2:14 P.M., the Infection Control Nurse/Staff Development Coordinator (ICP/SDC) indicated that performance appraisals should occur annually for staff and that the Director of Nursing or Unit Manager would be the person(s) responsible for completing nursing staff performance appraisals. ICP/SDC said that CNA #4 and CNA #5 should have had annual performance appraisals completed. During an interview on 5/24/24 at 3:21 P.M., the Regional Consultant Nurse #1 said that the facility could not produce evidence that performance appraisals had occurred for CNA #4 and CNA #5. The Regional Consultant Nurse #1 further said that the Administrator and DON were new and would not be able to answer for previous practice, and that the performance appraisals should have been completed annually and would be kept in the employee's HR records. During an interview on 5/24/24 at 5:00 P.M., the Administrator stated the facility did not have a policy for performance appraisals.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0740 (Tag F0740)

Could have caused harm · This affected 1 resident

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Based on record review and interview, the facility failed to provide the necessary Behavioral Health care and services to attain or maintain the highest practicable mental, and psychosocial well-being for one Resident (#56), out of a total sample of 21 residents. Specifically, the facility staff failed to provide Behavioral Health Services for Resident #56 when he/she displayed symptoms of Depression (a common and serious mood disorder that may include symptoms of fatigue, sleep and appetite disturbances, agitation, and expressions of guilt, difficulty concentrating, apathy, withdrawal, and suicidal ideation). Findings include: Resident #56 was admitted to the facility in August 2023 with diagnoses that include Parkinson's disease (a disorder of the central nervous system that affects movement, often including tremors) and Depression. Review of the Minimum Data Set (MDS) Assessment, dated 3/29/24, indicated the Resident had moderate cognitive impairment as evidenced by a Brief Interview for Mental Status (BIMS) exam score of 10 out of a possible 15, and took antidepressant medication. Review of the Physician's Orders dated 5/23/24 indicated the following: -Sertraline (an antidepressant used to treat the symptoms of depression) 50 milligrams (mg) one time daily for depression, date initiated 8/30/23. Review of the Request for Service form dated 12/21/23, indicated the Resident Representative had provided consent for Behavioral Health Services. Review of the Interdisciplinary Progress Note, dated 4/10/24, indicated the Resident's Health Care Proxy shared concerns for the Resident's depression. The note further indicated the Resident would be seen by Psychiatric services. Review of the Care Plan Meeting Note, dated 4/10/24, indicated the Resident's sister reported the Resident was more down lately, almost depressed. The note further indicated the Resident would be seen by Psychiatric services. Further review of the clinical record indicated no documented evidence the Resident was provided Behavioral Health Services. During an interview on 5/23/24 at 1:48 P.M., Social Worker (SW) #1 said the process for signing a resident up for Behavioral Health Services was to obtain consent, and then put the resident's name and the reason for the referral in the Behavioral Health book located in the Social Services office. She reviewed the book and said that she did not see a referral for Resident #56. She said Behavioral Health providers come to the facility about once a week, they review the book, and if a new resident was added, they will initiate services. She said Resident #56 had a consent on file but that she had no evidence that Behavioral Health services had been offered.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0825 (Tag F0825)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to provide specialized rehabilitation services for one Resident (#78) out of 21 total residents sampled. Specifically, for Resident #78 the facility failed to obtain specialized services relative to speech-language pathology for a Resident experiencing ongoing difficulty swallowing putting him/her at an increased risk of experiencing an adverse effect such as aspiration pneumonia (a type of lung infection that is due to a relatively large amount of material from the stomach or mouth entering the lungs) or choking. Findings include: Review of the Facility assessment dated [DATE] indicated the facility will provide Speech/language services based on the Resident's needs. Resident #78 was admitted to the facility in June 2023 and had the following diagnoses: of GERD (gastro-esophageal reflux disease, a condition that causes heartburn or acid indigestion) and Dysphagia (difficulty in swallowing food or liquid). Review of the 3/13/24 Minimum Data Set (MDS) Assessment indicated the Resident was cognitively intact as evidenced by a BIMS (Brief Interview for Mental Status) score of 14 out of 15. Review of the Physician's Order Summary Report as of 5/33/24, indicated an order for Speech Therapy to evaluate and treat as indicated, initiated on 6/8/23. Review of a dietary note dated 12/12/23 indicated the following: -Resident reports incomplete swallow, coughing with eating, feeling raspy crumbs in throat. -Kitchen, SLP (Speech and Language Pathologist) and NP (Nurse Practitioner) notified. Review of the NP encounter note dated 12/13/23 indicated the following: -Seen today regarding staff noting recent cough with meals. -Will request speech to evaluate and treat. -He/she stated he/she coughed when eating and drinking -He/she stated, it gets stuck and comes up mucous. During an interview on 5/22/23 at 2:00 P.M., the Director of Rehabilitation reviewed the Resident's medical record and said that she did not have any SLP notes available and further said that it did not appear that Resident #78 had been seen by a SLP. She further said that the referral process was for nursing staff to complete a therapy communication form that should be located on each unit and then brought to morning meeting each day. She said that if the therapy communication form was not brought to morning meeting and given directly to the Director of Rehabilitation, the completed form could be left in the bin outside of the rehabilitation gym door. The Director of Rehabilitation said that she had no evidence of receiving a referral for Resident #78 to be seen by the SLP. She further explained that the SLP worked full time at another facility but came in as needed. During an interview on 5/23/24 at 1:31 P.M., Nurse #3 said that the Resident continued to have swallowing concerns that included difficulty swallowing, feeling like food is too hard and increased mucus. She said that these concerns had been identified by both the Dietician and the NP in December 2023, both with recommendations to be seen by the SLP. She said that the referral had never been communicated therefore the Resident was never seen by the SLP, placing him/her at risk for an adverse situation to occur such as aspiration pneumonia or choking, due to his/her difficulty swallowing. Nurse #3 said that the referral should have been communicated back when it was first acknowledged that the Resident was having difficulty swallowing and was not. She further said there was a lack of communication and the referral fell through the cracks. During an interview on 5/23/24 at 2:13 P.M., NP #1 said when she made a referral or had a new order, she would write it down on a progress note, verbally communicate with nursing, review the handwritten progress note and the receiving nurse would then sign off acknowledging that the referral, recommendation and/or new order was received. She further said she could not speak to why the referral had not been completed for Resident #78.

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Accident Prevention (Tag F0689)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to ensure precautions are taken for the resident's individual safety relative to smoking. Specifically, the facility failed to: 1. Ensure fire prevention equipment was readily available in the smoking area to ensure a safe smoking environment. 2. Ensure the smoking plan of care was implemented for two Residents (#82 and #244) out of four applicable residents out of a total of 21 sampled residents relative to resident possession of smoking materials (Resident #82 and #244) and providing a safety intervention (smoking apron) (Resident #244 and #245) assessed to require one. 3. Ensure staff, who accompanied residents outside to smoke, were educated as to what safety interventions to implement in the event of an emergency relative to resident smoking. Findings include: Review of the Department of Health and Human Services Centers for Medicare and Medicaid Services Memorandum titled, Smoking Safety in Long Term Care Facilities, dated 11/10/11 included but was not limited to: - Facilities must include assessment of smoking areas and provision of emergency equipment in the designated smoking areas. - The facility is obligated to ensure the safety of designated smoking areas .the facility is also required to provide portable fire extinguishers in all facilities Review of the facility policy titled Smoking, revised 3/2022, indicated the following: -Smoking is only permitted in designated resident smoking areas, which are located outside of the building. -Metal containers, with self-closing cover devices, are available in smoking areas. - Residents who have independent smoking privileges are not permitted to keep cigarettes, pipes, tobacco, and other smoking articles in their possession. - Residents without independent smoking privileges may not have or keep any smoking articles including cigarettes, tobacco, etc., except when they are under direct supervision. 1. The facility failed to ensure fire prevention equipment such as a fire extinguisher and a fire blanket were readily available to ensure a safe smoking environment. During an observation and subsequent interview following a resident smoking break on 5/21/24 between 9:27 A.M. until 9:35 A.M., the surveyor observed Certified Nursing Assistant (CNA) #5 escort three residents (Residents #82, #244, and #245) outside to smoke. The surveyor did not observe any fire prevention equipment in the smoking area such as a fire blanket or fire extinguisher. The surveyor asked CNA #5 what she would do if there was a fire emergency. CNA #5 looked around the area and said, good question. The surveyor asked CNA #5 if there was a fire blanket or fire extinguisher nearby and CNA #5 said there was not. CNA #5 then said she did not know what to do if there were to be a fire that involved one of the residents other than attempt to pat the fire out and yell for help. During an observation and interview on 5/21/24 at 9:40 A.M., the surveyor observed the front entrance to the building, both inside and outside, as well as the main lobby and did not observe fire prevention equipment. The surveyor asked the receptionist if there were any fire extinguishing materials behind her desk or anywhere in the lobby and she said there were not. During an interview on 5/22/24 at 3:35 P.M., the Regional Director of Operations said there was not a fire extinguisher located in the vicinity of the designated smoking area. 2. The facility failed to implement the smoking plan of care for two Residents related to possession of smoking materials (Resident #82 and #244) and applying a protective smoking apron to two Residents assessed to need one (Resident #244 and #245) During an observation of resident smoking and a concurrent interview on 5/21/24 from 9:27 A.M. until 9:35 A.M., the surveyor observed three Residents (#82, #244, and #245) outside smoking accompanied by CNA #5. The surveyor asked CNA #5 if the residents were allowed to keep their cigarettes on their person or if they were required to have their smoking paraphernalia locked up on the unit. CNA #5 said Resident #82 and Resident #245 had permission to keep cigarettes in their possession, but Resident #244 was not allowed to keep cigarettes in his/her possession. At that time, Resident #244 spoke up and said he/she kept his/her cigarettes in his/her possession because, they trust me with them. 2a. Resident #82 was admitted to the facility in October 2023 with a diagnosis of Dementia. Review of the Resident's most recent Minimum Data Set (MDS) assessment dated [DATE] indicated the Resident had moderate cognitive impairment as evidenced by a Brief Interview for Mental Status (BIMS) score of 11 out of a possible 15. Further review of the MDS assessment indicated the Resident was able to make him/herself understood and understood others. Review of the Resident's Smoking Safety Screen dated 10/13/23 indicated the Resident was a smoker, required supervision, and that the Resident required the facility to store lighter and cigarettes. Review of the Resident's Smoking Care Plan dated 10/24/23 and revised on 5/6/24 indicated the Resident required supervised smoking, smoking materials were to be stored in a secured area and the smoking policy was to be reviewed with the Resident and/or his/her health care representative. During an observation and interview on 5/21/24 at 9:11 A.M., the surveyor observed Resident #82 seated in his/her wheelchair on the nursing unit waiting for a staff member to take him/her outside to smoke. Resident #82 said he/she goes outside approximately three times per day, depending on when staff were available to take him/her outside. Resident #82 then said that he/she keeps his/her cigarettes with him/her pointing to a small, zippered bag next to him/her on the wheelchair, and that staff trust him/her to keep the cigarettes with him/her. During an observation and interview on 5/23/24 at 9:05 A.M., Resident #82 said he/she was waiting to go outside to smoke and opened his/her zippered bag next to him/her on his/her wheelchair and showed the surveyor a pack of cigarettes in his/her bag. During an observation of resident smoking on 5/23/24 from 10:05 A.M. until 10:35 A.M., the surveyor observed Resident #82, with the assistance of the Activity Director, remove a cigarette from a pack of cigarettes Resident #82 removed from his/her zippered bag, and the Activity Director assisted the Resident in lighting his/her cigarette. 2b. Resident #244 was admitted to the facility in May 2024 with diagnoses including: Fractured Femur, Chronic Obstructive Pulmonary Disease (COPD, a group of diseases that block airflow and make it difficult to breathe), and Dementia. Review of the Nursing admission assessment dated [DATE] indicated the Resident was oriented to person, place, and time. Review of the Resident's Smoking Evaluation dated 5/13/24 indicated the Resident was a smoker, required supervision and smoking materials were to be stored by the facility. Review of the Resident's Smoking Care Plan dated 5/10/24 and revised on 5/17/24 indicated the Resident required supervised smoking and was to wear a smoking apron while smoking. During an observation of resident smoking on 5/21/24 from 9:27 A.M. until 9:35 A.M., the surveyor observed the Resident smoking without a smoking apron. During an observation on 5/23/24 at 9:50 A.M., the Resident showed surveyor a pack of cigarettes he/she keeps in his/her nightstand and said he/she was allowed to keep them because they trusted him/her. During an observation of resident smoking on 5/23/24 from 10:05 A.M. until 10:35 A.M., the surveyor observed the Resident to be smoking without a smoking apron. 2c. Resident #245 was admitted to the facility in May 2024 with a diagnosis of Acute Respiratory Failure. Review of the Resident's Nursing admission Evaluation dated 5/14/24 indicated Resident was alert, followed commands, and had both short- and long-term memory loss. Further review of the Nursing admission Evaluation dated 5/14/24 indicated the Resident was a smoker, required supervision, required the use of a smoking apron and smoking materials were to be stored by the facility. Review of the Resident's Smoking Care Plan dated 5/15/24 and revised on 5/16/24 indicated the Resident required supervised smoking and was to wear a smoking apron while smoking. During an observation of resident smoking on 5/21/24 from 9:27 A.M. until 9:35 A.M., the surveyor observed the Resident smoking without a smoking apron. During an interview on 5/22/24 at 2:55 P.M., CNA #5 said that smoking aprons were a new thing at the facility, they have not used them in the past and that they were on order for the residents who need them. During an interview on 5/22/24 at 4:00 P.M., CNA #6 said he often brings residents outside to smoke, smoking aprons were not available until yesterday and residents were not allowed to keep smoking materials in their possession due to safety concerns. During an interview on 5/23/24 at 8:00 A.M., the Director of Nursing (DON) said for the longest time the facility did not really have many smokers, however there are now several residents who smoke. The DON said there were currently residents whose care plans indicated a need for smoking aprons for safety, however the facility did not have any smoking aprons on hand. During an observation of resident smoking on 5/23/24 from 10:05 A.M. until 10:35 A.M., the surveyor observed the Activity Director place a smoking apron on Resident #245. Directly after the Activity Director placed the smoking apron on Resident #245, the Resident told the surveyor this was the first time he/she ever wore a smoking apron. During an interview concurrent with resident smoking on 5/23/24 from 10:05 A.M. until 10:35 A.M., CNA #4 said there have not been many residents who were smokers in the building until very recently. CNA #4 said there was no system in place to ensure the residents' smoking materials were secured as well as ensuring smoking aprons were provided as needed, and up until now, there were no smoking aprons, no fire blankets, and no fire extinguisher available to staff who take the residents out to smoke. CNA #4 further said there should be a process in place to ensure resident safety and there was none. CNA #4 also said if a resident required a smoking apron, that information should be available to CNAs in the resident's care plan, so the CNAs know which residents required them, and the reason he placed a smoking apron on Resident #245 was because he knew the Resident once burned a hole in his/her pants while smoking at the facility. CNA #4 said that no resident was allowed to keep smoking materials on their person or in their rooms, and they were supposed to be secured by the nursing staff. 3. During an interview on 5/23/24 at 1:40 P.M. Unit Manager (UM) #1 said education provided to facility staff regarding the resident smoking process and safety was ongoing, however no formal education was provided by the Staff Development Coordinator. During an interview on 5/23/24 at 1:55 P.M., CNA #7 said she takes residents outside to smoke occasionally and has not received any education related to the resident smoking process and smoking safety. During an interview on 05/23/24 at 2:25 P.M., CNA #4 said he takes residents outside to smoke regularly and has not received any education related to the resident smoking process and smoking safety. During an interview on 5/24/24 at 8:47 A.M., CNA #5 said she takes residents out to smoke regularly and has not received any education related to the resident smoking process and smoking safety. CNA #5 said she had never given it any thought until the surveyor asked her what she would do if a resident ignited him/herself. See F926

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0804 (Tag F0804)

Could have caused harm · This affected multiple residents

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Based on observations, interviews, and test tray results, the facility failed to serve palatable food at an appetizing temperature, to all residents, on three Units (Unit Two, Unit Three, and Unit Four) of three units observed as well as in the Main Dining Room. Findings include: On 5/22/24, the surveyor conducted a Resident Council Meeting with 11 residents. Of the 11 residents who were present, 10 actively participated in the meeting and resided Units Three and Four. The following concerns were identified by the participating residents: -Two residents said the food was always cold -One resident said the food was bland but otherwise is good -One resident said the food was either too bland or had too much salt -One resident agreed the food was salty, specifically that the gravy was salty During the initial walkthrough on 5/21/24 at 10:15 A.M., the surveyor received the following comments from two residents on Unit Two: -The food is cold and is never hot enough. -The food is always cold. I don't think they cook it right or they need heat boxes. 1. On 5/23/24 from 11:43 A.M. to 12:06 P.M., the surveyor observed meal tray pass on Unit Three. -At 11:43 A.M. the first meal cart was delivered to the unit. -At 11:45 A.M. Nurse #2 and an activities assistant began passing trays from the first meal cart. -At 11:49 A.M. the second meal cart was delivered to the unit. A second nurse joined Nurse #2 and the activities assistant in passing trays. -At 11:51 A.M. Regional Consultant Nurse #1 and a second Regional Consultant Nurse arrived to the unit and began to assist the two nurses and activities assistant with passing trays. -At 11:54 A.M. staff began passing trays from the second meal cart. -At 12:06 P.M. the last tray was passed from the second meal cart and tray pass was complete. On 5/23/24 at 12:06 P.M. Regional Consultant Nurse #1 took temperatures of the food on the Unit Three test tray and beverages with the surveyor as follows: -Hamburger macaroni: 108 degrees Fahrenheit (F) -Cooked carrots: 90 degrees F -Banana cream pie: 70 degrees F -Milk: 52 degrees F At 12:10 P.M. the surveyor tasted the test tray: -Hamburger macaroni: mixed temperature throughout, some areas warm, others cold to taste -Cooked carrots: lukewarm to taste -Banana cream pie: lukewarm to taste -Milk: cool to taste 2. On 5/23/24 at 11:55 A.M. on Unit Two, the surveyor along with Unit Manager #1 obtained temperatures from the lunch test tray. The temperatures were as follows: - Sliced carrots, 90 degrees F - cool to taste - Cheesburger macaroni, 119 degrees F in the center, however there were areas of warm mixed with very cool temperatures. 4. On 5/23/24 from 11:55 A.M. to 12:10 P.M., the surveyor observed the following on Unit Four: -11:55 A.M., the 2nd meal cart arrived on Unit Four, the 1st meal cart was already on the unit, but no trays had been passed from the 1st meal cart. -From 11:55 A.M. to 12:01 P.M., trays were passed from the 2nd meal cart -From 12:01 P.M. to 12:10 P.M., trays were passed from the 1st meal cart -12:10 P.M., the surveyor received the test tray which came up on the 2nd meal cart At 12:10 P.M., Nurse #5 and the Regional Consultant Nurse obtained temperature of the food on the test tray, the surveyor tasted each item, and the following was observed: -Pureed Pork with gravy- 82 degrees F, cool to taste and was very salty -Mashed Potatoes with gravy- 78 degrees F cool to taste -Pureed Carrots- 72 degrees F cold to taste and liquid in consistency -Chocolate pudding- 64 degrees F cool to taste but not cold -Carton of milk- 60 degrees F cool to taste but not cold During an interview following the test tray observation Nurse #5 said he was unsure what the temperature of the food should be when it was served to the residents. During an interview on 5/23/24 at 2:00 P.M., the FSD said hot food should arrive hot and cold foods should arrive cold to the units. When discussing the temperatures taken during the test trays on the units the FSD said food coming up from the kitchen to the units should change no more than 5-6 degrees F by the time it is served to the residents and should be a palatable temperature. 3. On 5/23/24 from 11:31 A.M. to 11:56 A.M., the surveyor observed the lunch service in the main dining room. At 11:56 A.M., the Food Service Director (FSD) and the surveyor obtained the temperature and tasted each item, and observed the following: -Cheeseburger macaroni- 155 degrees F -Steamed carrots- 128.4 degrees F -Roll - 76 degrees F The FSD and surveyor each tasted the cheeseburger macaroni and steamed carrots. The FSD said that both were lukewarm to taste. He said that it was hard maintain the temperature with the Styrofoam trays that the food was being served on today. He said they were serving the food on Styrofoam take out containers today due to the boiler that the kitchen runs off being down.

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Food Safety (Tag F0812)

Could have caused harm · This affected multiple residents

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Based on observation and interview the facility failed to ensure two Unit (Unit #3 and Unit #4) kitchenettes were maintained in a clean and sanitary manner out of three Unit kitchenettes observed. Findings include: Review of the facility policy titled Food Brought Into Facility, revised 5/22, indicated the following: -Perishable foods must be stored and identified with the resident ' s name, food item, and use by date. These can be stored in the nursing unit kitchen nourishment refrigerator. Review of the Daily Checklist for Dietary Cleanliness, undated, provided by the Food Service Director (FSD), indicated the following: -Make sure Unit Kitchens are stocked, cleaned, and rotated all shifts. This includes Microwave, Refrigerators, Toaster, etc. Unit Three During an observation on 5/21/24 at 8:47 A.M., in the Unit Three Kitchenette the following was observed: -Toaster crumb drawer laden with crumbs and toaster had burnt on material inside. -Frozen item in kitchenette freezer dated 6/1/24 with no name. During an observation on 5/22/24 at 12:38 P.M., in the Unit Three kitchenette the following was observed: -Toaster crumb drawer laden with crumbs and toaster had burnt on material inside. -Frozen item in kitchenette freezer dated 6/1/24 with no name. During an observation and interview on 5/22/24 at 12:53 P.M., Nurse #1 and the surveyor observed the Unit Three Kitchenette. Nurse #1 said it did not appear the toaster was cleaned regularly and having excess crumbs in the toaster was a fire risk. Additionally, Nurse #1 said all food items placed in the freezer should be labeled with the date the item was brought in and a resident ' s name and she was unsure who the item in the freezer belonged to or when it was placed in the freezer. Nurse #1 also said she was unsure whose responsibility it was to clean the kitchenette or how often it was cleaned. Unit Four During an observation and interview on 5/22/24 at 2:50 P.M., Nurse #3 and the surveyor observed the Unit Four kitchenette and the following was observed: -Toaster crumb drawer was laden with crumbs and large chunks of toasted were in the bottom of the toaster. Nurse #3 said the kitchenettes should be cleaned daily by the kitchen staff in the morning. She further said that amount of dried bread in the toaster was a fire risk. During an interview on 5/23/24 at 10:48 A.M., the surveyor showed the FSD the photos of the toasters on Unit Three and Unit Four and of the freezer item that was dated 6/1/24. The FSD said the kitchenettes should be cleaned daily and daily cleaning included the toasters. He said the toasters did not appear that they had been cleaned recently. The FSD further said items in the freezer should be dated with the date the food was brought in so it could be discarded after three days, and he was unsure why an item was dated 6/1/24. He said with out a proper date and name he could not be sure who the item belonged to and how long it had been in the freezer.

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Administration (Tag F0835)

Could have caused harm · This affected multiple residents

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Based on observations and interviews, the facility failed to ensure Administration and/or the Governing Body provided residents in the facility with appropriate care and services in order to maintain their highest practicable physical, mental, and psychosocial well-being. The facility failed to identify and implement plans to address numerous facility wide concerns, failed to fully assess the facility staffing needs in order to meet resident needs, and failed to ensure supplies for resident care were available and accessible. Findings include: During the re-certification survey conducted by the survey team from 5/21/24 through 5/24/24, the following concerns were identified by residents/resident representatives and staff: -resident supplies including incontinence briefs, washcloths or towels, and clothes were not always available 1. Review of the Facility Assessment, dated 4/17/24, indicated the facility accepts residents with a broad range of diseases and disabilities primarily including common diseases of the elderly for its long-term care unit. These conditions, physical and cognitive disabilities, or combinations of conditions require complex medical care and management and included: -urinary incontinence 2. On 5/22/24 at 10:32 A.M., the surveyor conducted a resident council meeting and 11 residents were present. One resident who was present did not participate. The following concerns were discussed: -One resident said they don't have enough incontinence briefs sized extra large -Two other residents said the facility does not have medium size incontinence briefs and that they had to purchase their own. -One resident said that facility staff recommended that he/she drink less so he/she does not need so many incontinence briefs -Four residents said they do not have enough soup, one of the resident said he/she has family bring in soap and has loaned it to facility staff to use on other residents because there is none. -One resident said that CNAs have purchased soap to use on the residents due to not having any. -One resident reported that he/she took a shower and the towel he/she used was thread bare and had holes in it. -One resident said the CNAs have cut up old towels to use as face clothes. During an interview on 5/22/24 at 3:13 P.M., CNA #13, who has worked on Unit Four, said they are short on incontinence briefs for residents and are currently using small incontinent briefs for residents who need large incontinence briefs. CNA #13 said this has been going occurring on/off for a long time. She said there is never have enough linen-specifically towels, wash cloths and the amount available varies. Sometimes when the CNAs ask for supplies and don't get it, they have to go downstairs (where the laundry room is located) to get linens, towels and face clothes and there isn't enough to take. CNA #13 said there isn't always soap available to use for the residents and sometimes she and other CNAs have had to bring their own soap to provide care. She said sometimes they have had to borrow from other residents family supplied soap because it was the only option to get residents washed. During an interview on 5/22/24 at 3:29 P.M., CNA #12 said sometimes they run out of incontinence briefs for residents. On 5/22/24 at 3:56 P.M., the surveyors observed the Unit Three clean utility room. There were minimal towels and washcloths available and one sized brief observed. A supply cart was observed outside of the clean utility room had a minimal supply of one size incontinence briefs and minimal linen available. During an interview on 5/22/24 at 4:04 P.M., CNA #14 said they do not always have incontinence briefs, soap, gloves and laundry items to care for the residents on the unit and at times there don't have the supplies in the building because they are waiting for a shipment. She said that many of the CNAs bring in their own supplies to use for resident care because they want to make sure they are clean and cared for. CNA #14 said that they currently only have large incontinence briefs for residents and there are residents who need the extra large size but they have to use what they have. During an interview on 5/22/24 at 4:20 P.M., CNA #3 said the CNAs are struggling to have the needed supplies like soap and incontinence briefs. She said they currently only have one size incontinence briefs on the unit she works. She further said there are times when they have to purchase soap to use for the residents because they don't have soap. CNA #3 said at times, there is not enough wash clothes/towels. She said they used to have disposable wipes but they don't have those anymore. During an interview on 5/23/24 at 6:45 A.M., CNA #10 said that they don't always have supplies like towels, washcloths, soap, tissues, incontinence briefs. She said currently they only have small incontinence briefs which they are using on residents who need larger sizes and this has been a struggle for awhile. CNA #10 said that administration has been told and tell them that they are working on it and that supplies are coming. She said that some of the CNAs have to hide supplies so they have a stash to use for their residents and that she has had to purchase tissues, soap, and incontinence briefs for residents. During an interview on 5/23/24 at 6:54 A.M., CNA #15 said there are not enough incontinence briefs for the larger residents. She said that have regular and medium sized incontinence briefs but don't have the larger ones. She said when this occurs, the CNAs will double up and use two smaller incontinence briefs to make a larger one. During an interview on 5/23/24 at 6:59 A.M., CNA#9 said they recently went a long time without soap and incontinence briefs. She said if they don't have to needed size for incontinence briefs, they put a small size on and don't tape it closed. When administration is told, they respond and say the supplies are coming and then it doesn't come. During an interview on 5/23/24 at 7:09 A.M., CNA #16 said sometimes there is no soap or incontinence briefs available. She said that she purchases soap to use for residents care. During an interview on 5/23/24 at 9:52 A.M., the Director of Laundry/Maintenance said supplies are delivered to the units at 6:00 A.M., 2:00 P.M. and 9:00 P.M. He said he orders supplies monthly and if supplies are needed like linen, washcloths and towels, he can order them or can get them from sister facilities if needed immediately. During an interview on 5/23/24 at 12:49 P.M., a family member of a resident who resided at the facility said there were no towels in the facility on 5/22/24 because staff told her. She said she previously had to buy toilet paper for her family member and roommate because the facility ran out and they have had to purchase incontinence briefs and hide them because they run out. During an interview on 5/23/24 at 8:26 A.M., the Administrator said the central supply position has been vacant for about a week and currently the Assistant Director of Nurses (ADON) and the Unit Manager (UM) on Unit Two have been ordering the facility supplies. She said she was not aware of any issues with lack of supplies, that two large orders with supplies recently came in, but has only worked in the facility for 16 days. She further said the ADON, the UM and the Infection Preventionist (IP) check in with the staff about supplies and what is needed. During an interview on 5/23/24 at 10:52 A.M., the ADON said she took over ordering facility supplies since the beginning of April. She said that there is an order that is completed weekly for facility supplies and she speaks with staff about what items are needed and what is out so that it can be added to the list to order. The ADON said there was a recent delay in an delivery, she had to contact the person who handles their account in order to get the order delivered. She said that if supplies are low or unavailable, they could contact their sister facility to get those supplies or they could purchase items from the store. The ADON said she was made aware of the shortage of incontinence briefs on Tuesday (5/21/24) evening and an order was placed on Wednesday. She said she was not made aware that there were continued to be a shortage of incontinence briefs on Wednesday and did not check in with staff about the supplies. The surveyor relayed concerns expressed by residents present in resident council as well as facility staff on the units about supplies and the ADON said she was not aware of any other resident supplies that were lacking. She said that if the incorrect incontinence briefs have been used for residents there could be a concern of skin breakdown. She further said that the facility is currently working on levels of what to order for supplies and that it felt like structure was needed.

CONCERN (F)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0725 (Tag F0725)

Could have caused harm · This affected most or all residents

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Based observations, interviews, policy and record review the facility failed to ensure that there was sufficient nursing staff to assist residents in attaining and maintaining the highest practicable physical, mental, and psycho-social well-being on three (Unit Two, Unit Three and Unit Four) out of three observed units. Specifically, the facility failed to: 1)Ensure sufficient staff as determined by the Facility Assessment 2)Ensure call bells were responded to timely for Residents #83 & Resident #22 Findings include: Review of the facility policy titled Emergency Staffing Strategies, dated September 2020, indicated but was no limited to the following: -In the event that sufficient staff is not available from the individual SNF's (Skilled Nursing Facility) workforce, the facilities incident commander shall coordinate other available corporate resources to obtain additional employees from other facilities to staff the stricken facilities during emergencies and disasters. -Assign ancillary staff who possess Registered Nurse (RN)/Licensed Practical Nurse (LPN)/Certified Nurse Aide (CNA) license to work on units for direct care 1) Review of the Facility Assessment (an assessment completed by the facility to identify what resources are necessary for competent care of residents on a day-to-day or emergency basis), dated 4/17/24, indicated but was not limited to: -Direct care staff CNA or Licensed Nurse providing Activity of Daily Living (ADL- self-care activities like bathing, dressing, eating) care to residents for the day ratio should be the following to meet the resident needs: > 1:10 (number of direct care staff to number of residents) on the Day shift (7:00 A.M.- 3:00 P.M.), >1:11 on the Evening shift (3:00 P.M.-11:00 P.M.), and >1:17 on the Night shift (11:00 P.M.- 7:00 A.M) Review of actual worked nursing schedules with daily unit census data (number or residents residing on a given unit on a given day) from 4/19/24 through 5/19/24 indicated the following: -Unit Two: > Day Shift Staffing Ratios had one day greater than the ratio per the Facility Assessment of 1:10 on 5/3/24 (1:16). >Evening Shift Staffing Ratios were greater than the 1:11 ratio on six days; 4/19/24, 4/20/24, 4/22/24, 5/2/24, 5/13/24, 5/14/24, and 5/18/24 (ratios ranged from 1:11.5 to 1:14.7). -Unit Three: >Day Shift Staffing Ratios were greater than the 1:10 ratio on 18 days; 4/19/24 through 4/25/24, 4/27/24 through 5/3/24, 5/11/24, 5/13/24, 5/18/24 and 5/19/24(ratios ranged from: 1:10.7 to 1:17) > Evening Shift Staffing Ratios were greater than the 1:11 ratio on 2 days; 5/1/24 and 5/14/24 (ratios ranged from 1:13.6 to 1:33) -Unit Four: > Day Shift Staffing Ratios were greater than the 1:10 ratio on 6 days; 4/20/24, 4/21/24, 4/23/24, 4/28/24, 5/18/24 and 5/19/24 (ratios ranged from 1:10.7 to 1:15) > Evening Shift Staffing Ratios were greater than the 1:11 ratio on 2 days; on 4/20/24 and 4/24/24 (ratio of 1:12.8) 2) On 5/21/24 from 9:46 A.M. until 9:51 A.M., the surveyor observed the following on Unit Four: -Resident #83's call bell light to be on -Call bell system located at the nurses indicated Resident #83's call bell light had been on for 13 minutes -Surveyor went to the Resident's room to inquire about the call bell wait time. Upon arriving to Resident #83's room, the surveyor found the Resident to be at the doorway, holding a soiled hospital gown, wearing a brief with feces coming out of the brief, onto his/her leg and on the wheelchair. -Resident said that he/she had trouble controlling his/her bowels and needed help getting cleaned up. The Resident thought his/her call bell light was not working because no one had come to see what he/she needed. Resident #83 said that because he/she thought the light was not working, he/she would go to the bathroom to pull the bathroom cord, hoping that would work. -9:47 A.M. bathroom light on and flashing red -9:48 A.M. Resident calling out hello from the bathroom. -9:51 A.M. CNA entered the bathroom to assisted Resident #83 -In total, the Resident waited 18 minutes for facility staff to provide assistance 3) On 5/22/24, the surveyor conducted a Resident Council Meeting with 11 residents. Of the 11 residents who were present, 10 actively participated in the meeting and resided Units 3 and 4. The following concerns were identified by the participating residents: -four residents said that there were long wait times for call bells due to low levels of staffing. -One resident specified at times the wait had been over a hour for the call bell to be answered. -One resident said that there was only two CNAs sometimes for 18 rooms that mostly house 2 residents per room, and it is not enough staff. -One resident said there are frequent call outs that leave them with 2 CNAs on a unit. 4) During an interview on 5/21/24 at 4:24 P.M., Nurse #3 said that today, on the 4th floor the staff worked the entire shift down two (CNA's). She said it was difficult, but the team worked together to get through the day to provide care for the residents. She said that she spent much of her day near the nurse's station and the dining room because they have multiple residents who are fall risks. During an interview on 5/22/24 at 7:30 A.M., Nurse #3 said that there were currently two Nurses and two CNA's. She said that there were four CNAs scheduled, one called out, one would be coming in at 7:30 A.M., and that two CNAs came in at 7:00 A.M. She said there were call outs on all three units today. During an interview on 5/22/24 at 3:13 P.M., CNA #13 said she worked at the facility 40 hours a week for several years on Unit Four. CNA #13 said it is hard to complete the assignments if the unit was short (2 CNAs for the unit) and residents sometimes have had to stay in bed because they don't have enough time to care for them. CNA #13 said that the facility considers Unit 4 fully staffed at 3 CNAs, but 4 CNAs are needed to properly care for the residents, many of whom were dependent on staff and use mechanical lifts (a machine that requires two qualified staff members to operate to lift a resident to transfer them to and from the bed and chair) to get them out of bed. During an interview on 5/22/24 at 4:04 P.M., CNA # 14 said that there were times the unit has been left with one CNA for the evening shift which can leave one staff member responsible for all the care of 29 residents or more. CNA #14 said it was extremely hard to provide the care the residents need with one CNA on the unit. During an interview on 5/22/24 at 4:20 P.M. CNA # 11 said she was a regular staff member for evening shift and work mostly on Unit Three and Unit Four. CNA #11 said they have typically worked with two CNAs on a unit once or twice a week. CNA #11 further said that call outs often left them short staffed and there was no plan or replacements for staff who called out. CNA #11 said when there was only two CNAs on a unit, nurses did not help, and the two CNAs were responsible for all the resident care, meal passes, assistance with eating and answering call bells for the residents. During an interview on 5/23/24 at 6:45 A.M. CNA #10 said she had worked at the facility for many years on Unit Four. CNA #10 said that night shift was usually staffed with two CNAs but that on occasions they have worked with only one CNA for the unit but that was not typical. During an interview on 5/23/24 at 6:59 A.M. CNA #9 said she was a regular staff member that had worked several years at the facility on Unit Three. CNA #9 said sometimes they work alone on night shift (as the only CNA for the unit) but that staffing on day shift was always bad causing night shift staff to have to unexpectedly stay late when relief didn't arrive or came in late. CNA #9 further said that Unit Three often had two CNAs on day and evening shift. CNA #9 said that short staffing caused her to not be able to take care of residents the way she wanted or should and it was frustrating. During an interview on 5/23/24 at 7:09 A.M. CNA #8 said she typically worked on Unit Two but sometimes worked Unit Three. CNA #8 said they typically have two to three CNAs for Unit Three but when they have two it is hard to provide care to the residents due to the workload. During an interview on 5/23/24 at 8:27 A.M., the Administrator said they currently did not have a staffing coordinator for the last week or two but had hired someone who had not started yet, and the Assistant Director of Nursing (ADON) was currently overseeing staffing for nursing staff on the units. The Administrator said that they had agency contracts in place, but they did not use agency staff at all since she had been there (started in the beginning of May). When asked for contingency staffing plan, the Administrator indicated the Emergency Staffing Strategies policy would be utilized. 5) During an observation and interview on Unit Three on 5/23/24 at 10:22 A.M., the surveyor heard the call bell system ringing at the nurse's station for Resident #22. The surveyor went to the Resident's room, observed the call bell light to be on at the Resident's door, and the Resident (who was in the room) said he/she had been waiting a long time and just wanted to have his/her radio plugged in and turned on. During an interview and observation on 5/23/24 at 10:28 A.M., directly following the surveyor's interaction with the Resident #22, the surveyor and Nurse #2 observed the call bell system at the nurse's station indicated the call bell in Resident #22's room had been on for 82 minutes. Nurse #2 said the call bell system at the nurse's station starts when the call bell system is activated in a resident's room and tracks how long the call light is on for. He said currently on Unit Three there was only two CNAs, and this was not enough CNAs on the Unit to meet the needs of the residents and to answer call bell lights timely. He further said the Unit needed three CNAs for the resident's needs to be met and that initially at the beginning of the day the Unit only had one CNA until a CNA from another unit came to assist. 6) During an interview on 5/23/24 at 10:52 A.M. the ADON said she did not know when she took over staffing the facility but believed it was in the beginning of April. The ADON said prior to taking over she had not been involved with staffing. The ADON said that on day shift Units Two and Three should have three CNAs and Unit Four should have four, on evening shift Unit Two should have two CNAS, Unit Three should have three CNAs and Unit Four should have four CNAs, and on night shift all three units should have 2 CNAs. The ADON said this staffing pattern was based off of census and the acuity (need level) of the residents on each unit. The ADON sad that she had heard from staff almost weekly that they were frustrated when they had to work short due to call outs. The ADON said that the Director of Nursing, Unit Manager and Infection Control Nurse were all hands on with the schedule but that there were still issues with staffing and that staffing issues would cause problems with everything including meals and call bell response times. Relative to call bell wait times the ADON said that her expectation would be no more than 15 minutes at the longest to wait but would more likely be five to ten minutes for someone to respond. During an interview on 5/23/24 at 2:13 P.M., Nurse Practitioner (NP) #1 said that it had been frustrating to ensure follow up appointments and referrals were completed. She said that there seemed to be a communication breakdown maybe due to lack of consistent staff, staff being per diem and not having enough staff. She said that the NP's try to follow up on referrals and recommendations that have made but do not always have time to do so and that the NP's relied on the staff to ensure the orders and referrals are being carried out.

CONCERN (F)

Potential for Harm - no one hurt, but risky conditions existed

Smoking Policies (Tag F0926)

Could have caused harm · This affected most or all residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to establish and implement policies, in accordance with applicable Federal, State and local laws and regulations regarding smoking for two Residents (#82 and #244) out of four applicable residents out of a total sample of 21 residents. Specifically, the facility failed to: 1. Ensure their smoking policy addressed what preventative measures were in place in the event of a fire emergency. 2. The facility failed to ensure they implemented their smoking policy relative to two Residents (#82 and #244) relative to possession of smoking materials. Finding include: Review of the Department of Health and Human Services Centers for Medicare and Medicaid Services Memorandum titled, Smoking Safety in Long Term Care Facilities, dated 11/10/11 included but was not limited to: - Facilities must include assessment of smoking areas and provision of emergency equipment in the designated smoking areas. - The facility is obligated to ensure the safety of designated smoking areas .the facility is also required to provide portable fire extinguishers in all facilities 1. The facility failed to ensure their smoking policy addressed what preventative measures were in place in the event of a fire emergency. Review of the facility policy titled Smoking, revised 3/2022, indicated the following: -Smoking is only permitted in designated resident smoking areas, which are located outside of the building. -Metal containers, with self-closing cover devices, are available in smoking areas - Residents who have independent smoking privileges are not permitted to keep cigarettes, pipes, tobacco, and other smoking articles in their possession. - Residents without independent smoking privileges may not have or keep any smoking articles including cigarettes, tobacco, etc., except when they are under direct supervision. Further review of the facility smoking policy did not indicate what fire prevention equipment should be available in the smoking areas or what preventative measures were to be implemented in the event of a fire emergency related to smoking. 2. The facility failed to ensure they implemented their smoking policy relative to two Residents (#82 and #244) relative to possession of smoking materials. During an observation of resident smoking and a concurrent interview on 5/21/24 from 9:27 A.M. until 9:35 A.M., the surveyor observed three Residents (#82, #244, and #245) outside smoking accompanied by Certified Nursing Assistant (CNA) #5. The surveyor asked CNA #5 if the residents were allowed to keep their cigarettes on their person or if they were required to have their smoking paraphernalia locked up on the unit. CNA #5 said Resident #82 and Resident #245 had permission to keep cigarettes in their possession, but Resident #244 was not allowed to keep cigarettes in his/her possession. At that time, Resident #244 spoke up and said he/she kept his/her cigarettes in his/her possession because, they trust me with them. 2a. Resident #82 was admitted to the facility in October 2023 with a diagnosis of Dementia. Review of the Resident's most recent Minimum Data Set (MDS) assessment dated [DATE] indicated the Resident had moderate cognitive impairment as evidenced by a Brief Interview for Mental Status (BIMS) score of 11 out of a possible 15. Further review of the MDS assessment indicated the Resident was able to make him/herself understood and understood others. Review of the Resident's Smoking Safety Screen dated 10/13/23 indicated the Resident was a smoker, required supervision, and that the Resident required the facility to store lighter and cigarettes. Review of the Resident's Smoking Care Plan dated 10/24/23 and revised on 5/6/24 indicated the Resident required supervised smoking, smoking materials were to be stored in a secured area and the smoking policy was to be reviewed with the Resident and/or his/her health care representative. During an observation and interview on 5/21/24 at 9:11 A.M., the surveyor observed Resident #82 seated in his/her wheelchair on the nursing unit waiting for a staff member to take him/her outside to smoke. Resident #82 said he/she goes outside approximately three times per day, depending on when staff were available to take him/her outside. Resident #82 then said that he/she keeps his/her cigarettes with him/her pointing to a small, zippered bag next to him/her on the wheelchair, and that staff trust him/her to keep the cigarettes with him/her. During an observation and interview on 5/23/24 at 9:05 A.M., Resident #82 said he/she was waiting to go outside to smoke and opened his/her zippered bag next to him/her on his/her wheelchair and showed the surveyor a pack of cigarettes in his/her bag. During an observation of resident smoking on 5/23/24 from 10:05 A.M. until 10:35 A.M., the surveyor observed Resident #82, with the assistance of the Activity Director, remove a cigarette from a pack of cigarettes Resident #82 removed from his/her zippered bag, and the Activity Director assisted the Resident in lighting his/her cigarette. 2b. Resident #244 was admitted to the facility in May 2024 with diagnoses including: Fractured Femur, Chronic Obstructive Pulmonary Disease (COPD, a group of diseases that block airflow and make it difficult to breathe), and Dementia. Review of the Nursing admission assessment dated [DATE] indicated the Resident was oriented to person, place, and time. Review of the Resident's Smoking Evaluation dated 5/13/24 indicated the Resident was a smoker, required supervision and smoking materials were to be stored by the facility. Review of the Resident's Smoking Care Plan dated 5/10/24 and revised on 5/17/24 indicated the Resident required supervised smoking and was to wear a smoking apron while smoking. During an observation of resident smoking on 5/21/24 from 9:27 A.M. until 9:35 A.M., the surveyor observed the Resident smoking without a smoking apron. During an observation on 5/23/24 at 9:50 A.M., the Resident showed surveyor a pack of cigarettes he/she keeps in his/her nightstand and said he/she was allowed to keep them because they trusted him/her. During an interview on 5/22/24 at 4:00 P.M., CNA #6 said he often brings residents outside to smoke and residents were not allowed to keep smoking materials in their possession due to safety concerns. During an interview concurrent with resident smoking observation on 5/23/24 from 10:05 A.M. until 10:35 A.M., CNA #4 said there have not been many residents who were smokers in the building until very recently. CNA #4 said there was no system in place to ensure the residents' smoking materials were secured and up until now there were no smoking aprons, no fire blankets, and no fire extinguisher available to staff who take the residents out to smoke. CNA #4 further said there should be a process in place to ensure resident safety and there was none. CNA #4 said that no resident was allowed to keep smoking materials on their person or in their rooms, and they were supposed to be secured by the nursing staff.

MINOR (B)

Minor Issue - procedural, no safety impact

Assessment Accuracy (Tag F0641)

Minor procedural issue · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure staff accurately coded Minimum Data Set (MDS) Assessments for three Residents (#9, #50, and #56) out of a total sample of 21 residents. Specifically, 1. For Resident #9 the facility failed to ensure the MDS Assessments were coded accurately related to the use of an anticoagulant medication (medication that thins blood), 2. For Resident #50 the facility failed to ensure the MDS Assessments were coded accurately related to the use of a pressure relieving device (mattress that assists in reducing the likelihood of a resident developing pressure ulcers) on the Resident ' s bed and the use of a restraint., 3. For Resident #56 the facility failed to ensure the MDS Assessments were coded accurately related to the use of an anticoagulant medication. Findings include: 1. Resident #9 was admitted to the facility in October 2020 with a diagnosis of Vascular Dementia. Review of the MDS assessment dated [DATE] indicated the Resident received an anticoagulant medication within seven days of the assessment reference date (ARD-a specific end point for a look back period, utilized to complete a MDS Assessment). Review of the Resident ' s medical record indicated no documentation the Resident had received an anticoagulant medication during the review period for the MDS Assessment. 2. Resident #50 was admitted to the facility in July 2023 with diagnoses of Dementia with Anxiety, Chronic Pain Syndrome, and history of a wound to his/her coccyx (tail bone region of the back). During an observation and interview on 5/22/24 at 8:51 A.M., Nurse #4 and the surveyor observed the Resident to be in bed on a pressure relieving mattress. During the observation Nurse #4 said Resident #50 had been on a pressure relieving mattress since his/her admission as he/she had a history of wounds to his/her coccyx area. Nurse #4 further said she had worked at the facility the entire time Resident #50 had been in the facility and Resident #50 never had any restraints used on him/her. Review of the Residents May 2024 Physician's Orders indicated an order for a therapeutic mattress with a start date of 2/12/24. Review of the Resident's medical record indicated no documentation the Resident had ever utilized a limb restraint while in the facility. Review of the MDS assessment dated [DATE] indicated the Resident was not utilizing a pressure reducing device on his/her bed and had a limb restraint during the review period for the 4/24/24 MDS Assessment. 3. Resident #56 was admitted to the facility in August 2023 with diagnoses of Parkinson's Disease, Hypertension, and Peripheral Vascular Disease. Review of the MDS assessment dated [DATE] indicated the Resident received an anticoagulant medication within seven days of the assessment reference date. Further review of the Resident's record indicated no documentation the Resident had received an anticoagulant medication during the review period of the MDS Assessment. During an interview on 5/22/24 at 12:02 P.M., the MDS Nurse said for Resident #9 the 4/6/24 MDS Assessment was coded inaccurately and the Resident was not on an anticoagulant medication, for Resident #50 the 4/24/24 MDS Assessment was coded inaccurately and the Resident was using a pressure reducing device on his/her bed and he/she had never had a limb restraint, and for Resident #56 the 3/29/24 MDS Assessment was coded inaccurately and the Resident was not on an anticoagulant medication. She further said all three of the MDS Assessments needed to be modified to correct the errors.

Oct 2023 3 deficiencies 2 Harm

SERIOUS (G) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Actual Harm - a resident was hurt due to facility failures

Comprehensive Care Plan (Tag F0656)

A resident was harmed · This affected 1 resident

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Based on observation, records reviewed and interviews, for one of three sampled residents (Resident #3), who was readmitted to the Facility with a reddened area to the coccyx (lower back), and was assessed by nursing as being at high risk for skin breakdown, the Facility failed to ensure that a comprehensive person-centered care plan based on his/her individual wound care needs for the promotion of healing or the prevention of worsening of wounds, which included and identified interventions, measurable objectives and desired outcomes was developed, and that interventions that were in place were consistently implemented by nursing, as a result Resident #3's wound deteriorated to an unstageable pressure injury (full-thickness skin and tissue loss that is obscured by eschar and slough- dead tissue). Findings Include: Review of the Facility's Policy, Pressure Ulcers/Injuries Overview, dated as revised March 2022, indicated the following: -Pressure injuries are defined as localized damage to the skin and/or underlying soft tissue usually over a bony prominence, and occur as a result of intense and/or prolonged pressure or pressure and combination of shear. Review of the Facility's Policy, Pressure Ulcer/Injury Risk Assessment, dated as revised March 2022 indicated the following: -Once the assessment is conducted and risk factors are identified and characterized, a resident-centered care plan can be created to address the modifiable risks for pressure ulcers/injuries. -Develop the resident-centered care plan and interventions based on the risk factors identified in the assessments, the condition of the skin, the resident's overall clinical condition, and the resident's stated wishes and goals. -The interventions must be based on current, recognized standards of care. -The effects of the interventions must be evaluated -The care plan must be modified as the resident's condition changes, or if current interventions are deemed inadequate. Resident #3 was admitted to the Facility in December 2022, diagnoses included partial symptomatic epilepsy, Hypertension and a history of falls. Review of Resident #3's Nurse Progress Note, dated 09/25/23, indicated Resident #3 was readmitted to the Facility following a brief hospitalization, wished to be Comfort Measures Only (CMO) and to transition to Hospice services. Review of Resident #3's Skin Condition Evaluation Form, dated 09/25/23, indicated that Resident #3 had a pressure injury to the coccyx that measured 3 centimeters (cm) x 3 cm. Further review of the Skin Condition Evaluation Form indicated the stage of the pressure injury was listed as Not Available. Review of Resident #3's Norton Plus Pressure Scale Assessment, dated 09/26/23, indicated that Resident #3 was assessed by nursing to be at high risk for skin breakdown as evidenced by a score of 7 (a score of less than 10 indicates very high risk for skin breakdown). Review of Resident #3's medical record indicated he/she had a quarterly Minimum Data Set (MDS) Assessment completed on 9/21/23, and his/her care plans were reviewed and renewed at that time. Review of Resident #3's Care Plan related to Potential Alteration in Skin Integrity, indicated Resident #3 had the potential for an alteration in skin integrity and the goal was to keep Resident #3's skin intact. Further review of Resident #3's Care Plan related to Potential Alteration in Skin Integrity, indicated that only the following interventions were in place: -Follow Physician's orders for skin care and treatments -Dietary intervention/evaluation -Protect skin with incontinent care -Toileting assistance on toileting schedule or routine However, further review of Resident #3's care plan indicated that although he/she was assessed upon readmission to have actual skin breakdown on 09/26/23, with a pressure injury to his/her coccyx, the care plan was not updated, and there were no additional interventions identified related to wound healing or for prevention of deterioration. Review of Resident #3's Physician's Orders for October 2023, indicated he/she had an order for Barrier Cream to the coccyx twice a day and as needed. The Order also included that nursing was to the cover the coccyx wound with Optifoam (foam adhesive) dressing every day and evening shift for wound care. Review of Resident #3's TAR, dated October 2023, indicated he/she had an order to apply Barrier Cream to the coccyx twice a day and as needed, and for nursing to cover with Optifoam dressing every day and evening shift for wound care. Further review of the TAR indicated that the treatment was signed off by nursing as having been completed twice a day, as ordered, from 10/01/23 through 10/11/23. Review of Resident #3's Skin Observation Tool, dated 10/03/23 and signed by Nurse #2, indicated Resident #3 had pressure wounds on his/her coccyx area and Barrier Cream had been applied. However, there were no measurements of the pressure wounds documented on the Tool. During an interview on 10/12/23 at 2:30 P.M., Nurse #2 said that she did the skin evaluation for Resident #3 on 10/03/23. Nurse #2 said Resident #3 had reddened pressure areas to his/her coccyx but she did not think it required a dressing. Nurse #2 said Resident #3 was getting Barrier Cream to the area and she thought that was all Resident #3 needed. Nurse #2 said that the CNAs apply the Barrier Cream and the nurses sign it off on the TAR. Nurse #2 said the CNAs were not supposed to apply dressings. Nurse #2 said that she had worked the evening shift on 10/10/23 and a CNA told her that Resident #3's dressing needed to be changed. Nurse #2 said she removed the dressing from Resident #3's coccyx and it was rolled up and had a mix of drainage on it. Nurse #2 could not identify what type of drainage was on the old dressing. Nurse #2 said the dressing she removed was dated as either 10/03/23 or 10/04/24, but said she could not remember exactly which date was on the dressing. Nurse #2 said when she removed the dressing she saw a red, open wound that had areas of white tissue in the wound bed. Nurse #2 said she went to the supply room to get an Optifoam dressing, because that's what the physician ordered. Nurse #2 said she could not find the foam dressing so she used a tan square dressing but she did not know the name of the dressing. Nurse #2 said when she signed off on Resident #3's treatment for application of Barrier Cream on the TAR on 10/02/23, 10/03/23, 10/05/23, 10/06/23, and 10/08/23, but said she had not realized that the order for Barrier Cream to the coccyx also included applying an Optifoam dressing, so on those days she had not applied a dressing Nurse #2 said the last time she had seen Resident #3's coccyx prior to 10/10/23, was on 10/03/23, when she did the weekly skin assessment. Nurse #2 said the first time she applied a dressing to Resident #3's coccyx was on 10/10/23. Nurse #2 said she had not reported anything about the status of the wound to either the Wound Nurse of the Nursing Supervisor. On 10/11/23 at 1:40 P.M., the surveyor observed the Wound Nurse complete Resident #3's dressing change. The Wound Nurse removed a tan colored dressing, dated 10/10/23, from Resident #3's coccyx, there was no drainage on the dressing. The Wound Nurse said the dressing she removed was a DuoDerm (waterproof dressing used to treat mildly draining wounds) and not an Optifoam as was ordered. The Wound Nurse cleansed Resident #3's coccyx with Wound Cleanser. The surveyor observed an area on Resident #3's coccyx that had eschar and an area of slough along the bottom edge of the wound, there was also an intact reddened area above the eschar. The Wound Nurse said there was necrotic tissue and slough in the wound bed. The Wound Nurse said she did not have anything to measure Resident #3's wound with her, but said it looked to be approximately 5 cm x 5 cm and that she could not determine the depth of the wound because of the slough. The Wound Nurse applied Barrier Cream to the surrounding skin of the wound and covered the wound with a foam dressing. The Wound Nurse said she did not want to apply Barrier Cream to the eschar area. The Wound Nurse said that today (10/11/23) was the first day she observed Resident #3's wound. The Wound Nurse said no one (nurses caring for and treating Resident #3) had given her any updates of the status of the wound and she would have expected the nurses to have notified her of the wound's deterioration. The Wound Nurse said Resident #3's physician order was for Optifoam dressing, not a DuoDerm dressing. The Wound Nurse said that Resident #3's wound should have been measured weekly. The Wound Nurse said that once a pressure injury was identified on Resident #3, a care plan with specific interventions, and goals related to the pressure injury should have been put in place. The Wound Nurse said she was the one responsible for creating care plans when a pressure injury was newly identified. During an interview on 10/12/23 at 11:37 A.M., the Director of Nurses (DON) said that Resident #3's Care Plan had not been updated until 10/11/23, after the Wound Nurse changed Resident #3's dressing.

SERIOUS (G) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Actual Harm - a resident was hurt due to facility failures

Pressure Ulcer Prevention (Tag F0686)

A resident was harmed · This affected 1 resident

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Based on observation, records reviewed and interviews, for one of three sampled residents (Resident #3), who was readmitted to the Facility with a reddened area to the coccyx (lower back), and was assessed by nursing as being at high risk for skin breakdown, the Facility failed to ensure Resident #3 received care and services consistent with professional standards of practice related to the promotion of healing or the prevention of worsening of his/her wound, when treatment orders were not implemented as ordered by the physician, the wound was not adequately assessed by nursing, and the wound deteriorated to an unstageable pressure injury (full-thickness skin and tissue loss that is obscured by eschar and slough- dead tissue). Findings Include: Review of the Facility's Policy, Pressure Ulcers/Injuries Overview, dated 03/2022, indicated the following: -Pressure injuries are defined as localized damage to the skin and/or underlying soft tissue usually over a bony prominence, and occur as a result of intense and/or prolonged pressure or pressure and combination of shear. -Avoidable means the resident developed a pressure ulcer/injury and that one or more of the following was not completed: -Definition or implementation of interventions that are consistent with resident needs, resident goals, and professional standards of practice. -Monitoring or evaluation of the impact of the interventions; or revision of the interventions as appropriate. Review of the Facility's Policy, Pressure Ulcer/Injury Risk Assessment, dated 03/22, indicated the following: -Once the assessment is conducted and risk factors are identified and characterized, a resident-centered care plan can be created to address the modifiable risks for pressure ulcers/injuries. -Develop the resident-centered care plan and interventions based on the risk factors identified in the assessments, the condition of the skin, the resident's overall clinical condition, and the resident's stated wishes and goals. -The interventions must be based on current, recognized standards of care. -The effects of the interventions must be evaluated. -The care plan must be modified as the resident's condition changes, or if current interventions are deemed inadequate. Resident #3 was admitted to the Facility in December 2022, diagnoses included: partial symptomatic epilepsy, Hypertension and history of falls. Review of Resident #3's Nurse Progress Note, dated 09/21/23, indicated Resident #3 was lethargic and pocketing food in his/her mouth. Resident #3's blood pressure was 62/44, pulse was 132, and respirations were 40. The on-call Physician/Nurse Practitioner was notified and Resident #3 was sent to the Hospital Emergency Department (ED)for an evaluation. Review of Resident #3's Nurse Progress Note, dated 09/23/23, indicated the Facility was notified that Resident #3 was admitted to the Hospital with a diagnosis of a bacterial infection. Review of Resident #3's Nurse Progress Note, dated 09/25/23, indicated Resident #3 was readmitted to the Facility following the hospitalization, wished to be Comfort Measures Only (CMO) and to transition to Hospice services. The Progress Note indicated Resident #3 had redness to his/her coccyx area. Review of Resident #3's Nursing Evaluation, dated 09/25/23, indicated the following: -Upon assessment no observable pressure injuries were present however the Resident does have some redness to his/her bottom and barrier cream has been applied. -Resident requires extensive assistance for bed mobility. -Resident is always incontinent of urine, requires assistance for incontinence care. -Resident is always incontinent of bowels, requires assistance for incontinence care. Review of Resident #3's Skin Condition Evaluation Form, dated 09/25/23, indicated that Resident #3 had a pressure injury to the coccyx that measured 3 centimeters (cm) x 3 cm. However, further review of the Skin Condition Evaluation Form indicated the stage of the pressure injury was listed as Not Available. Review of Resident #3's Norton Plus Pressure Scale Assessment, dated 09/26/23, indicated that Resident #3 was assessed by nursing to be at high risk for skin breakdown as evidenced by a score of 7 (a score of less than 10 indicates very high risk of skin breakdown). Review of Resident #3's Physician's Orders, dated October 2023, indicated he/she had an order to apply Barrier Cream to the coccyx twice a day and as needed. The Order also indicated nursing to cover with Optifoam (foam adhesive used to provide thermal insulation and maintain moisture to the wound and prevent damage to the wound at the time of it's removal) dressing every day and evening shift for wound care. Review of Resident #3's Treatment Administration Record (TAR), dated September 2023, indicated he/she had an order to apply Barrier Cream to the coccyx twice a day and as needed, and to cover with Optifoam dressing every day and evening shift for wound care. Further review of the TAR indicated that nurses signed off on the treatment as completed twice a day, as ordered. Review of Resident #3's TAR, dated October 2023, indicated he/she had an order to apply Barrier Cream to the coccyx twice a day and as needed. The Order also indicated to cover with Optifoam dressing every day and evening shift for wound care. Further review of the TAR indicated that nurses signed off on the treatment as having been completed twice a day, as ordered, from 10/01/23 through 10/11/23. Review of Resident #3's Skin Observation Tool, dated 10/03/23 and signed by Nurse #2, indicated Resident #3 had pressure wounds on his/her coccyx area and Barrier Cream had been applied. However, the further review of the Tool indicated it was incomplete, because there were no measurements of the pressure wounds documented in the required section of the Tool. During an interview on 10/11/23 at 12:56 P.M., the Wound Nurse said the nurses were responsible to notify her when a resident had a change in their skin condition. The Wound Nurse said she was notified somewhere between 09/25/23 and 09/28/23 that Resident #3 had an area on his/her coccyx when he/she returned from the hospital, but said she could not recall the exact date she was notified. The Wound Nurse said once she was notified that a resident had a skin condition or pressure ulcer, she entered their name on her tracking log and that she usually sees the wound herself within a day or two. The Wound Nurse said she did not know the current status of Resident #3's wound. On 10/11/23 at 1:40 P.M., the surveyor observed the Wound Nurse complete Resident #3's dressing change. The Wound Nurse removed a tan colored dressing, dated 10/10/23, from Resident #3's coccyx, and there was no drainage on the dressing. The Wound Nurse said the dressing she removed was a DuoDerm (waterproof dressing used to treat mildly draining wounds) and not an Optifoam as was ordered. The Wound Nurse cleansed Resident #3's coccyx with Wound Cleanser. The surveyor observed an area on Resident #3's coccyx that had eschar and an area of slough along the bottom edge of the wound, there was also an intact reddened area above the eschar. The Wound Nurse said there was necrotic tissue and slough in the wound bed. The Wound Nurse said she did not have anything to measure Resident #3's wound with her, but said it looked to be approximately 5 cm x 5 cm and that she could not determine the depth of the wound because of the slough. The Wound Nurse applied Barrier Cream to the surrounding skin of the wound and covered the wound with an Optifoam dressing. The Wound Nurse said that today (10/11/23) was the first day she had observed Resident #3's wound. The Wound Nurse said no one (nurses caring for and treating Resident #3) had given her any updates of the status of the wound and she would have expected the nurses to have notified her of the wound's deterioration. The Wound Nurse said that Resident #3's wound should have been measured weekly. The Wound Nurse said Resident #3 was never put on the list to be seen by the Wound Physician who visits the facility weekly because she thought the area was originally reported to her as being excoriated and not as a pressure injury. During an interview on 10/12/23 at 1:54 P.M., Certified Nurse Aide (CNA) #1 said when Resident #3 returned from the hospital he/she had a small reddened area on his/her bottom. CNA #1 said she showed one of the nurses (exact name unknown), and was told to put Barrier Cream on it. CNA #1 said she had not taken care of Resident #3 in a couple of weeks. During an interview on 10/12/23 at 2:30 P.M., Nurse #2 said that she did the skin evaluation for Resident #3 on 10/03/23. Nurse #2 said Resident #3 had reddened pressure areas to his/her coccyx but she did not think it required a dressing. Nurse #2 said Resident #3 was getting Barrier Cream to the area and she thought that was all Resident #3 needed. Nurse #2 said that the CNAs apply the Barrier Cream and the nurses sign it off on the TAR. Nurse #2 said the CNAs were not supposed to apply dressings. Nurse #2 said that she had worked the evening shift on 10/10/23 and a CNA told her that Resident #3's dressing needed to be changed. Nurse #2 said she removed the dressing from Resident #3's coccyx that was rolled up and said it had a mix of drainage on it. Nurse #2 said the dressing she removed was dated as either 10/03/23 or 10/04/24, but said she could not remember exactly which date was on the dressing. Nurse #2 said when she removed the dressing she saw a red, open wound that had areas of white tissue in the wound bed. Nurse #2 said she went to the supply room to get an Optifoam dressing, because that's what was ordered, but could not find that dressing so she used a tan square dressing, but did not know the name of the dressing. Nurse #2 said when she signed off on Resident #3's TAR on 10/02/23, 10/03/23, 10/05/23, 10/06/23, and 10/08/23, that the treatment for the Barrier Cream had been completed, said she had not realized that the treatment order to the coccyx also included that nursing was to apply an Optifoam dressing. Nurse #2 said the last time she had seen Resident #3's coccyx prior to 10/10/23, was on 10/03/23, when she did the weekly skin assessment. Nurse #2 said the first time she applied a dressing to Resident #3's coccyx was on 10/10/23. Nurse #2 said she had not reported anything about the status of the wound to either the Wound Nurse of the Nursing Supervisor. During an interview on 10/12/23 at 4:21 P.M., Nurse #4 said he had done Resident #3's skin assessment on 10/10/23. Nurse #4 said he had a hard time getting help to reposition Resident #3 so he completed the skin assessment to the best of his ability. Nurse #4 said he could not turn Resident #3 on his own, so he had not assessed his/her coccyx area. Nurse #4 said he was not told that Resident #3 had a wound. During an interview on 10/12/23 at 4:33 P.M., Nurse #1 said she was unaware of Resident #3 having any wounds. Nurse #1 said Resident #3 had an order for Barrier Cream to his/her coccyx, but did not have an order for a dressing. Nurse #1 said she could not recall the last time she saw Resident #3's coccyx. Nurse #1 said she had never applied a dressing to Resident #3's coccyx. Nurse #1 said when she signed off on the TAR on 10/05/23 and 10/07/23 (day and evening shift), that his/her treatment for Barrier Cream had been completed, said she did not realize that the treatment to the coccyx also included for nursing to apply an Optifoam dressing. Nurse #1 said that although she signed off on the order, said the CNAs applied the Barrier Cream , and she did not know a dressing was included in the order, so she did not apply one. During an interview on 10/11/23 at 2:57 P.M., the Director of Nurses (DON) said that the nursing staff should be reporting any new skin conditions or changes in skin conditions to the Wound Nurse. The DON said she expected the nursing staff to follow the physician's orders and that the nursing staff should call the physician for new orders when there has been a change in a wound condition.

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Medical Records (Tag F0842)

Could have caused harm · This affected 1 resident

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2) Resident #1 was admitted to the Facility in August 2017, diagnoses included congestive heart failure, diabetes, and osteoarthritis. Review of the Treatment Administration Record (TAR), dated 05/2023 and 06/2023, indicated Resident #1 had a Physician's Order for nursing staff to complete a Skin Observation Tool assessment every Tuesday. Further review of Resident #1's Medical Record indicated: On 05/02/23, 05/09/23, 05/16/23, 05/23/23, 05/30/23, 06/60/23, 06/13/23, 06/20/23, and 06/27/23 nursing staff initialed that the Skin Observation Tool was completed, however further review of Resident #1's medical record indicated there was no documentation to support the Skin Observation Tools were completed for those dates. During interview on 10/12/23 at 1:23 P.M., the Director of Nurses (DON) said nursing staff should complete the Skin Observation Tools for every skin observation performed, but had not. During interview on 10/12/23 at 3:40 P.M., the Regional Nurse said nursing staff should complete the Skin Observation Tool for every skin observation. Based on interview and records reviewed, for two of three sampled residents (Resident #3 and #1), the facility failed to ensure they maintained a completed and accurate medical record (1) for Resident #3, Nursing documentation in his/her Treatment Administration Record (TAR) related to the application of Optifoam Dressing was inaccurate and the Certified Nurse Aide Activity of Daily Living (ADL) Flow sheet during the month of October 2023, was incomplete, (2) for Resident #1 his/her weekly skin observation tools were not completed by Nursing, as ordered by the Physician during the months of May 2023 and June 2023. Findings Include: Review of the Facility's policy, Pressure Ulcer/Injury Risk Assessment, dated 03/2022, indicated the type of skin care provided and the condition of the resident's skin (i.e. the size and location of any red or tender areas), should be recorded in the resident's medical record. Review of the Facility's policy, Preventative Pressure Ulcer, dated 04/2022, indicated to reposition residents who are dependent on staff for repositioning, at least every two hours. Review of the Facility's policy, Charting and Documentation, dated 04/2022, indicated the following: -Services provided to the resident, progress toward the care plan goals, or any changes in the resident's medical, physical, functional or psychosocial condition, shall be documented in the resident's medical record. -The following information is to be documented in the resident medical record: Treatments or services performed. 1. Resident #3 was admitted to the Facility in December 2022, diagnoses included: partial symptomatic epilepsy, Hypertension and history of falls. Review of Resident #3's TAR, dated October 2023, indicated he/she had a Physician's order to apply Barrier Cream to the coccyx twice a day and as needed. Further review of the order indicated that it included to cover with Optifoam dressing every day and evening shift for wound care. The treatment was signed off by the nurses as being completed twice a day, as ordered, from 10/01/23 through 10/11/23. During an interview on 10/12/23 at 2:30 P.M., Nurse #2 said that she did the skin evaluation for Resident #3 on 10/03/23. Nurse #2 said Resident #3 had reddened pressure areas to his/her coccyx but she did not think it required a dressing. Nurse #2 said Resident #3 was getting Barrier Cream to the area and she thought that was all Resident #3 needed. Nurse #2 said that the CNAs apply the Barrier Cream and the nurses sign it off on the TAR. Nurse #2 said the CNAs were not supposed to apply dressings. Nurse #2 said when she signed off on the TAR on 10/02/23, 10/03/23, 10/05/23, 10/06/23, and 10/08/23, she had not realized that the order for Barrier Cream to the coccyx included an Optifoam dressing. Nurse #2 said the last time she had seen Resident #3's coccyx prior to 10/10/23, was on 10/03/23, when she did the weekly skin assessment. Nurse #2 said the first time she applied a dressing to Resident #3's coccyx was on 10/10/23. During an interview on 10/12/23 at 4:33 P.M., Nurse #1 said she was unaware of Resident #3 having any wounds. Nurse #1 said Resident #3 had an order for Barrier Cream to his/her coccyx, but did not have an order for a dressing. Nurse #1 said she could not recall the last time she saw Resident #3's coccyx. Nurse #1 said she had never applied a dressing to Resident #3's coccyx. Nurse #1 said when she signed off on the TAR on 10/05/23 and 10/07/23 (day and evening shift), she did not realize that the order for Barrier Cream to the coccyx included an Optifoam dressing. Nurse #1 said she signed off on the order but the CNAs applied the Barrier Cream and she did not know a dressing was included in the order, and therefore did not apply one. Review of Resident #3's CNA Documentation Report, dated October 2023, related to turning and repositioning indicated there was no evidence that Resident #3 was repositioned from left to right while in his/her bed, as the boxes for the CNAs to sign off that they repositioned Resident #3, were left blank on: -10/09/23: 7:00 A.M. - 3:00 P.M. entire shift left blank, -10/10/23: 7:00 A.M.- 3:00 P.M entire shift left blank, -10/10/23: 3:00 P.M. - 11:00 P.M. entire shift left blank, -10/11/23: 7:00 A.M. - 3:00 P.M. entire shift left blank, -10/11/23 11:00 P.M.- 7:00 A.M. entire shift left blank, During an interview on 10/11/23 at 2:57 P.M., the Director of Nurses (DON) said that her expectation was for the nurses to follow the orders that were in place. During an interview on 10/12/23 at 12:17 P.M., the DON said the CNAs should reposition residents at least every two hours. The DON said the CNAs should have documented that Resident #3 had been repositioned and there should not have been any blanks spaces on the October 2023 CNA flow sheet for Resident #3.

Sept 2023 1 deficiency

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0883 (Tag F0883)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on records reviewed and interviews, the facility failed to ensure two Residents (#4 and #2) in a total sample of five residents were up to date with their Pneumococcal (name for any infection caused by bacteria called Streptococcus pneumoniae) Vaccinations, according to National standards for Pneumococcal Vaccination and the facility's policy. Specifically, the facility failed to: 1. Offer a Pneumococcal Vaccination to Resident #4 when the Resident had previously received one dose of the vaccine, but was not up to date with the Pneumococcal Vaccination series. 2. Determine whether Resident #2 was eligible to receive an additional dose of Pneumococcal Vaccine when staff failed to obtain the date Resident #2 received his/her first dose. Findings include: Review of the facility's policy, titled Pneumonia Vaccination, dated April 2017 and revised April 2022, indicated: - All residents will be offered pneumococcal vaccines to aid in preventing pneumonia/pneumococcal infections. - Upon admission, residents will be assessed for eligibility to receive the pneumococcal vaccine series, and when indicated, will be offered the vaccine unless medically contraindicated, refusal by the resident or health care representative, or the resident has already been vaccinated. - Administration of the pneumococcal vaccines or revaccinations will be made in accordance with current Centers for Disease Control and Prevention (CDC) recommendations at the time of the vaccination. Review of the CDC document, titled Pneumococcal Vaccine Timing for Adults, dated 3/15/23, indicated the following relative to complete Pneumococcal Vaccine schedules for adults aged 65 years and older: -Individuals who receive the Pneumococcal Polysaccharide Vaccine (PPSV 23- vaccine that protects against 23 types of bacteria which cause Pneumococcal disease) only at any age would be eligible to receive either one dose of Pneumococcal Conjugate Vaccine (PCV) 20 or one dose of PCV 15 at least one year after having received the dose of PPSV 23 to be considered up to date. -Individuals who receive the PCV 13 only at any age would be eligible to receive either one dose of PCV 20 or one dose of PPSV 23 at least one year after having received the dose of PCV 13 to be considered up to date. 1. Resident #4 was admitted to the facility in November 2022 with diagnoses of Vitamin D Deficiency and Adult Failure to Thrive. Review of Resident #4's clinical record indicated the Resident was over [AGE] years of age when he/she was admitted to the facility. Review of Resident #4's Immunization Record indicated the Resident received one dose of PPSV 23 on 7/15/21, prior to his/her admission to the facility. Further review of the Resident's Immunization Record included no evidence that any additional doses of Pneumococcal Vaccine had been administered. Review of Resident #4's September 2023 Physician's orders included the following active order, initiated 11/6/22: -Assess Pneumococcal Vaccination status. -Administer if not given prior to admission, with Resident consent. Review of Resident #4's clinical record on 9/27/23, included no evidence the facility offered either one dose of PCV 20 or PCV 15 to be administered to the Resident. During an interview on 9/27/23 at 10:35 A.M., Nurse #1 said Pneumococcal Vaccines were supposed to be offered to residents upon admission to the facility. Nurse #1 said a resident's consent or declination for the vaccine was to be recorded in the resident's medical record. Nurse #1 also said there were no longer any paper records at the facility and that all documents were to be scanned into the residents' electronic health records (EHRs). Nurse #1 then reviewed Resident #4's EHR and said there was no evidence that the Resident had been offered a Pneumococcal Vaccine since his/her admission to the facility. During an interview on 9/27/23 at 2:00 P.M., the Director of Nursing (DON) said an audit for residents' Pneumococcal Vaccination status had been initiated in May 2023, but the audit was still in process and had not yet been completed. Review of the facility's Pneumococcal Vaccination Audit, undated, indicated Resident #4 had received one dose of PPSV 23 on 7/15/21, but the column for what vaccine the Resident was eligible for, was blank. During a follow-up interview on 9/27/23 at 2:19 P.M., the DON said there was no evidence Resident #4 had been offered a Pneumococcal Vaccination to complete his/her vaccine series and to ensure the Resident was up to date. 2. Resident #2 was admitted to the facility in March 2023 with diagnoses including Sepsis (a life-threatening emergency that encompasses a spectrum of illness that range from minor signs and symptoms through to organ dysfunction and shock), Multiple Sclerosis (a disease in which the immune system eats away at the protective covering of the nerves), and was over [AGE] years of age. Review of a Physician's order dated 3/21/23, indicated: -Assess pneumococcal vaccination status. -Administer if not given prior to admission, with Resident consent. Review of a Minimum Data Set (MDS) Assessment, dated 4/5/23, indicated Resident #2's Pneumococcal Vaccine status was not assessed. Review of the Resident #2's Immunization Consent Form signed and dated 4/6/23, indicated the Resident had received the PCV 13 vaccine. The form did not indicate the month and year the vaccine was administered. Review of Resident #2's medical record indicated no documented Pneumococcal Vaccinations under the immunization status. During an interview on 9/27/23 at 2:00 P.M., the Director of Nurses (DON) said that an audit of Pneumococcal Vaccine status for all residents had begun in May 2023, but had not been completed. A copy of the audit was provided to the surveyor. Review of the audit indicated no documented Pneumococcal Vaccine information for Resident #2. During a follow-up interview on 9/27/23 at 2:19 P.M., the DON said there was no evidence that the facility staff obtained the date of Resident #2's PCV 13 Vaccine administration. She said the Resident had not received any additional Pneumococcal Vaccinations since admission but might be eligible for one. She said the facility had PPSV 23 and PCV 13 vaccines available to administer if needed.

Jun 2023 2 deficiencies

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Comprehensive Care Plan (Tag F0656)

Could have caused harm · This affected 1 resident

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Based on records reviewed and interviews, for one of three sampled residents (Resident #1), whose physician's orders included the administration of psychotropic medications, the Facility failed to ensure they developed and implemented an individualized comprehensive plan of care that included objectives, interventions and outcomes related to the use of psychotropic medications and the need for monitoring by nursing. Findings include: Review of the Facility Policy, titled, Comprehensive Care Plan, dated April 2022, indicated a comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. Review of the Facility Policy, titled, Psychotropic Medications, dated April 2022, indicated the Interdisciplinary Team assesses and monitors the appropriateness, effectiveness, and side effects associated with psychoactive medications for each resident via resident care plan review. The Policy indicated psychotropic medication documentation, record the approaches and interventions taken for behavior problems in the care plan. Resident #1 was admitted to the Facility in March 2023, diagnoses included vascular dementia, anxiety, and depressive disorders. Review of Resident #1's Order Summary Report indicated he/she had the following Physician's Orders: - 03/05/23, Citalopram Hydrobromide (treats depression) 15 mg by mouth one time a day for depression. - 03/05/23, Escitalopram Oxalate (treats depression) 7.5 mg by mouth one time a day for depression. Review of Resident #1's Comprehensive Care Plan, dated 03/07/23, indicated there was no documentation to support that an individualized plan of care had been developed for him/her which identified measurable objectives, interventions, or outcomes, as part of his/her treatment plan to support and monitor him/her. Further review of Resident #1's Comprehensive Care Plans indicated although he/she had a chronic/progressive decline in intellectual functioning characterized by; deficit in memory, judgement, decision making and thought process related to Dementia and alterations in his/her psychosocial well being, that plan of care had not identified or addressed the use of psychotropic medications. During interview on 06/29/23 at 2:18 P.M., the Director of Nursing (DON) said psychotropic medication should be documented including monitoring of the medication. The DON said there should be a comprehensive Plan of Care developed for any resident, including Resident #1, with psychotropic medications that included objectives, interventions, outcomes and monitoring. The DON was unable to provide any additional documentation to support Resident #1's individualized plans of care addressed the administration of psychotropic medications.

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Quality of Care (Tag F0684)

Could have caused harm · This affected 1 resident

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Based on records reviewed and interviews for one of three sampled residents (Resident #2), who was admitted to the Facility after undergoing abdominal surgery, with Hospital Discharge Instructions for the need to be seen by the surgeon for follow-up appointment scheduled for 06/07/23, the Facility failed to ensure he/she was provided services that met professional standards of practice when transportation was not booked by facility staff, Resident #1 missed his/her follow-up appointment, and as a result Resident #2 was not seen by the surgeon for a follow-up appointment until more than three weeks later. Findings include: Resident #2 was admitted to the Facility in May of 2023, diagnoses included, perforated sigmoid colon (a hole in the lining of the colon), intra-abdominal abscess (collection of pus or infected fluid inside the abdomen), status post septic shock, abdominal wound dehiscence (partial or total separation of previously approximated wound edges), requiring a wound vac, colostomy, and deep vein thrombosis (a blood clot in a deep vein, usually in the legs). Review of the Hospital Post-Acute Discharge Report, dated 05/24/23, indicated a surgical follow-up appointment had been booked for Resident #2 on 06/07/23 at 10:20 A.M. Review of Resident #2's Physician's Order Summary, dated 05/25/23, indicated that a post operative appointment had been booked for 06/07/23 at 10:20 A.M. with the surgeon and that transportation needed to be arranged for him/her. Review of Resident #2's Nurse Practitioner Progress Note, dated 06/06/23, indicated he/she had a follow-up appointment for 06/07/23 with the surgeon related to his/her perforation of colon and status post multiple surgeries, ostomy placement, wound vac for abdominal incision and follow up on status post septic shock. Review of Resident #2's Nurse Practitioner (NP) Progress Note, dated 06/08/23, indicated there was a question if he/she had gone to the appointment and that nursing was to follow-up. Review of Resident #2's Nurse Progress Note, dated 06/08/23, indicated he/she had an appointment with the surgeon on 06/07/23, and that there was a question (from the NP) wanting to know if Resident # 2 had made it to the appointment. During an interview on 07/05/23 at 11:42 A.M. Nurse # 2 said she wrote a Progress Note on 06/08/23 referring to Resident #2's follow up appointment on 06/07/23 because the Nurse Practitioner requested that nursing to follow-up to see if Resident #2 had gone on the appointment. Nurse #2 said, as an agency nurse, she made note of the Nurse Practitioners question in the Progress Note to alert regular facility staff and said she notified the Director of Nursing (DON) of the need for nursing to follow up. The Surveyor reviewed the facility's Appointment Book, located on the short-term rehabilitation unit on the second floor, accompanied by the Unit Manager, which indicated there was no documentation to support that an appointment was recorded in the Appointment Book for Resident #2 on 06/07/23, and that the page for that date was blank. The Surveyor reviewed the Receptionist Appointment Transportation Binder, located in the front lobby at the reception desk, accompanied by the Director of Nursing (DON), which indicated that no transportation had been arranged for Resident #2 for 06/07/23 and his/her name was not found in the transportation binder. Review of Resident #2's Medical Record indicated there was no documentation to support that transportation had been arranged by facility staff, or that Resident #2 had left the facility that day for an appointment. Furthermore there was no documentation to support that Resident #2 was seen by the surgeon for the follow-up appointment on 06/07/23, as there was no consult form or recommendations from the surgeon in Resident #2's medical record. During an interview on 06/28/23 at 1:51 P.M., Nurse #1 said Resident #2 had a follow-up appointment on 06/07/23 with the surgeon but there was no transportation to get him/her there and that transportation could be hard to arrange. During an interview on 06/29/23 at 11:50 A.M., the Unit Manager said that typically follow-up appointments are booked by the hospital or the admission nurse at the Facility and that the facility receptionist was responsible for booking transportation for the appointments. During an interview on 06/29/23 at 1:12 P.M., the Director of Nursing (DON) said the process for appointments at the Facility is that the nurses' put appointments in the Appointment Book located on each unit and the receptionist would then check each unit's Appointment Book. The DON said the receptionist would put appointments in her own binder located at the reception desk and arrange for the transportation. The DON said the receptionist would fill out the required transportation forms and once approved, then transportation is booked with their provider. During a follow-up interview on 07/11/23 at 1:00 P.M., (via telephone) the DON said that it was unclear why Resident #2 had not attended the follow-up appointment with the surgeon on 6/07/23, and could not say whether it was a transportation issue or otherwise. The DON said a new follow-up appointment had scheduled for 06/28/23, for Resident #2 to be seen by the surgeon

Feb 2023 12 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

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility and its staff failed to provide a dignified existence for two Residents (#8 and #174), out of a total sample of 18 residents. Specifically, the facility staff failed to: 1. provide a urinary catheter bag privacy cover (covers a catheter bag so urine is not visible) for Resident #8, and 2. provide activities of daily living (ADL) care that included removal of unwanted facial hair for Resident #174. Findings Include: 1. Resident #8 was admitted in April 2022 with a diagnosis of urine retention (the inability for a person to voluntarily release urine from the bladder). Review of the most recent Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #8 had an indwelling foley catheter (tubing that is inserted into the bladder to help drain urine). During observations on 2/14/23 at 8:22 A.M., and 2/15/23 at 9:53 A.M., the surveyor observed Resident #8 lying in bed. His/her foley catheter bag was hanging at the foot of the Resident's bed and was visible from the doorway. The bag did not have a privacy cover on it and urine was visible in the catheter bag. During an interview on 2/15/23 at 9:53 A.M., following the observation the surveyor invited Nurse #3 to observe the room. Nurse #3 said the Resident's catheter bag was visible from the doorway and that if a catheter bag was visible when hanging on the bed it should be covered with a privacy cover, and this was not done, as required. 2. For Resident #174, the facility failed to ensure its staff provided grooming to maintain personal dignity, relative to facial hair removal for a dependent resident. Review of the facility policy titled Activities of Daily Living (ADL), revised 3/2022, indicated that residents will be provided with care, treatment and services as appropriate, and residents who are unable to carry out ADLs independently will receive the services necessary for activities of daily living, including support and assistance with hygiene including grooming. Resident #174 was admitted to the facility in February 2023. Review of the MDS dated [DATE] indicated the resident had moderate cognitive impairment as evidenced by a score of 9 out of 15 in the Brief Interview of Mental Status (BIMS) assessment, and needed limited assistance of one with personal hygiene. During an observation and interview on 2/15/23 at 10:41 A.M., the surveyor noted multiple hairs an inch or longer on Resident #174's chin and upper lip. The Resident said that he/she used to get help getting cleaned up but doesn't get help any more. The Resident further stated that his/her children mentioned that the facial hair was unsightly but the Resident said he/she cannot take care of it by himself/herself and would like it taken care of. During an interview on 2/15/23 at 11:05 A.M., Certified Nurse's Aide (CNA) #1 said that Resident #174 was an assist of one for personal care, and that the Resident could wash his/her face when provided with the washcloth and the staff do everything else. She said that shaving of the facial hair was done if there was any. CNA #1 looked at the Resident's chin with the surveyor and said the Resident had long chin hairs and needed to be shaved. During an interview on 2/15/23 at 11:24 A.M., Nurse #1 said that the expectation was for residents with facial hair who wanted it removed, would have it shaved for dignity. She said, after looking at Resident #174's chin, that the Resident's facial hairs were long, and appeared as though they had not been shaved in a while. During an interview on 2/15/23 at 2:06 P.M., the Assistant Director of Nurses (ADON) said removal of facial hair is a part of care, and that shaving Resident #174's facial hair should have been done and it was not.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0572 (Tag F0572)

Could have caused harm · This affected 1 resident

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Based on interview and record review, the facility and its staff failed to provide a notice of rights and services to residents during the residents stay. Findings include: Review of the facility policy titled Resident Rights, revised 4/2022, indicated .these rights include the resident's right to be informed about his/her rights and responsibilities. Review of the Resident Council Meeting minutes for 11/30/22, 12/28/22 and 1/21/23 did not indicate that any resident rights had been reviewed. On 2/16/23 at 10:31 A.M., the survey team held a group meeting with 11 residents. The Resident group stated to the survey team that they could not recall when the last in-person meeting was held. They said that the activities department came around to some of them to discuss any concerns. Additionally, the group said that no staff had reviewed their rights with them. During an interview on 2/16/23 at 1:18 P.M., the Activities Director said that she was new and did not know how the facility notified the residents in the past of the residents rights, and the facility had not done so since she started working there. During an interview on 2/16/23 at 1:25 P.M., the Regional Director of Operations said that the resident rights are typically reviewed at the resident council meetings. He further said, after reviewing the Resident Council Minutes for November 2022, December 2022, and January 2023, it did not appear that the resident rights had been reviewed during those meetings. During a follow up interview, the Regional Director of Operations provided evidence that the resident rights had previously been reviewed (April-September) at the resident council meetings (choosing one right per month to review with the residents who were in attendance). When the surveyor asked how the facility reviewed resident rights for the resident representatives and for other residents in the facility who did not attend resident council meetings, the Regional Director of Operations said he was unable to speak to that.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Safe Environment (Tag F0584)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations and interviews, the facility failed to ensure its staff provided a safe, clean, comfortable homelike environment on one (Unit Four) out of three units. Findings include: During an observation and interview on 2/14/23 at 9:05 A.M., on Unit Four, the surveyor observed Resident #11's carpet next to his/her bed full of crumbs, the area under his/her bed cluttered with items such as clothing in bags, opened soda bottles, a plastic pitcher of juice, an opened bag of potato chips, an open bowl with candy way underneath his/her bed against the wall, and visible dirt all over the floor surrounding the Resident's multiple totes, containers and belongings. The Resident said housekeeping had not been in to clean his/her room since Saturday (three days prior). During observations on 2/14/23 between 9:18 A.M. until 10:12 A.M., on Unit Four, the surveyor observed the following: -room [ROOM NUMBER] - Bathroom with visible dirt/dust over the corners of the floor and the caulk underneath the toilet, dried, cracked and dirty. -room [ROOM NUMBER] - the walls behind both beds were observed to be badly damaged, one covered with spackle and the other wall with deep scrapes. In the bathroom, the area behind the toilet seat and the toilet was soiled, and the floor behind the toilet and against the tile wall was observed with stained grout and multiple areas of a crumbly brown substance. -room [ROOM NUMBER] - the Resident's wheelchair had washcloths wrapped around the metal frame above the front wheels secured with silk tape. The silk tape was loose, hanging, and soiled. The wall behind the Resident's bed had significant damage. The baseboard heater in the bathroom was not securely attached to the wall, hanging at an angle with holes in the wall visible behind it, the bathroom floor was visibly soiled and a bedpan with what appeared to be stuck on pieces of toilet paper inside was laying on the floor next to the toilet. During an observation and interview on 2/16/23 at 10:25 A.M., on Unit Four, Housekeeper #1 was beginning to clean Resident #11's room. Housekeeper #1 said the Resident's belongings needed to be moved in order to clean his/her room effectively and it did not appear this had been done in a long time. She pointed out the food that the Resident kept around the room, specifically pointing underneath the Resident's bed where there was an opened bag of chips and said this food could attract pests and rodents. Housekeeper #1 further said the Resident likes to keep plants in his/her room and staff should be moving items in order to clean the dirt that might have spilled out of the plants. In addition, she said that all rooms should be cleaned every day and that should entail wiping down all surfaces such as bureaus, nightstands, over-bed tables, sinks and toilets. She further stated all floors should be swept and mopped daily and there should be a schedule in place to deep clean resident rooms in addition to the daily, routine cleaning. During a complete tour of Unit Four on 2/16/23 from 10:25 A.M. to 11:45 A.M., the surveyor observed the following: -room [ROOM NUMBER]- brown sticky substance on the floot next to a recliner chair. Caulk around the toilet was dry, stained, cracked and missing in many places, the toilet bowl was loose on the floor. Dirt and debris noted around all four corners of the bathroom floor. -room [ROOM NUMBER] - caulk around toilet missing, rusty stains on the floor all around the edge of toilet. -room [ROOM NUMBER] -Bed one- headboard loose, walls damaged behind both beds, foam fall mat next to Bed two stained and dirty, toilet was clogged, raised toilet seat laying on the bathroom floor and the area between the toilet seat and toilet tank soiled with a build up of yellowish/ brown substance. -room [ROOM NUMBER] - glass cover over safety light outside of bathroom door was broken, the bathroom heater was hanging off the wall, there was dirt and debris around the corners of the bathroom floor, the area between toilet seat and toilet tank was soiled, caulk around toilet cracked, stained and missing in places. -room [ROOM NUMBER] - one toilet safety handle was wrapped with foam and duct tape. -room [ROOM NUMBER]- glass cover over safety light outside bathroom door was loose, bathroom floor with ground in dirt, caulk around toilet dry, missing in areas and stained. -room [ROOM NUMBER]- bathroom floor with visible dirt. -room [ROOM NUMBER]- area between toilet seat and toilet tank stained, glass cover over safety light outside the bathroom door caved in, rubber moulding on the wall behind Bed one was pulling away from wall and covered with debris. -room [ROOM NUMBER] - hole in the wall outside of the bathroom door with crumbling plaster, rubber wall moulding pulling away from walls, chipped paint, toilet seat dirty. -room [ROOM NUMBER]- area between toilet seat and toilet tank stained and dirty. -room [ROOM NUMBER] - bathroom wall near the floor with crumbling plaster, non skid tape on the bathroom floor was peeling backwards, the frame of the safety light outside the bathroom door was coming out of the wall, floors with ground in dirt. During an interview on 2/16/23 at 11:10 A.M., Certified Nursing Assistant (CNA) #3 said with the facility's previous owners, there used to be what was called room of the day where all of the furniture was removed from the room, walls were repaired if needed, the floors were stripped and waxed and the room was deep cleaned and this doesn't seem to happen anymore. She further said there are times where they have had to go three days without housekeeping services and the CNAs have to pick up the slack and the rooms should be maintained better for the residents. On 2/16/23 from 1:00 P.M. to 2:00 P.M., during a tour of Unit Four with the surveyor and the Administrator, the Administrator acknowledged the following: -Resident #11's room still needed further cleaning, -room [ROOM NUMBER]'s floors needed to be stripped and refinished, -room [ROOM NUMBER]'s toilet needed repair, the bathroom needed cleaning and the headboard needed screws. Bed two's fall mat needed to be replaced and the walls behind the bed required repair. -The Administrator removed the soiled tape from the wheelchair in room [ROOM NUMBER] and said there should have been something else to use on the Resident's wheelchair if the washcloths wrapped in tape were placed on the wheelchair to prevent injury. -room [ROOM NUMBER]'s bathroom needed to be cleaned more thoroughly and the corners of the bathroom required scrubbing. -the wall behind the first bed in room [ROOM NUMBER] required repair as does the bathroom and toilet. -the hole outside the bathroom in room [ROOM NUMBER] should not be there and required repair. -room [ROOM NUMBER]'s bathroom wall was crumbling and needed repair. He further said that it did not appear the facility staff have been implementing the room of the day and the unit needed attention relative to maintenance and housekeeping.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

PASARR Coordination (Tag F0644)

Could have caused harm · This affected 1 resident

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Based on interview and record review, the facility failed to ensure its staff referred one Resident (#2), out of a total sample of 18 residents, for a Level II evaluation (an evaluation to determine if a resident needs specialized services to address his/her Mental Illness (MI)) once it was identified post admission that the Resident had a diagnosis of MI. Findings Include: Resident #2 was admitted the facility in March 2022. Review of the Resident's Level I Preadmission Screening and Resident Review (PASRR-an evaluation to determine if a Resident has MI or Intellectual or Developmental Disability (ID/DD) and needs an additional Level II evaluation) dated 4/19/22, indicated Resident #2 did not have any diagnosis of MI. Review of the Physician's Progress Note dated 4/21/22, indicated the Resident had a previous medical history of Schizoaffective Disorder (a MI that is a combination of symptoms of Schizophrenia and mood disorder). Review of the Behavioral Health Care Team's progress note dated 4/27/22, indicated the Resident had a diagnosis of Schizoaffective Disorder, and had a history of needing both outpatient and inpatient Behavioral Health Services. Further review of the chart indicated no additional documentation that once the Resident's MI was identified, his/her Level I was updated and submitted to be assessed for a Level II evaluation. During an interview on 2/15/23 at 3:24 P.M., with the Social Worker (SW) and Regional Director of Operations, the SW said the Level I should have been updated and submitted as required when it was identified the Resident had a diagnosis of MI, and this had not been done, as required.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0694 (Tag F0694)

Could have caused harm · This affected 1 resident

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Based on record review and interview, the facility failed to ensure that its staff provided care and services in accordance with professional standards for one Resident (#46) with an intravenous line out of a total sample of 18 residents. Specifically, the facility failed to ensure staff developed and implemented measures to ensure the peripherally inserted central catheter (PICC: an intravenous line that is inserted in the arm, threaded through the veins and ends in the larger vein of the heart) was assessed for migration (movement), flushed to maintain patency and that the needleless connection caps were changed per facility policy and professional standards. Findings include: Review of an online article by the Infusion Nurses Society titled Infusion Therapy Standards of Practice, 8th edition, revised 2021, indicated: -The Infusion Therapy Standards of Practice is applicable to any patient population and any setting in which vascular access devices (VADs: intravenous lines) are inserted and/or managed and where infusion therapies are administered -Change the needleless connector no more frequently than 96-hour intervals or according to the manufacturers' directions for use. Changing on a more frequent time interval has been shown to increase the risk of Catheter Associated Blood Stream Infection (CABSI). -VADs are flushed and aspirated for a blood return prior to each infusion to assess catheter function and prevent complications. -VADs are flushed after each infusion to clear the infused medication from the catheter lumen, thereby reducing the risk of contact between incompatible medications. -Site care, including skin antisepsis and dressing changes, is performed at established intervals and immediately if the dressing integrity becomes compromised. -Measure the external CVAD (central venous access device/ catheter) length at each dressing change or when catheter dislodgement is suspected and compare to the external CVAD length documented at insertion. -Measure circumference of the extremity and compare to baseline measurement when clinically indicated to assess the presence of edema and possible catheter-associated deep vein thrombosis (DVT). Review of the facility policy titled Central Venous Catheter Care and Dressing Changes, revised 4/2022, indicated the following: -perform site care and dressing changes at established intervals. -maintain a sterile dressing, either transparent semi-permeable membranes (TSM) dressing or sterile gauze for all central venous catheter devices. -change the dressing if it becomes damp, loose, redness, tenderness and swelling, or visibly soiled. -with each infusion and at least daily: palpate and inspect the skin dressing and securement device for signs of complications such as dislodgement, tenderness, swelling. -measure the length of the external venous access device with each dressing change, or if dislodgement is suspected. Compare the measured length with the length documented at insertion. -for a PICC line, measure arm circumference and compare to baseline to assess for edema and possible deep-vein thrombosis (DVT) when clinically indicated. Resident #46 was admitted to the facility in January 2023 with a chronic Diabetic Ulcer of the right foot and Cellulitis of the right lower limb. During an observation on 2/14/23 at 9:01 A.M., the surveyor observed the Resident with a PICC line dressing on the left upper arm. There was an IV pole in the room with an empty bag of antibiotic solution and attached tubing. It was not connected to the resident. During a subsequent brief record review, it was noted that there were no comprehensive orders in place for the care and services related to the PICC line. During an observation on 2/15/23 at 9:42 A.M., the surveyor observed the Resident seated on side of the bed wearing a johnny (facility gown), there was an undated dressing on his/her right foot, and a PICC line present in the upper left arm with an intact TSM dressing dated 2/14/23. Review of the active Physician's orders as of 2/21/23 indicated the following orders present since admission: -change transparent dressing to PICC line every day shift, every Friday for IV maintenance (order date: 1/6/23) -change TSM dressing to PICC as needed (order date:1/6/23) -Ertapenem sodium solution, one gram intravenously every 24 hours for infection x 41 days (order date 1/6/23) -change IV primary tubing one time a day use during administration of antibiotic (order date: 1/17/23) -Observe insertion site at least every shift for redness swelling or pain at site (1/6/23) Review of record indicated no documented evidence that the PICC line care and services related to measurements to determine line migration or measurements to determine arm circumference were done prior to the survey start or were in place until 2/14/23. Further review of the record indicated no documented evidence that flushing protocols or needleless connection device changes were ordered or implemented prior to 2/14/23. Review of the January 2023 Medication Administration Record (MAR) indicated the Resident had received daily doses of antibiotics. There was no documented evidence that the line had been flushed to maintain patency, the arm circumference had been monitored, the needleless connection device had been changed, or the tubing length had been measured. Review of the February 2023 MAR indicated the Resident had received daily doses of antibiotics as of 2/14/2023. There was no documented evidence that the line had been flushed to maintain patency, the arm circumference had been monitored, the needleless connection device had been changed, or the tubing length had been measured. During an interview on 2/15/23 at 11:28 A.M., Nurse #1 said the care of a PICC line should include: flushing the line every shift with Normal Saline (NS: a sterile salt water solution), and sometimes administering Heparin (a medication used to prevent blood clots) to keep the line patent (open), the dressing (s) needed to be changed once a week, the site should be monitored for signs and symptoms of infection, redness and increased arm circumference and the length of the external catheter tubing should be measured to make sure the line was not dislodged or pulled. Nurse #1 viewed the Resident's record with the surveyor and said the Resident was admitted and started the antibiotic on 1/6/23 and the orders for site care were entered yesterday, 2/14/23. During an interview on 2/15/23 at 2:20 P.M., the Assistant Director of Nurses (ADON) said the care and services for a resident with a PICC line should include: -external tubing length measurements -flushing orders using NS and/or Heparin to maintain patency -arm circumference measurements She viewed the orders and said there were no orders in place from admission until yesterday (2/14/23) for arm circumference, external tubing length measurements, flushing and cap changes. After she reviewed the MAR/TAR for January, she said there was no documented evidence that the arm circumference, external tubing measurements, flushing, and cap changes were completed as required and they should have been implemented upon admission.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Drug Regimen Review (Tag F0756)

Could have caused harm · This affected 1 resident

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Based on interview and record review, the facility and its staff failed to ensure: 1. development of a policy that provided time frames for the different steps of the Medication Regime Review (MRR-review done by the facility Pharmacist that provides recommendations monthly for each resident regarding their medications), and 2. the attending Physician reviewed and documented they accepted and/or declined the MRR for one Resident (#43), out of a total sample of 18 residents. Findings Include: Review of the facility policy titled Medication Regimen Review (MRR), revised December 2019, indicated the following: -Recommendations are acted upon and documented by the facility staff and/or the prescriber. -Prescriber accepts and acts upon suggestion or rejects and provides an explanation for disagreeing. -The Director of Nursing or designated licensed nurse addresses and documents recommendations that do not require a Physician intervention . Further review of the facility policy indicated no indication of the time frames for the different steps of the MRR. Resident #43 was admitted to the facility in July 2022 with diagnoses including Chronic Obstructive Pulmonary Disease (COPD), Vascular Dementia, Major Depressive Disorder, Anxiety Disorder, and was on Hospice Services. Review of the Pharmacist Progress Note dated 10/24/22 indicated the Pharmacist had performed a MRR and made suggestions. Review of the MRR dated 10/24/22 indicated the following recommendation: -Resident is receiving the following PRN (as needed) psychotropic medication with no stop date: ABH gel (a topical gel used to treat terminal restlessness at the end of life made from the combination of Lorazepam (an antianxiety medication), Diphenhydramine (an antihistamine), and Haloperidol (an antipsychotic) this medication is required to be re-evaluated after 14 days if being used as PRN. Review of the January 2023 Order Summary Report indicated the following order: -ABH gel .every four hours PRN with a start date of 10/17/22 and no stop date indicated Review of the January 2023 Medication Administration Record (MAR) indicated the Resident had received the PRN ABH gel eight times during the month of January 2023. Review of the Pharmacist Progress Note dated 11/25/22 indicated the Pharmacist had performed a MRR and made suggestions. Review of the MRR dated 11/25/22 indicated the following recommendation: -Resident is receiving Trelegy inhaler (an inhaled steroid medication used for COPD). In order to help prevent the development of thrush (fungal infection) please update order to instruct resident to rinse mouth after use . Review of the January 2023 Order Summary Report indicated the following order: -Trelegy .one dose inhale orally one time a day with a start date of 11/3/22. Further review of the order did not indicate instructions the Resident should rinse their mouth after the medication was dispensed as recommended by the Pharmacist. Review of the January 2023 MAR indicated Resident #43 utilized the Trelegy inhaler once daily from 1/1/23 through 1/20/23 (20 times). During an interview on 2/21/23 at 8:40 A.M., Nurse #2 said when a resident is on a PRN antipsychotic medication it should have a stop date after 14 days so it can be reviewed by the Physician for ongoing use or to be discontinued. She reviewed Resident #43's order and confirmed the PRN ABH gel did not have a stop date and she was unable to find evidence that the Physician had reviewed it every 14 days. She further said when a Resident receives an inhaled steroid medication it was important for the Nurse to have the Resident rinse their mouth out after administering medication as this reduces the likelihood of a Resident getting thrush. During an interview on 2/21/23 at 8:59 A.M., the Regional Nurse reviewed the MRRs from 10/24/22 and 11/25/22 and said the Pharmacist's recommendations had not been reviewed and responded to by the Physician, as required. She said the Resident's ABH gel should be reviewed every 14 days by the Physician and it was not being done as recommended. She further said the Trelegy order should have been updated to include having the Resident rinse his/her mouth after administration and this was also not done as recommended. When asked if the facility policy indicated a time frame for completing the steps of the MRR the Regional Nurse said MRRs should be responded to within 30 days and the facility policy did not have a timeframe included in it, but she was unsure if the policy should contain a timeframe for the steps of the MRR.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Medication Errors (Tag F0758)

Could have caused harm · This affected 1 resident

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Based on interview and record review, the facility failed to ensure its staff limited a PRN (as needed) antipsychotic medication order to 14 days for one Resident (#43), out of a total sample of 18 residents. Findings Include: Resident #43 was admitted to the facility July 2022 with diagnoses including Vascular Dementia, Major Depressive Disorder, Anxiety Disorder, and was on Hospice Services. Review of the January 2023 Order Summary Report indicated the following order: -ABH gel (a topical gel used to treat terminal restlessness at the end of life made from the combination of Lorazepam (an antianxiety medication), Diphenhydramine (an antihistamine), and Haloperidol (an antipsychotic) . every four hours PRN with a start date of 10/17/22 and no stop date indicated. Review of the January 2023 Medication Administration Record (MAR) indicated the Resident received the PRN ABH gel eight times during the month of January 2023. During an interview on 2/21/23 at 8:40 A.M., Nurse #2 said when a resident is on a PRN antipsychotic medication it should have a stop date after 14 days so it can be reviewed by the Physician for ongoing use or to be discontinued. She reviewed Resident #43's order and confirmed the PRN ABH gel did not have a stop date and she was unable to find evidence that the Physician was reviewing it every 14 days.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0825 (Tag F0825)

Could have caused harm · This affected 1 resident

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Based on record review and interview, the facility failed to ensure its staff provided specialized rehabilitative services relative to Speech and Language Pathology (SLP) for one Resident ( #44) out of a sample of 18 residents. Findings include: Resident #44 was admitted to the facility in January 2019 with diagnoses including Parkinson's Disease, Epilepsy (neurological disorder where brain activity becomes abnormal causing seizures or periods of unusual behavior, sensations and sometimes loss of awareness), significant weight loss in the last six months, and oropharyngeal Dysphagia (difficulty swallowing). Review of the SLP Therapy Note dated 11/21/22, indicated the following: -Resident was alert, but had severely impaired swallow function. -He/she tolerated only several bites of pureed foods, holding each bite for many minutes before swallowing. -He/she was unable to tolerate liquids except via teaspoon on this day. Review of the of the February 2023 Physician's Orders included the following ordered on 11/28/22: -Speech Therapy: ten visits for oral/pharyngeal swallow evaluation for treatment of swallow dysfunction secondary to oropharynheal Dysphagia Review of the most recent SLP Skilled Service Note, provided by the Director of Rehabilitation (Rehab) and dated 1/16/23, indicated to continue skilled SLP treatment. During an interview on 2/16/23 at 9:57 A.M., the Director of Rehab said that 1/16/23 was the last day Resident #44 was seen by SLP services. She said that he/she should be seen two to three times per week and that is currently not being done. She said that the Resident was currently on their case load however with the staffing issue they are experiencing, Resident #44 was not receiving services as ordered.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0924 (Tag F0924)

Could have caused harm · This affected 1 resident

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Based on observation and interview, the facility staff failed to ensure a secure handrail was in place on one Unit (Unit Three) out of three total Units. Findings include: During an observation on 2/16/23 at 11:49 A.M., the surveyor observed an unsecured handrail on the left side of the nurses' station on Unit Three. The left side of the handrail was no longer attached to the wall and there was broken plaster on the wall where the handrail should have been attached. During an observation and interview on 2/16/23 at 2:10 P.M., the Administrator said the handrail was not secured as required and was in need of repair.

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

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Resident #174 was admitted to the facility in February 2023. Review of the facility policy titled Bowel Regimen Protocol, revised 4/2022, indicated that if a resident has had no bowel movement (BM) for 9 consecutive shifts, the bowel protocol should be initiated on the next shift. Review of the February 2023 Physician's Orders indicated the Resident was on the following medications: -Oxycodone Hydrochloride (an opioid medication used to treat pain with a side effect of constipation) one 5 milligram tablet by mouth every six hours as needed (PRN) for pain (start date 2/3/23) -Milk of Magnesia Suspension (MOM: a medication used to treat constipation), Give 30 milliliters (ML: a liquid measurement) daily, for bowel management as needed (PRN) for no bowel movement (BM) in nine shifts (three days) -Bisacodyl Suppository (a medication in suppository form, to treat constipation) 10 milligrams (mg: a measurement of weight denoting strength) rectally as needed (PRN) daily for no BM if MOM ineffective -Fleet Enema (a liquid medication used to treat constipation) one application daily as needed (PRN) if no BM and Bisacodyl suppository ineffective. Review of the Unit Two's BM Sheet, indicated that Resident #174 had gone twelve shifts without a BM. In addition, there were five shifts in which there was no documentation to indicate whether, or not, the resident had a BM. Review of the February 2023 Medication Administration Record (MAR) indicated that Resident #174 had received Oxycodone seven times since admission. Further review indicated no documented evidence that the Resident had received MOM, Bisacodyl suppository or Fleet Enema to date. During an interview on 2/15/23 at 4:58 P.M., Certified Nurse's Assistant (CNA) #4 reviewed the BM sheet for Unit Two with the surveyor and said the empty boxes were missing documentation and it was impossible to know if the Resident had a bowel movement or not. She said if a resident doesn't have a BM in a couple of days the CNAs needed to tell the nurse. During an interview on 2/16/23 at 8:29 A.M., the Assistant Director of Nurses (ADON) said the bowel protocol was initiated after nine shifts with no BM. She said the protocol was to start with MOM, and if no results (no BM) the suppository is administered, and if that doesn't work, administer the enema. If there were still no results, the Physician was called. She further said when there was missing documentation on the BM sheets, err on the side of caution and assume that there was no BM. Blank squares on the BM sheets were counted as no BM. She said that there are 19 zeros if you count the empty spots. She said the bowel protocol should have been initiated after the ninth zero square and this was not done. She further said that when a Resident doesn't have a bowel movement in a long time it can result in constipation and potential bowel obstruction. During an interview on 2/21/23 at 9:00 A.M., the Director of Nurses (DON) said based on the documentation, the Resident should have been started on the bowel protocol on the evening of the ninth shift without a BM, and that was not done. 3. The facility staff failed to ensure Oxygen (O2) was delivered at the ordered flow rate for a resident with chronic pulmonary disease. Resident #15 was admitted to the facility in September 2022 with Chronic Respiratory Failure (CRF) and Chronic Obstructive Pulmonary Disease (COPD). Review of the facility policy titled Oxygen Use, revised 4/2022, included guidelines for the safe administration of Oxygen and the first step was to verify the Physician's orders, and subsequently to adjust the oxygen delivery device so that the proper flow of Oxygen was being administered. During an observation and interview on 2/14/23 at 10:11 A.M., the surveyor observed Resident #15 lying in bed receiving humidified Oxygen via nasal cannula tubing (NC: a tube used to deliver oxygen into the nares), which was attached to the oxygen concentrator and was set at 3 liters per minute (LPM: the flow rate of Oxygen delivery). The Resident said he/she had COPD, and had been on Oxygen for a while. Resident #15 expressed no concerns at the time of the interview. During a subsequent observation on 2/15/23 at 9:22 A.M., the surveyor observed the Resident lying in bed. Humidified oxygen was set at 3.5 LPM and was being administered to Resident #15 via nasal cannula. During the time of observation, Nurse #1 entered the room to give Resident #15 his/her medications. During an interview on 2/15/23 at 10:12 A.M., Nurse #1 said the Resident had an order for Oxygen at 1 LPM and there was no order to titrate (adjust based on the Resident's condition) the Oxygen. She said the Oxygen flow rate was set incorrectly at 3.5 LPM. She checked the Resident's oxygen saturation and it was 98% on 3.5 LPM. She said for a resident with COPD, the oxygen set at that setting (higher than ordered) could result in the retention of carbon dioxide (CO2: a by product of ineffective breathing) and cause respiratory distress. Review of the Minimum Data Set (MDS) Assessment, dated 2/4/23, indicated the Resident was cognitively intact as evidenced by a score of 15 out of 15 on the Brief Interview of Mental Status (BIMS) exam, required extensive assist with transfers and hygiene, did not ambulate, and received Oxygen. During an observation and interview on 2/16/23 at 8:45 A.M., the surveyor observed the Resident in bed with Oxygen delivered by NC and the flow rate set on the oxygen concentrator at 1 LPM. The Resident said he/she had no concerns at the time of the interview. Review of the February 2023 Physician's Orders indicated: -Ipratropium Albuterol solution updraft every 4 hours while awake, and every 2 hours as needed (PRN) -Symbicort puffs 2 twice a day -change nebulizer tubing once a week on Wednesday night -change O2 tubing/filter once a week on Wednesday night, date, and initial new tubing -O2 at 1 LPM via N/C continuous/PRN for shortness of breath Review of the Nursing care plan, initiated 10/21/22, indicated to administer and monitor the effectiveness of treatments including Oxygen and to see current Physician's orders. Review of the February 2023 Treatment Administration Record (TAR) indicated that the Resident had received Oxygen at 1 LPM on 14 out of 15 day shifts, 12 out of 14 evening shifts and 12 out of 14 night shifts and the oxygen saturation (the amount of oxygen in the blood) measurements ranged from 92-100 %, (within normal limits for chronic pulmonary disease). There was no documented evidence that the resident had experienced any episodes of shortness of breath, requiring an adjustment to the Oxygen flow rate. During an interview on 2/15/23 at 2:15 P.M., the Assistant Director of Nurses (ADON) said the Oxygen order was for 1 LPM and that the Oxygen should not be delivered above the flow rate that was ordered. She further said that for a resident with COPD the Oxygen setting should not be above 2-3 liters because of a concern about CO2 retention, and there was no order for titrating Oxygen delivery to maintain the oxygen saturation above a certain percent. Based on observation, record review, and interview, the facility failed to ensure its staff implemented the plan of care for two Residents (#44, and #174) out of 18 sampled residents. Specifically, failure to implement: 1. a) monitoring meal intake while transitioning from NPO (does not receive fluid or solids by mouth) to PO (does receive fluid or solids by mouth), b) monitoring weights, and c) fall safety interventions for Resident #44, 2. initiated the bowel regimen protocol as care planned for Resident #174, and 3. ensure Oxygen (O2) was delivered at the ordered flow rate for Resident #15. Findings include: 1. Resident #44 was admitted to the facility in January 2019 with diagnoses including Parkinson's Disease, Epilepsy, significant weight loss in the last six months, and legal blindness. a) Review of the current Physician's orders indicated to document breakfast, lunch, and dinner percentages while the Resident transitions from NPO to PO starting on 1/10/23. Review of the medical record indicated no evidence that the Resident's meal intake percentage was documented after 1/26/23. During an interview on 2/21/23 at 8:26 A.M., Nurse #2 said that the order was to document in a progress note what the Resident's meal intake percentage was for each meal. Together, Nurse #2 and the surveyor reviewed progress notes. She said that it appeared that staff were not documenting the meal intake percentage as per the Physician's order and should have. Additionally, Nurse #2 reviewed the Treatment Administration Record (TARs) and the Medication Administration Record (MARs) with the surveyor and said that it appeared the nurses were checking that it was administered however did not document the percentage as required per Physician orders. b) Review of the current Physician's orders for Resident #44 indicated to obtain a weekly weight, every day shift on Monday with a start date of 12/12/22. Review of the Weights and Vitals Summary indicated a significant weight loss of 14.45% from 9/13/22 to 2/04/23. In addition to the Weights and Vitals Summary, a review of the MARs for January 2023 and February 2023, indicated that no weights had been obtained for the following weeks as ordered: 1/9/23, 1/23/23 and 2/6/23. During an interview on 2/16/23 at 8:36 A.M., Certified Nurse's Assistant (CNA) #2 said that she obtains the weights for residents monthly unless requested otherwise. She additionally said that she was not told by the nurse to obtain weekly weights for Resident #44. During an interview on 2/16/23 at 9:36 A.M., the Director of Nursing (DON) said that the weights had not been obtained and should have been completed weekly as ordered. c) Review of a progress note dated 2/18/23 indicated that Resident # 44 had an unwitnessed fall around 4:40 P.M., (no injury occurred) in the dining room Resident had a chair alarm however it was turned off. That the CNA that got the Resident out of bed, forgot to turn the alarm on and forgot to put his/her personal alarm on. Review of the [NAME] (a tool utilized by the CNAs found in the electronic medical record, that gives information on how to provide individualized care for each resident) indicated that staff were educated to maintain alarm placement and functioning every shift, initiated on 2/18/22. Review of the Risk for Falls Care Plan, indicated for an alarm to be in place, initiated on 9/1/22. During an interview and observation on 2/21/23 at 8:39 A.M., CNA #2 and the surveyor observed the Resident to be in bed with the bed alarm hanging from side rail, not flashing. CNA #2 unplugged the cord from the alarm box to test it. The alarm did not sound. She said that the alarm was not turned on and should have been. She switched the button to the on position and the alarm box began to flash, indicating it was now turned on. During an interview on 2/21/23 at 8:49 A.M., the Director of Nursing (DON) said that the CNAs and the nurses are responsible for ensuring the alarms are in place, turned on and functioning.

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Food Safety (Tag F0812)

Could have caused harm · This affected multiple residents

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Based on observations, interviews and policy review, the facility failed to ensure its staff stored and prepared food in accordance with professional standards for food service and safety. Specifically, they failed to ensure a sanitary environment in the facility main kitchen, as well as in three out of three unit kitchens. Findings include: Review of a facility memo to all kitchen staff, dated 8/10/16 indicated: - All personal belongings brought into the kitchen may be stored in the storeroom. - No food or drink is allowed in the main kitchen work area. This means no eating or drinking in the kitchen. -All personal food and beverage is to be stored in the staff refrigerator and consumed during breaks. -Employees may have a glass of water if thirsty but only in the supervisor's office or the dish room. Review of the facility's Safety and Sanitation Best Practice Guidelines, revised 1/2011 indicated: - Ovens: should be cleaned daily, weekly, or as needed. Daily: Wipe up spills as they occur, remove shelves, scrape burned particles from hearth, brush out interior, shelf ledges, and door crevices, replace shelves, wash outside of door and frame, rinse and wipe dry. Weekly: Allow oven to cool, remove shelves and scrub in the pot and pan sink, rinse and wipe dry. Scrape burned on particles from hearth, brush interior, shelf ledges, and door crevices, scrub interior (or use oven cleaner), shelf ledges, rinse inside and outside of oven, replace clean shelves, wipe outside, dry and polish metal trim. -Tables/Countertops: should be cleaned daily and as needed. Daily: wipe up spills as they occur with damp cloth or paper towel, wipe surface of tables and countertops with cloth dipped in mild detergent solution, rinse with clean cloth dipped in hot water, spray or wipe with sanitizing solution and allow to air dry. Weekly: clean legs, shelves, rolled edges and underside of tables, remove utensils from drawers and items from shelves, wipe all surfaces and inside drawers with cloth dipped in mild detergent solution, rinse with clean cloth dipped in hot water, spray or wipe with sanitizing solution, allow to air dry and spray drawer slides with silicone spray to assist in easier sliding. During an initial tour of the facility's main kitchen on 2/14/23 at 7:15 A.M., the surveyor observed the following: - in beverage preparation area: a cell phone was plugged in for charging, a water bottle and a plastic container of food enclosed in a grocery bag. - food preparation bench: bottle of power aid drink. - convection oven: floor grease laden, outside handle grease laden. - shelf underneath food preparation bench: stainless steel pans used to serve meals face down on a greasy, dust-laden surface. During an interview on 2/14/23 at 8:05 A.M., with the Food Service Director (FSD), the FSD said the shelf containing the steam tray pans should have been cleaned weekly, but upon the surveyor showing him dust and grime on her finger after wiping it across the surface of the shelf, he said obviously it was not done correctly. He also said that the exhaust vents above the stove area should be cleaned monthly, however it had been over two months since they were cleaned and should be cleaned immediately. He further said the ovens were usually deep cleaned every two weeks and the convection oven was in need of cleaning. After observing the area where the beverage pitchers were stored, he said they usually utilized shelf liners, however they had run out. He further said that the cell phone, power aid drink, the water bottle and the personal food in the grocery bag should not have been in areas where the residents' food was prepared. During a follow up kitchen walk through on 2/16/23 at 9:25 A.M., with the FSD, the surveyor observed observed a fan, that was dust laden on the front grill and fan blades positioned approximately three feet away and blowing air towards the cook who was preparing food for resident meal service. The FSD said the fan should not be in use in the food preparation area. He further said that there was no formal kitchen cleaning schedule and without one, there was no documented evidence on what was to be cleaned, when it was to be cleaned, or how often equipment was to be deep cleaned other than the daily regular maintenance cleaning. During an inspection of the nursing unit nourishment kitchens on 2/17/23 between 8:30 A.M. and 9:15 A.M., the surveyor observed the following: On Unit Two: -the Refrigerator had an unlabeled and undated McDonalds plastic cup filled with a brown beverage with a straw inside located on the shelf inside the door and an unlabeled and undated bottle of Vitamin Water -the cabinet over the sink had an McDonald's paper bag (unlabeled, undated) with a hash brown inside. On Unit Three: -the refrigerator had a Styrofoam container with food, dated 2/12/23, an unsealed Ziploc bag containing a roll and an unsealed container of sliced cheese, dated 2/12/23, that were not labeled with a resident's name. On Unit Four: - the refrigerator had unlabeled, undated containers of cottage cheese and sliced fruit covered with plastic wrap and an unlabeled, undated plastic container with food inside a plastic bag. -the cabinet over the sink had a lidded plastic cup (unlabeled, undated) which contained a frothy pink colored liquid. During observations and interview on 2/17/23 from 9:20 A.M. to 9:35 A.M., the FSD said the McDonald's food and drink were unlabeled and undated and should be discarded. He said that the Vitamin water was probably an employee's and that it should not have been stored in the refrigerator. He further said the container of cottage cheese and fruit and the plastic container with food were not dated and should be discarded. The FSD said that the food items should only be stored in the refrigerator for three days and then should be discarded. He further said the Styrofoam container with food and the clear plastic bag containing the roll and container of sliced cheese should have been discarded on 2/15/23 and was not, as required. The FSD said that the plastic cup containing the frothy liquid should not be in the cabinet and should be discarded.

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Infection Control (Tag F0880)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, and record review, the facility failed to ensure its staff maintained an infection prevention program to prevent the transmission of a communicable disease for one Resident (#223), out of a total sample of 18 residents. Specifically, they failed to: 1) utilize the appropriate personal protective equipment (PPE) while providing care to the Resident, and 2) initiate precautions appropriate to the Resident's condition. Findings include: Review of the facility's policy titled, Isolation - Categories of Transmission Based Precautions, revised April 2022, indicated the following under Contact Precautions: - In addition to Standard Precautions (minimum infection prevention practices which apply to all patient care regardless of suspected or confirmed infection status of the patient, in the setting where health care is delivered), implement Contact Precautions for residents known or suspected to be infected with microorganisms that can be transmitted by direct contact with the resident or indirect contact with environmental surfaces or resident care items in the resident's environment. - Examples of infections requiring Contact Precautions include but are not limited to .Diarrhea associated with Clostridium difficile (a bacterium that causes an infection of the large intestine (colon) with symptoms ranging from diarrhea to life-threatening damage to the colon, also referred to as C.diff. - In addition to wearing gloves as outlined under Standard Precautions, wear gloves when entering the room - While caring for the resident, change gloves after having contact with infective material (for example fecal material and wound drainage). - Remove gloves before leaving the room and perform hand hygiene. - Wear a disposable gown upon entering the Contact Precautions room and after removing gown do not allow clothing to contact potentially contaminated environmental surfaces. Review of the facility's policy titled, Infection Control, revised April 2022 indicated the following: - Employees must wash their hands for 10 to 15 seconds using antimicrobial (a product that kills or slows the spread of bacteria) or non-antimicrobial soap and water under the following conditions .when there is likely exposure to spores (when C.diff germs are outside the body - an inactive form of the germ with protective coating allowing them to live for months or sometimes years on surfaces), alcohol based hand rubs (ABHR) are ineffective against spores. For the effective mechanical removal of spores, wash hands for 30-60 seconds with soap and water. Resident #223 was admitted to the facility in February 2023 with a diagnosis of C.diff infection. Review of the Resident's medical record included a Discharge summary, dated [DATE], that indicated the Resident had C.diff infections multiple times, currently had a C.diff infection and was on Vancomycin (an antibiotic that is used to treat C.diff, among other infections). Further review of the Resident's medical record included laboratory results, dated 2/8/23, that indicated the Resident was positive for C.diff infection. During observation and interview of a medication pass on 2/15/23 at 10:30 A.M., the surveyor observed Nurse #1 remove medications to administer to Resident #223. Nurse #1 said one of the medications was Vancomycin to treat the Resident's C.diff infection. When Nurse #1 walked to the Resident's room, the surveyor observed a sign outside of Resident #223's door indicating he/she was on Enhanced Barrier Precautions (not Contact Precautions for C.diff) which indicated the following: -Everyone must clean their hands including before entering and when leaving the room. -Providers and staff must wear gloves and a gown for the following high contact activities: dressing, bathing/showering, transferring, changing linens, providing hygiene, changing briefs or assisting with toileting, device care or use, and wound care. The surveyor observed Nurse #1 don (put on) only gloves and enter the Resident's room to provide medications. The surveyor further observed Nurse #1 leaning over the Resident, moving his/her bedding and assisting the Resident from a lying to a seated position in order to administer the medications. Nurse #1 did not don an isolation gown despite coming in close contact with the Resident and his/her personal environment. During an interview on 2/15/23 at 10:40 A.M., the Resident's Attending Physician reviewed the Resident's Discharge Summary and said the Resident was positive for C.diff infection and should be on Contact Precautions, not Enhanced Barrier Precautions as indicated on the signage placed outside the Resident's room. At this time, the surveyor observed Nurse #1 remove (doff) and discard her gloves and washed her hands with ABHR. When the surveyor asked Nurse #1 what PPE should have been worn in the Resident's room, Nurse #1 said she should have worn an isolation gown and since the Resident had C.diff she should have washed her hands with soap and water instead of ABHR. During an interview on 2/15/23 at 2:10 P.M., the Assistant Director of Nursing (ADON) said the Resident had an active diagnosis of C.diff as evidenced by a copy of the lab work located in the Resident's medical record. During an interview on 2/15/23 at 5:15 P.M., the Director of Nursing (DON) said the facility's staff should have initiated Contact Precautions versus Enhanced Barrier Precautions upon the Resident's admission and did not, as required. He further said with Contact Precautions, donning of gown and gloves was required prior to entering the Resident's room and Enhanced Barrier Precautions only required gown and gloves when providing direct care to the Resident.

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

• 46 deficiencies on record, including 2 serious (caused harm) violations. Ask about corrective actions taken.
• $26,071 in fines. Higher than 94% of Massachusetts facilities, suggesting repeated compliance issues.
• Grade F (25/100). Below average facility with significant concerns.

Bottom line: Trust Score of 25/100 indicates significant concerns. Thoroughly evaluate alternatives.

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About This Facility

What is Regalcare At Holyoke's CMS Rating?

CMS assigns REGALCARE AT HOLYOKE 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 Regalcare At Holyoke Staffed?

CMS rates REGALCARE AT HOLYOKE's staffing level at 2 out of 5 stars, which is below average compared to other nursing homes. Staff turnover is 51%, compared to the Massachusetts average of 46%. RN turnover specifically is 78%, which is notably high. RNs provide skilled clinical oversight, so turnover in this role can affect medical care quality.

What Have Inspectors Found at Regalcare At Holyoke?

State health inspectors documented 46 deficiencies at REGALCARE AT HOLYOKE during 2023 to 2025. These included: 2 that caused actual resident harm, 42 with potential for harm, and 2 minor or isolated issues. Deficiencies causing actual harm indicate documented cases where residents experienced negative health consequences.

Who Owns and Operates Regalcare At Holyoke?

REGALCARE AT HOLYOKE is owned by a for-profit company. For-profit facilities operate as businesses with obligations to shareholders or private owners. The facility is operated by REGALCARE, a chain that manages multiple nursing homes. With 102 certified beds and approximately 92 residents (about 90% occupancy), it is a mid-sized facility located in HOLYOKE, Massachusetts.

How Does Regalcare At Holyoke Compare to Other Massachusetts Nursing Homes?

Compared to the 100 nursing homes in Massachusetts, REGALCARE AT HOLYOKE's overall rating (1 stars) is below the state average of 2.9, staff turnover (51%) is near the state average of 46%, and health inspection rating (2 stars) is below the national benchmark.

What Should Families Ask When Visiting Regalcare At Holyoke?

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 Regalcare At Holyoke Safe?

Based on CMS inspection data, REGALCARE AT HOLYOKE 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 Regalcare At Holyoke Stick Around?

REGALCARE AT HOLYOKE has a staff turnover rate of 51%, which is about average for Massachusetts nursing homes (state average: 46%). Moderate turnover is common in nursing homes, but families should still ask about staff tenure and how the facility maintains care continuity when employees leave.

Was Regalcare At Holyoke Ever Fined?

REGALCARE AT HOLYOKE has been fined $26,071 across 3 penalty actions. This is below the Massachusetts average of $33,340. While any fine indicates a compliance issue, fines under $50,000 are relatively common and typically reflect isolated problems that were subsequently corrected. Families should ask what specific issues led to these fines and confirm they've been resolved.

Is Regalcare At Holyoke on Any Federal Watch List?

REGALCARE AT HOLYOKE 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.

Facility Details

Beds: 102
Avg. Residents: 92
Occupancy: 90.4%
Ownership: For profit - Limited Liability company
Chain: REGALCARE
Medicare: Yes
Medicaid: Yes
Sprinklers: Yes

Trust Score Breakdown

Base Score: 50
1-Star Rating: +0
2 Actual Harm citations: -10
46 Deficiencies: -10
Fines ($26,071): -5
Final Score: 25/100

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Data: CMS Medicare Care Compare

Updated: November 2025

Facility ID: 225232