MELROSE HEALTHCARE
For profit - Limited Liability company
106 Beds
NEXT STEP HEALTHCARE
Data: November 2025
Trust Grade
20/100
#300 of 338 in MA
Last Inspection: April 2025
Within standard 12-15 month inspection cycle. Federal law requires annual inspections.
Overview
Melrose Healthcare has received a Trust Grade of F, which indicates significant concerns about the quality of care provided. Ranking #300 out of 338 facilities in Massachusetts places it in the bottom half, and #63 out of 72 in Middlesex County suggests that there are only a few local options that are better. Unfortunately, the facility is worsening, with issues increasing from 17 in 2024 to 27 in 2025. While the staffing rating is below average at 2 out of 5 stars and has a turnover rate of 46%, the quality measures rating is better at 4 out of 5 stars. However, the facility has incurred $110,773 in fines, which is higher than 87% of other facilities in Massachusetts, indicating ongoing compliance problems. Specific incidents include a failure to provide necessary wound care for a resident, leading to serious health issues, and a lack of dignity in dining and personal care experiences for several residents, which highlights both care and environmental concerns. Overall, while there are some strengths in quality measures, the significant issues and fines raise serious red flags for prospective residents and their families.
- Trust Score
- F
- In Massachusetts
- #300/338
- Safety Record
- High Risk
- Inspections
- Getting Worse
- Staff Stability ⚠ Watch
- 46% turnover. Above average. Higher turnover means staff may not know residents' routines.
- Penalties ✓ Good
- $110,773 in fines. Lower than most Massachusetts facilities. Relatively clean record.
- Skilled Nurses ⚠ Watch
- Each resident gets only 27 minutes of Registered Nurse (RN) attention daily — below average for Massachusetts. Fewer RN minutes means fewer trained eyes watching for problems.
- Violations ⚠ Watch
- 67 deficiencies on record. Higher than average. Multiple issues found across inspections.
20/100
Bottom 12%
Review needed
17 → 27 violations
★☆☆☆☆
1.0
Overall Rating
★★☆☆☆
2.0
Staff Levels
★★★★☆
4.0
Care Quality
★☆☆☆☆
1.0
Inspection Score
↔
Stable
2024: 17 issues
2025: 27 issues
The Good
-
4-Star Quality Measures · Strong clinical quality outcomes
-
Full Sprinkler Coverage · Fire safety systems throughout facility
-
No fines on record
Facility shows strength in quality measures, fire safety.
The Bad
1-Star Overall Rating
Below Massachusetts average (2.9)
Significant quality concerns identified by CMS
Staff Turnover: 46%
Near Massachusetts avg (46%)
Higher turnover may affect care consistency
Federal Fines: $110,773
Well above median ($33,413)
Significant penalties indicating serious issues
Chain: NEXT STEP HEALTHCARE
Part of a multi-facility chain
Ask about local staffing decisions and management
The Ugly 67 deficiencies on record
1 actual harm
Apr 2025
27 deficiencies
1 Harm
SERIOUS
(G)
Actual Harm - a resident was hurt due to facility failures
Pressure Ulcer Prevention
(Tag F0686)
A resident was harmed · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record review, the facility failed to provide necessary treatment, services, interventions...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record review, the facility failed to provide necessary treatment, services, interventions to promote healing and prevent new ulcers from developing for one Resident (#9) out of 23 total sampled residents. Specifically, for Resident #9, the facility failed to implement multiple wound care treatment recommendations as recommended by the consultant Wound Physician Assistant (PA), including not implementing the recommended treatment type and/or at the recommended frequency, resulting in the deterioration of pressure ulcers and development of bilateral heel osteomyelitis (an infection of the bone).
Findings include:
Review of the facility policy titled 'Prevention and management of Pressure Ulcers/Injuries', revised November 2024, indicated:
- If a new pressure ulcer is identified, assess the area and notify the provider for treatment order.
Resident #9 was admitted to the facility in November 2024 with diagnoses including diabetes and mild cognitive impairment.
Review of the Minimum Data Set (MDS) assessment, dated 1/23/25, indicated Resident #9 had severe cognitive impairment as evidenced by a Brief Interview for Mental Status (BIMS) score of 4 out of 15. This MDS indicated Resident #9 had two unstageable pressure ulcers. This MDS also indicated Resident #9 was unable to walk and was dependent on staff for turning in bed, hygiene, and transferred.
Review of Resident #9's medical record indicated he/she had been transferred and admitted to the hospital on [DATE] for bilateral heel osteomyelitis.
On 4/7/25 at 10:36 A.M., the surveyor observed Nurse #5 perform the wound dressing change on Resident #9's bilateral heels. Resident #9's right heel was observed to be the size of a [NAME] with a red wound bed and the left heel was also approximately the size of a [NAME] with black and tan wound bed. During these wound dressing changes Nurse #5 did not perform any hand hygiene after removing gloves and before applying new ones during six out of eight glove changes. During the other two glove changes, Nurse #5 used alcohol prep pads to sanitize and said this was because she forgot hand sanitizer.
During an interview on 4/7/25 at 11:14 A.M., Nurse #5 said she should have performed hand hygiene during all glove changes but did not.
Review of Resident #9's consultant Wound PA progress note, dated 1/6/25, indicated:
- Left heel unstageable deep tissue injury (DTI) pressure ulcer: not improved.
- Right heel unstageable deep tissue injury pressure ulcer: improved.
- Plan: Left heel: Iodosorb (a wound care product, specifically a gel containing iodine, used to clean and promote healing in wet, chronic, or infected wounds) and DPD (dry protective dressing) (4x4 gauze) to the left heel wound changed daily and PRN (as needed).
- Plan: Right heel: Iodosorb and DPD (4x4 gauze) to the right heel wound changed daily and PRN.
Review of Resident #9's physician's order indicated:
- DTI left heel (Daily/prn) Cleanse with saline, apply iodosorb, covered by DPD. Apply skin prep to surrounding daily/prn, initiated 1/8/25, scheduled three times a day (once every shift), instead of once daily as recommended by the consultant Wound PA.
- DTI right heel was implemented as recommended.
Review of Resident #9's Treatment Administration Record (TAR), dated 1/8/25 to 1/12/25, indicated the above order for the left heel was documented as implemented three times each day (once every shift), instead of once daily as recommended by the consultant Wound PA).
Review of Resident #9's consultant Wound PA progress note, dated 1/13/25, indicated:
- Left heel unstageable deep tissue injury pressure ulcer: not improved.
- Right heel unstageable necrosis pressure ulcer: not improved.
- Plan: Left heel: Iodosorb and DPD (4x4 gauze) to the left heel wound changed daily and PRN.
- Plan: Right heel: Iodosorb and DPD (4x4 gauze) to the right heel wound changed daily and PRN.
Review of Resident #9's physician's order indicated:
- DTI left heel (Daily/prn) Cleanse with saline, apply iodosorb, covered by DPD. Apply skin prep to surrounding daily/prn, initiated 1/8/25, scheduled three times a day (once every shift), instead of once daily as recommended by the consultant Wound PA.
- DTI right heel was implemented as recommended.
Review of Resident #9's Treatment Administration Record (TAR), dated 1/13/25 to 1/19/25, indicated the above order for the left heel was documented as implemented three times each day (once every shift), instead of once daily as recommended by the consultant Wound PA.
Review of Resident #9's consultant Wound PA progress note, dated 1/20/25, indicated:
- Left heel unstageable necrosis pressure ulcer: not improved.
- Left heel unstageable necrosis pressure ulcer size increased since last visit on 1/13/25 from 1.6 cm (centimeters) length x 3.8 cm width x non-measurable depth to 2.0 cm length x 4.2 cm width x non-measurable depth.
- Right heel unstageable necrosis pressure ulcer: improved.
- Plan: Left heel: Iodosorb and DPD (4x4 gauze) to the left heel wound changed daily and PRN.
- Plan: Right heel: Iodosorb and DPD (4x4 gauze) to the right heel wound changed daily and PRN.
Review of Resident #9's physician's order indicated:
- DTI Left heel (Twice Daily/prn) Cleanse with saline, apply iodosorb, covered by DPD. Apply skin prep to surrounding daily/prn, initiated 1/22/25, scheduled two times a day (day and evening shift), instead of once daily as recommended by the consultant Wound PA.
Review of Resident #9's Treatment Administration Record (TAR), dated 1/20/25 to 1/22/25, indicated the above order for the left heel was documented as implemented three times a day (once each shift) on 1/20/25 and 1/21/25, instead of once daily; and was documented as implemented twice daily (day and evening shift) on 1/22/25 (instead of once daily as recommended by the consultant Wound PA).
Review of Resident #9's nursing progress note, dated 1/23/25, indicated:
- R (right) heel warm to touch, malodorous, purulent (containing or producing pus) drainage, erythema.
- New orders received for doxycycline (an antibiotic medication).
- New wound care orders. wound dressing change bid (twice daily), may apply betadine(a topical antiseptic)/iodosorb cover with hydrofera blue (an antibacterial wound dressing).
- Review of this note failed to indicate any changes in condition or changes to physician's orders to left heel wound treatment.
Review of Resident #9's physician's order indicated:
- DTI Left heel (Twice Daily/prn) Cleanse with saline, apply iodosorb, covered by DPD. Apply skin prep to surrounding daily/prn, initiated 1/22/25, scheduled two times a day (day and evening shift), instead of once daily as recommended by the consultant Wound PA.
- DTI right heel was implemented as ordered by the physician.
Review of Resident #9's Treatment Administration Record (TAR), dated 1/23/25 to 1/26/25, indicated the above order for the left heel was documented as implemented two times (day and evening shift) each day (instead of once daily as recommended by the consultant Wound PA).
Review of Resident #9's consultant Wound PA progress note, dated 1/27/25, indicated:
- Left heel unstageable necrosis pressure ulcer: not improved.
- Left heel unstageable necrosis pressure ulcer size increased since last visit on 1/20/25 from 2.0 cm length x 4.2 cm width x non-measurable depth to 2.5 cm length x 5.0 cm width x non-measurable depth.
- Right heel unstageable necrosis pressure ulcer: not improved.
- Right heel unstageable necrosis pressure ulcer size increased from 1.4 cm length x 3.0 cm width x non-measurable depth to 2.0 cm length x 5.0 cm width x non-measurable depth.
- Plan: Left heel: Iodosorb, DPD (4x4 gauze), and kling to left heel wound changed daily and PRN.
- Plan: Right heel: Bactroban, Alginate, DPD (4x4 gauze), and kling to the right heel changed daily and PRN.
Review of Resident #9's physician's order indicated:
- DTI left heel (Twice Daily/prn) Cleanse with saline, apply iodosorb, covered by DPD. Apply skin prep to surrounding daily/prn, initiated 1/22/25, scheduled twice (day and evening shift) a day, instead of once daily as recommended by the consultant Wound PA.
- DTI right heel (Twice Daily/prn) Cleanse with saline, apply bactroban followed by Alginate, skin prep to surroundings, DPD, initiated 1/29/25, scheduled twice daily (day and evening shift), instead of once daily as recommended by the consultant Wound PA.
- Iodosorb External Gel 0.9%, apply to bilateral heels topically, once daily, initiated 1/8/25, instead of being discontinued for the right heel as recommended by the consultant Wound PA.
Review of Resident #9's Treatment Administration Record (TAR), dated 1/27/25 to 2/2/25, indicated the above order for the left heel and right heel was documented as implemented two times each day (day and evening shift), instead of once daily as recommended by the consultant Wound PA.
Review of Resident #9's Medication Administration Record (MAR), dated 1/27/25 to 2/2/25, indicated the following order documented as implemented daily.
- Iodosorb External Gel 0.9%, apply to bilateral heels topically, once daily, initiated 1/8/25, instead of being discontinued for right heel as recommended by the consultant Wound PA.
During an interview on 4/8/25 at 10:56 A.M., Nurse #5 said she had put an additional order in for Iodosorb on 1/8/25 so it would be ordered from the pharmacy. Nurse #5 said that order should have been discontinued when the Wound PA recommended it to be discontinued but was not. Nurse #5 said since it was not, the iodosorb had been applied to heels since 1/8/25, even when it shouldn't have been.
Review of Resident #9's consultant Wound PA progress note, dated 2/3/25, indicated:
- Left heel unstageable necrosis pressure ulcer: improved.
- Right heel unstageable necrosis pressure ulcer: not improved.
- Plan: Left heel: Iodosorb, DPD (4x4 gauze), and kling to left heel wound changed daily and PRN.
- Plan: Right heel: Bactroban, Alginate, DPD (4x4 gauze), and kling to the right heel changed daily and PRN.
Review of Resident #9's physician's order indicated:
- DTI right heel (Twice Daily/PRN) Cleanse with saline, apply bactroban followed by alginate, skin prep the surroundings, DPD/kling wrap, once daily (of note, this order also indicates twice daily), initiated 2/5/25.
- Iodosorb External Gel 0.9%, apply to bilateral heels topically, once daily, initiated 1/8/25, instead of being discontinued for the right heel as recommended by the consultant Wound PA.
Review of Resident #9's Medication Administration Record (MAR), dated 2/3/25 to 2/9/25, indicated the following order documented as implemented daily.
- Iodosorb External Gel 0.9%, apply to bilateral heels topically, once daily, initiated 1/8/25, instead of being discontinued for the right heel as recommended by the consultant Wound PA.
Review of Resident #9's consultant Wound PA progress note, dated 2/10/25, indicated:
- Recommend X-ray of the right heel to rule out osteomyelitis of the right heel.
- Left heel arterial wound: improved.
- Right heel arterial wound: not improved.
- New right proximal heel arterial wound.
- Plan: Left heel: Iodosorb, DPD (4x4 gauze), and kling to left heel wound changed daily and PRN.
- Plan: Right heel: Iodosorb, DPD (4x4 gauze), and kling to right heel wound changed daily and PRN.
- Plan: Right proximal heel: Iodosorb, DPD (4x4 gauze), and kling to right proximal heel wound changed daily and PRN.
During an interview on 4/7/25 at 11:47 A.M., the consultant Wound PA was unable to say why her documentation for Resident #9's bilateral heels had changed from pressure ulcers to arterial ulcers, but that they were the same wounds.
Review of Resident #9's physician's orders indicated:
- Left heel wound treatment was implemented as recommended.
- DTI right heel (Twice Daily/PRN) Cleanse with saline, apply bactroban followed by alginate, skin prep surroundings, DPD/kling, once daily (of note, this order also indicates twice daily), initiated 2/5/25, instead of Iodosorb, DPD (4x4 gauze), and kling to left heel wound changed daily and PRN which was not implemented as recommended by the consultant Wound PA until 2/18/25, eight days after it was recommended.
- The orders failed to indicate the right proximal heel treatment recommendation for Iodosorb, DPD (4x4 gauze), and kling to right proximal heel wound changed daily and PRN. was ever implemented.
Review of Resident #9's medical record failed to indicate any rationale for the right heel and right proximal heel treatments not being implemented as recommended by the consultant Wound PA.
Review of Resident #9's consultant Wound PA progress note, dated 2/17/25, indicated:
- Left heel arterial wound: not improved
- Right heel arterial wound: not improved
- Right heel arterial wound measurements increased in length and depth since last visit on 2/10/25 from 2.0 cm x 5.0 cm x non-measurable depth to 3.0 cm x 4.0 cm x 0.1 cm depth
- Right proximal heel arterial wound healed.
- Recommendations included for left and right heels were implemented as recommended. Right proximal heel was never discontinued because it had never been implemented after recommendation by consultant Wound PA 2/10/25.
Review of Resident #9's nursing progress note, dated 2/19/25, indicated:
- X-ray of right heel came in and was reviewed by NP #1, findings suspicious for calcaneal osteomyelitis, recommend MRI (a non-invasive imaging that visualizes soft tissues and bones in detail, aiding in the diagnosis and treatment of osteomyelitis).
During an interview on 4/7/25 at 9:39 A.M., Nurse #6 said she booked the MRI for 3/4/25.
Review of Resident #9's consultant Wound PA progress note, dated 2/24/25, indicated:
- Recommend consult with PCP (primary care provider) for systemic antibiotic pending culture results.
- Left heel arterial wound: not improved
- Right heel arterial wound: not improved. There is bone exposed (which is a new finding).
- New recurrent right proximal heel arterial wound present.
- Plan: Left heel: Vashe (a type of wound cleanser) (or similar antibacterial wound cleanser), Iodosorb, DPD (4x4 gauze), and kling to the left heel wound changed daily and PRN.
- Plan: Right heel: Vashe (or similar antibacterial wound cleanser), Bactroban, Alginate, DPD, and kling to the right heel wound changed twice daily and PRN.
- Plan: Right proximal heel: Vashe (or similar antibacterial wound cleanser), Adaptic, Alginate, DPD (4x4 gauze) and kling to the right proximal heel wound changed daily and PRN.
Review of Resident #9's physician's orders indicate:
- DTI left heel implemented as recommended by consultant Wound PA on 2/27/25.
- DTI right heel (Twice Daily/PRN) Cleanse with vashe, apply bactroban followed by alginate, DPD 4x4 gauze, skin prep surroundings, kling wrap lightly, scheduled once daily (day shift), instead of twice daily as recommended by the consultant Wound PA, initiated 2/27/25.
- DTI right proximal heel (Twice Daily/PRN) Cleanse with vashe, apply Adaptic followed by Alginate, DPD 4x4 gauze, skin prep surroundings, kling wrap lightly, scheduled twice (day and evening shift) daily (instead of once daily as recommended by the consultant Wound PA), initiated 2/24/25.
- Iodosorb External Gel 0.9%, apply to bilateral heels topically, once daily (instead of being discontinued as recommended by the consultant Wound PA), initiated 1/8/25.
Review of Resident #9's Treatment Administration Record (TAR), dated 2/24/25 through 2/26/25, indicated:
- No wound treatment was documented to have been completed for left heel wound on 2/26/25.
- No wound treatment was documented to have been completed for right heel wound on 2/26/25.
- No wound treatment was documented to have been completed for right proximal heel wound on 2/25/25.
Review of Resident #9's Medication Administration Record (MAR), dated 2/24/25 to 2/25/25, indicated the following order documented as implemented daily.
- Iodosorb External Gel 0.9%, apply to bilateral heels topically, once daily (instead of being discontinued as recommended by the consultant Wound PA), initiated 1/8/25.
Review of Resident #9's physician progress note, written by NP #1, dated 2/25/25, indicated:
- XR (X-ray) right heel - findings suspicious for calcaneal osteomyelitis, recommend MRI. Wound examined today, overall worsening this week. Discussed with [consultant Wound PA] and agrees with proactive treatment. Will start rocephin 1g IM (intramuscular) pending wound culture results and toiler further IV antibiotics. MRI has been scheduled 3/4/25 at 8 A.M. Wound tx (treatment)- Vashe (or similar antibacterial wound cleanser), Bactroban, Alginate, DPD (4x4 gauze), and kling to right heel wound changed twice daily.
-This physician progress note does not include any changes to left heel wound treatment.
Review of Resident #9's Treatment Administration Record (TAR), dated 2/26/25 to 3/3/25, indicated the following physician's order documented as implemented:
- No wound treatment was documented to have been completed for right heel wound on 2/26/25.
- DTI right heel (Twice Daily/PRN) Cleanse with vashe, apply bactroban followed by alginate, DPD 4x4 gauze, skin prep surroundings, kling wrap lightly, implemented once daily (instead of twice daily as ordered by NP #1) from 2/27/25 to 3/3/25.
Review of Resident #9's Medication Administration Record (MAR), dated 2/26/25 to 3/3/25, indicated the following order documented as implemented daily.
- Iodosorb External Gel 0.9%, apply to bilateral heels topically, once daily (instead of being discontinued as recommended by the consultant Wound PA and NP #1), initiated 1/8/25.
Review of Resident #9's nursing progress note, dated 3/1/25, indicated:
- Continued on Amoxicillin (an antibiotic medication) 500-125 mg (milligrams) for bacterial infection. Also, he/she received Doxycycline 200 mg for wound infection.
Review of Resident #9's nursing progress note, dated 3/3/25 at 12:08 P.M., indicated:
- Resident's appointment [MRI] has been cancelled, may re-schedule if residents' health dictates.
Review of Resident #9's consultant Wound PA progress note, dated 3/3/25 at 1:09 P.M., indicated:
- Resident #9 is currently on antibiotics for wound infection.
- X-ray results of the right heel noted findings suspicious for calcaneal osteomyelitis, recommend MRI. Per Nursing staff MRI is pending.
- Wound culture of the right heel revealed moderate growth of mixed gram positive organisms consistent with normal skin flora. Moderate growth of multiple gram negative organisms.
- Left heel arterial wound: Not improved. increased in size
- Right heel arterial wound: Improved. There is bone is exposed.
- Right proximal heel arterial wound: Not improved.
Review of Resident #9's physician progress note, written by NP #1, dated 3/3/25 and time of visit undocumented, indicated:
- Continues on augmentin, doxycycline for R (right) calcaneal osteo (osteomyelitis).
- MRI has been scheduled for 3/4/25 at 8 am.
- Wound tx (treatment)- Vashe, Bactroban, Alginate, DPD (4x4 gauze), and kling to right heel wound changed twice daily.
- This physician progress note does not include any changes to left heel wound treatment.
Review of Resident #9's physician's order indicated:
- DTI right heel (Twice Daily/PRN) Cleanse with vashe, apply bactroban followed by alginate, DPD 4x4 gauze, skin prep surroundings, kling wrap lightly, scheduled once daily (day shift) (instead of twice daily as ordered by NP #1), initiated 2/24/25.
Review of Resident #9's Treatment Administration Record (TAR), dated 3/3/25 to 3/5/25, indicated the following physician's order documented as implemented:
- DTI right heel (Twice Daily/PRN) Cleanse with vashe, apply bactroban followed by alginate, DPD 4x4 gauze, skin prep surroundings, kling wrap lightly, implemented once daily (day shift) (instead of twice daily as ordered by NP #1) from 3/3/25 to 3/5/25.
Review of Resident #9's physician's orders indicated:
- DTI left heel implemented as recommended by consultant Wound PA on 3/3/25.
- DTI right proximal heel (Twice Daily/PRN) Cleanse with vashe, apply Adaptic followed by Alginate, DPD 4x4 gauze, skin prep surroundings, kling wrap lightly, scheduled twice daily (instead of once daily), initiated 2/24/25.
- Iodosorb External Gel 0.9%, apply to bilateral heels topically, once daily, initiated 1/8/25, instead of being discontinued for the right heel as recommended by the consultant Wound PA and ordered by NP #1.
Review of Resident #9's Treatment Administration Record (TAR), dated 3/3/25 to 3/6/25, indicated the above order for the right proximal heel was documented as implemented two times each day, instead of once daily as ordered by NP #1.
Review of Resident #9's Medication Administration Record (MAR), dated 3/3/25 to 3/5/25, indicated the following order documented as implemented daily.
- Iodosorb External Gel 0.9%, apply to bilateral heels topically, once daily, initiated 1/8/25, instead of being discontinued for the right heel as recommended by the consultant Wound PA and ordered by NP #1.
Review of Resident #9's medical record indicated he/she had been transferred and admitted to the hospital on [DATE] for bilateral heel osteomyelitis.
Review of Resident #9's hospital Discharge summary, dated [DATE], indicated:
- Hospital Course: Bilateral heel wounds, necrotic, decubitus ulcers (pressure ulcers) with right heel osteomyelitis and left heel osteomyelitis.
- Summary: Pt (patient) remains for medical management of bilateral heel wounds, necrotic, decubitus ulcer with MRI evidence of bilateral calcaneal osteomyelitis, receiving IV (intravenous) IVF (intravenous fluids) and IV abx (antibiotics).
Review of Resident #9's medical record indicated he/she was readmitted to the facility 3/17/25.
Review of Resident #9's nursing admission note, dated 3/17/25, indicated:
- During his/her hospital stay MRI revealed R (right) heel osteomyelitis.
- Wounds to BLE (bilateral lower extremities).
Review of Resident #9's consultant Wound PA progress note, dated 3/24/25, indicated:
- Left heel arterial ulcer: Improved.
- Right heel arterial ulcer: Not improved.
- Right proximal heel arterial ulcer appears healed.
- Plan: Left heel: Vashe (or similar antibacterial wound cleanser), Iodosorb, DPD (4x4 gauze), and kling to the left heel wound changed daily and PRN.
- Plan: Right heel: Vashe (or similar antibacterial wound cleanser), Adaptic, Alginate, DPD (4x4 gauze), and kling to the right heel wound changed daily and PRN.
Review of Resident #9's physician's orders indicated:
- Left heel (Daily/PRN) Cleanse with wound vashe, apply skin prep to surroundings, apply adaptic to wound bed, followed by iodosorb, lightly pad with 4x4 gauze, secure with kerlix/paper tape, once daily, initiated 3/25/25, instead of Vashe (or similar antibacterial wound cleanser), Iodosorb, DPD (4x4 gauze), and kling to the left heel wound changed daily as recommended by the consultant Wound PA.
- Right heel (Daily/PRN) Cleanser with wound vashe, apply skin prep to surroundings, apply Adaptic to wound bed, followed by alginate, lightly pad with 4x4, secure with kerlix/paper tape, once daily, initiated 3/25/25.
- Iodosorb External Gel 0.9%, apply to bilateral heels topically, once daily, initiated 1/8/25, instead of being discontinued for the right heel as recommended by the consultant Wound PA.
Review of Resident #9's Medication Administration Record (MAR), dated 3/24/25 to 3/30/25, indicated the following order documented as implemented daily.
- Iodosorb External Gel 0.9%, apply to bilateral heels topically, once daily, initiated 1/8/25, instead of being discontinued for the right heel as recommended by the consultant Wound PA.
Review of Resident #9's record failed to indicate any rationale for initiation of adaptic in left heel treatment.
Review of Resident #9's consultant Wound PA progress note, dated 3/31/25, indicated:
- Left heel arterial ulcer: Improved.
- Right heel arterial ulcer: Improved.
- Plan: Left heel: Vashe (or similar antibacterial wound cleanser), Adaptic, Alginate, DPD (4x4 gauze), and kling to the left heel wound changed daily and PRN.
- Plan: Right heel: Vashe (or similar antibacterial wound cleanser), Adaptic, Alginate, DPD (4x4 gauze), and kling to the right heel wound changed daily and PRN.
Review of Resident #9's physician's orders indicated:
- Left heel (Daily/PRN) Cleanse with wound vashe, apply skin prep to surroundings, apply adaptic to wound bed, followed by iodosorb, lightly pad with 4x4 gauze, secure with kerlix/paper tape, once daily, initiated 3/25/25, instead of Vashe (or similar antibacterial wound cleanser), Adaptic, Alginate, DPD (4x4 gauze), and kling to the left heel wound changed daily as recommended by the consultant Wound PA.
- Right heel (Daily/PRN) Cleanser with wound vashe, apply skin prep to surroundings, apply Adaptic to wound bed, followed by alginate, lightly pad with 4x4, secure with kerlix/paper tape, once daily, initiated 3/25/25.
- Iodosorb External Gel 0.9%, apply to bilateral heels topically, once daily, initiated 1/8/25, instead of being discontinued for the right heel as recommended by the consultant Wound PA.
Review of Resident #9's Medication Administration Record (MAR), dated 3/31/25 to 4/7/25, indicated the following order documented as implemented daily.
- Iodosorb External Gel 0.9%, apply to bilateral heels topically, once daily, initiated 1/8/25, instead of being discontinued for the right heel as recommended by the consultant Wound PA.
Review of Resident #9's Treatment Administration Record (TAR), dated 4/5/25 to 4/7/25, indicated:
- Left heel: Cleanse with wound vashe, apply adaptic, alginate, DPD, and kling to left heel wound, once daily, initiated 4/2/25 and discontinued 4/5/25.
- Left heel: Cleanse with wound vashe, apply iodosorb, DPD, kling to left heel wound, once daily, initiated 4/5/25.
- Audit history of Left heel treatment order initiated 4/5/25 indicated it was input by the Director of Nursing (DON).
Review of Resident #9's medical record failed to indicate any rationale for wound order change on 4/5/25.
During an interview on 4/8/25 at 11:07 A.M., the DON said she did not contact the provider to obtain any orders to change the left heel wound treatment. The DON said she thinks it's because she saw iodosorb being used so she may have just added it.
Review of Resident #9's consultant Wound PA progress note, dated 4/7/25, indicated:
- Left heel arterial ulcer: not improved.
- Left heel arterial wound measurements increased in length since last visit on 3/31/25 from 3.0 cm length x 3.7 cm width x non-measurable depth to 3.8 cm length x 3.7 cm width x 0.1 cm depth.
- Right heel arterial ulcer: improved.
During an interview on 4/7/25 at 9:03 A.M., Nurse #5 said the nurses on the floor are not usually involved in transcribing treatment recommendations from the consultant Wound PA. Nurse #5 said the DON is responsible for following up on consultant Wound PA recommendations.
During an interview on 4/7/25 at 11:47 A.M., the consultant Wound PA said she expects physician's orders to be implemented according to her recommendations, unless the attending physician or nurse practitioner decline. She said she expects that they would address and document any rationale for the wound treatment recommendations not being implemented as she recommended based on the facility's policy.
During an interview on 4/7/25 at 2:32 P.M., the Regional Nurse said the iodosorb that was initiated 1/8/25 was never discontinued but should have been multiple times. The Regional nurse said wound orders should be implemented and completed following the physician's order.
During an interview on 4/8/25 at 8:55 A.M., Resident #9's Nurse Practitioner (NP) #1 said the consultant Wound PA sends her wound progress notes with recommendations to the facility and she expects the facility to implement them according to the consultant Wound PA's treatment recommendations. NP #1 said she rarely disagrees with the wound treatment recommendations and if she did, the rationale for not implementing should be documented in the record. NP #1 said she is rarely notified regarding wound orders, unless there is a significant concern. NP #1 says she expects the consultant Wound PA to manage the wounds and if the facility does not implement her recommendations as recommended it could cause a decline in the wound or wound infection.
During an interview on 4/8/25 at 9:36 A.M., The DON said she expects wound treatment orders to be transcribed directly into the physician's orders according to the consultant Wound PA's treatment recommendations. The DON said every wound treatment recommendation should be implemented as recommended, and if for some reason it was not, the rationale should be documented in the medical record.
During an interview on 4/11/25 at 11:08 A.M., the DON said wound treatment orders should be implemented at the frequency the physician orders. The DON said if a dressing is implemented too frequently or not frequently enough it puts the wound at risk for deterioration or infection.
Refer to F726 and F880.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0552
(Tag F0552)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to obtain consent for the use of psychotropic medication for one Resi...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to obtain consent for the use of psychotropic medication for one Resident (#8) out of a total sample of 23 residents.
Findings include:
Review of the facility policy titled, Psychotropic Medication, dated 7/2023, indicated the following:
-A written informed consent from the resident (or legally authorized individual in the case of competency) is required for administration of psychotropic medication.
-The interdisciplinary team assesses and monitors the appropriateness, effectiveness, and side effects associated with psychotropic medications for each resident via resident care plan review period the resident, and one indicated, the family or responsible person, will be included in this process prior to the administration of dose.
Resident #8 was admitted to the facility in August 2019 with diagnoses including unspecified dementia, unspecified severity, without behavioral disturbance, mood disturbance, anxiety.
Review of Resident #8's most recent Minimum Data Set (MDS) dated [DATE], indicated the Resident score a 3 out of a possible 15 on the Brief Interview for Mental Status (BIMS) which indicated he/she had severe cognitive impairment. The MDS also indicated Resident #8 was dependent on staff for self-care tasks.
Review of Resident #8's physician orders indicated the following order written on 3/29/25:
-Seroquel (an antipsychotic medication) oral tablet 50 mg (milligrams) give 1 tablet two times a day related to paranoid schizophrenia.
Review of Resident #8's medical record indicated the following:
-Resident #8 has a legal guardian who makes all medical decisions for the Resident
-Resident #8 has a Roger's orders (a judge and legal guardian decide when an antipsychotic medication can be administered). Resident #8's treatment plan did not include Seroquel as an agreed upon medication for the Resident.
-The medical record failed to indicate Resident #8 or his/her legal guardian was informed of the new order for Seroquel and the risks/benefits of the medication in advance of administration of the medicine.
During an interview on 4/7/25 at 7:48 A.M., Nurse #2 said all psychotropic medications require consent prior to their administration.
During an interview on 4/7/25 at 11:45 A.M., the Director of Nursing said all psychotropic medications require consent prior to their administration. The Director of Nursing was unaware if a consent had been obtained for the use of Seroquel for Resident #8.
During an interview on 4/7/25 at 1:48 P.M., the Social Worker said Resident #8 has a Roger's order for the use of anti-psychotic medication. The Social Worker said she is responsible for ensuring Resident #8's Roger's order is kept up to date and if the facility wants to make changes, she would be the person responsible for contacting the lawyer to make a court appointment for the changes. The Social Worker said she was unaware an antipsychotic was added to Resident #8's physician orders and the guardian was not contacted about this medication change for consent.
REF F578
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0578
(Tag F0578)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to ensure a Roger's treatment plan (a judge and legal guardian decide...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to ensure a Roger's treatment plan (a judge and legal guardian decide when an antipsychotic medication can be administered) was valid and kept up to date for one Resident (#8) out of a total of 23 sampled Residents.
Findings include:
Resident #8 was admitted to the facility in [DATE] with diagnoses including unspecified dementia, unspecified severity, without behavioral disturbance, mood disturbance, anxiety.
Review of Resident #8's most recent Minimum Data Set (MDS) dated [DATE], indicated the Resident score a 3 out of a possible 15 on the Brief Interview for Mental Status (BIMS) which indicated he/she had severe cognitive impairment. The MDS also indicated Resident #8 was dependent on staff for self-care tasks.
Review of Resident #8's medical record indicated the Resident has active physician orders for two antipsychotic medications.
Review of Resident #8's medical record indicated a Roger's treatment plan that expired on [DATE].
When asked, the facility was unable to provide any documentation that Resident #8's Roger's treatment plan had been renewed and kept up to date by the facility.
During an interview on [DATE] at 1:48 P.M., the Social Worker said Resident #8 has a Roger's treatment plan for the use of anti-psychotic medication. The Social Worker said she is responsible for ensuring Resident #8's Roger's order is kept up to date and if the facility wants to make changes, she would be the person responsible for contacting the lawyer to make a court appointment for the changes. The Social Worker said she was unaware Resident #8's Roger's treatment plan was expired and needed to be renewed by the courts.
During an interview on [DATE] at approximately 8:00 A.M., the Corporate Nurse said the facility discovered Resident #8's Roger's treatment plan was expired on [DATE]. The Corporate Nurse said the social services department should have kept track of this treatment plan and ensured it was kept current and did not expire.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Grievances
(Tag F0585)
Could have caused harm · This affected 1 resident
Based on observation, record review and interviews, the facility failed to file a grievance for one Resident (#80), out of 23 total sampled residents. Specifically, the facility failed to ensure staff...
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Based on observation, record review and interviews, the facility failed to file a grievance for one Resident (#80), out of 23 total sampled residents. Specifically, the facility failed to ensure staff filed a grievance on behalf of Resident #80, who complained that his/her pants were missing.
Findings include:
Review of the facility policy titled 'Grievances, revised February 2024, indicated:
- If a resident, and/or health care representative, or another interested family member of a resident has a complaint, a staff member will inform the person of the grievance process and assist the resident, or person acting on the resident's behalf, to file a written grievance with the facility using the Grievance form as needed.
- Grievances may be submitted orally or in writing. Note: If a grievance is submitted orally, the facility employee taking the grievance must write it up on the grievance report form.
- The Administrator will document receipt of all grievances on the Grievance Log.
Resident #80 was admitted to the facility in February 2024 with diagnoses including hypertension and chronic kidney disease.
Review of the most recent Minimum Data Set (MDS) assessment, dated 1/30/25, indicated Resident #80 was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) score of 13 out of 15.
On 4/6/25 at 7:28 A.M., Resident #80 approached the surveyor in the hallway and said the facility often loses laundry and they do nothing about it. Resident #80 said he/she lost his/her peach pants over two weeks ago and that he/she needs them back because they are important to him/her. Resident #80 said he/she told multiple staff members, and they have done nothing to help him/her get them back. Resident #80 said staff told him/her that he/she is always complaining about something and can you prove those were your pants?
Review of the facilities binder titled 'Grievance Log', dated 2025, on 4/7/25 at 7:20 A.M., failed to indicate any grievances were filed for Resident #80's missing peach pants in the last four months.
During an interview on 4/7/25 at 8:48 A.M., Certified Nurse Assistant (CNA) #7 said Resident #80 often complains of missing laundry but that she does not believe it's actually missing, and he/she probably just misplaced it because the Resident is messy.
During an interview on 4/7/25 at 8:54 A.M., the Activities Director said Resident #80 complained about missing pants about two weeks ago and she took him/her down to the laundry department to look for them. The Activities Director said she assumed Resident #80 filled out a grievance form, so she did not fill one out on his/her behalf.
During an interview on 4/7/25 at 9:15 A.M., Resident #80 said he/she went down to the laundry with the Activities Director about two weeks ago to look for the peach pants and they were unable to find them, but that he/she really needs them back for an important appointment.
During an interview on 4/7/25 at 9:32 A.M., the Administrator said every time any item is reported missing by a resident a grievance form should be filed by either the resident or a staff member. The Administrator said any staff member can fill one out. The Administrator said even if a Resident has behaviors of falsely reporting missing items, or if staff believe they might just have been misplaced, a grievance form always needs to be completed and filed so the missing item can be investigated. The Administrator said a grievance form should have been completed and filed regarding Resident #80's missing peach pants.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Quality of Care
(Tag F0684)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview, the facility failed to provide treatment and care in accordance with professi...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview, the facility failed to provide treatment and care in accordance with professional standards of practice for two Residents (#20, and #9), out of a total sample of 23 residents. Specifically,
1. For Resident #20, the facility failed to ensure his/her pacemaker checks were completed.
2. For Resident #9, the failed ensure six bilateral foot wounds were assessed and measured weekly.
Findings include:
1. Review of the facility policy titled, Care of a Resident with a Pacemaker, dated 3/18, indicated the following:
-2. When the resident's pacemaker is monitored by the Physician, document the date and results of the pacemaker surveillance, including:
a. How the resident's pacemaker was monitored (phone, office, internet);
1. Resident #20 was admitted to the facility in October 2024 with diagnoses that included dementia, presence of cardiac pacemaker, heart failure, asthma, and type 2 diabetes.
Review of Resident #20's most recent Minimum Data Set (MDS) assessment, dated 1/9/25, indicated he/she scored a 3 out of a possible 15 on the Brief Interview for Mental Status (BIMS) indicating severe cognitive impairments.
During interview on 4/8/25 at 12:20 P.M., Resident #20 said he/she has a pacemaker.
On 4/6/25 at 12:36 P.M. and 4/8/25 at 12:23 P.M., the surveyor observed Resident #20's room, there was not a pacemaker monitor observed his/her room.
Review of Resident #20's hospital Discharge summary, dated [DATE], indicated AV block (Atrioventricular block - type of heart block) status post pacemaker 3/2022. The discharge summary also indicated the pacemaker checks will be remote on 10/23/24, 1/22/25 and 4/29/25.
Review of Resident #20's cardiac care plan, dated 10/6/24, indicated checks as ordered.
Review of Resident #20's nursing progress note, dated 10/23/24, indicated Resident has an appointment for remote MD visit (via phone) at 09:30 am [sic] but no call received.
Review of Resident #20's medical record failed to indicate this pacemaker check was ever rescheduled or that the Resident was scheduled for a cardiology appointment outside of the facility.
Review of Resident #20's nursing progress note, dated 2/24/25, indicated HCP (Health Care Proxy) asking about whether the Resident is following with cardiology - pacemaker - reassured resident is being followed by cardiology and had a pacemaker check recently.
Review of Resident #20's physician note, dated 3/5/25, indicated AV block status post pacemaker.
Review of Resident #20's physician orders failed to indicate orders relating to his/her pacemaker.
Review of Resident #20's nursing progress notes from admission to present failed to indicate if his/her pacemaker had been checked.
During an interview on 4/8/25 at 12:21 P.M., Nurse #4 said Resident #20 does have a pacemaker but she is not sure how it is monitored or any other details of the pacemaker.
During an interview on 4/8/25 at 2:14 P.M. the Director of Nursing said there should be nursing progress notes about his/her pacer checks and said she thinks that this Resident goes out to Cardiology for the checks.
2.) Resident #9 was admitted to the facility in November 2024 with diagnoses including diabetes and mild cognitive impairment.
Review of the Minimum Data Set (MDS) assessment, dated 1/23/25, indicated Resident #9 had severe cognitive impairment as evidenced by a Brief Interview for Mental Status (BIMS) score of 4 out of 15. This MDS indicated Resident #9 had two unstageable pressure ulcers. This MDS also indicated Resident #9 was unable to walk and was dependent on staff for turning in bed, hygiene, and transfers.
Review of Resident #9's entire plan of care related to skin, revised 3/24/25, indicated the Resident had left and right heel arterial ulcers. The entire plan of care failed to indicate the Resident had any other wounds.
On 4/7/25 at 10:36 A.M., the surveyor observed Nurse #5 perform the wound dressing change on Resident #9's bilateral heel pressure ulcers. During this observation, there were six additional wounds on the bilateral feet. The following additional wounds were observed on Resident #9's left foot: two dime sized wounds on the left lateral foot and one dime sized wound on the left ankle. The following additional wounds were observed on Resident #9's right foot: one dime sized wound on the right lateral foot and two dime sized wounds on the anterior foot. Nurse #5 said all six of these wounds appear to be eschar (necrotic tissue that can develop in wounds). Certified Nurse Assistant (CNA) #7 was present during this observation. Nurse #5 and CNA #7 said these six wounds developed shortly after he/she returned from the hospital (Resident #9 was readmitted to the facility from the hospital on 3/17/25). Nurse #5 said there are no wound treatment orders for these six wounds, and she does not know what type of wounds they are. Nurse #5 said the consultant Wound PA is responsible for assessing these six wounds, in addition to the bilateral heel pressure ulcers, weekly.
Review of Resident #9's admission assessment, dated 3/17/25, indicated the following wounds:
- Right Heel, Type Pressure, length 6 centimeters (cm) by 6.2 cm.
- Left Heel, Type: Pressure, length 4.8 cm by 6.5 cm.
- Anterior l. (left) foot, Type: Other (specify), length 1.3 cm by 2.1 cm.
- Left late (lateral), Type: Other (specify), length 1.5 cm by 1.5 cm.
- Medial Left Archille [sic], Type: Other (specify), length 2 cm by 1.8 cm.
- Right heel proximal scab, Type: Other (specify), length 2 cm by 2.1 cm.
Review of Resident #9's assessments titled 'Weekly Skin Evaluation', dated 3/20/25, 3/27/25, and 4/3/25, failed to indicate any wounds in addition to the left heel and right heel pressure ulcers.
Review of Resident #9's assessments titled 'Non-Pressure Ulcer Evaluation', dated 3/17/25, 3/24/25, and 3/31/25, include assessments and measurements of the left heel and right heel pressure ulcers, but fail to include any mention, assessment, or measurement of the six additional wounds on the bilateral feet. These 'Non-Pressure Ulcer Evaluation' assessments were completed by the Director of Nursing (DON).
Review of Resident #9's consultant Wound PA progress notes, dated 3/24/25 and 3/31/25, failed to include any assessment or measurements of the six additional wounds on the Resident's bilateral feet.
Review of Resident #9's medical record failed to include any wound treatment orders, mention of, assessment, or measurements of any wounds other than relating to the left heel and right heel pressure ulcers from 3/18/25 until the surveyor's wound observation on 4/7/25 (a duration of three weeks).
During an interview on 4/7/25 at 11:42 A.M., The Director of Nursing (DON) said the consultant Wound Physician Assistant (PA) was responsible for assessing and measuring all the wounds on Resident #9's feet. The DON said the Resident had additional wounds on his/her feet when they were re-admitted from the facility on 3/17/25. The DON said they spoke about the additional wounds weekly during risk meeting since his/her re-admission and they should have been assessed and measured weekly. The DON said she expected the consultant Wound PA to have assessed and measured these as well as the bilateral heel wounds weekly.
During an interview on 4/7/25 at 11:47 A.M., the consultant Wound PA said she only assessed any wounds addressed in his/her documentation and the facility was responsible for assessing and measuring any wounds that she was not following. The consultant Wound PA said she did not assess Resident #9's additional six foot wounds and that was the facility's responsibility.
During an interview on 4/7/25 at 2:32 P.M., the Regional Nurse said the facility does not have a policy specific to wound care, but that the expectation is to follow physician's orders for any wounds and the nurses should have wound competencies completed annually to ensure they know how to care for the wounds. The Regional Nurse said all wounds should be assessed and measured weekly.
During a follow up interview on 4/9/25 at 8:07 A.M., the Regional Nurse said those six additional wounds on Resident #9's bilateral feet looked like they were arterial ulcers to her, and they should have been assessed and measured weekly.
Refer to F726.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Accident Prevention
(Tag F0689)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, and interview, the facility failed to ensure that the resident environment remained free o...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, and interview, the facility failed to ensure that the resident environment remained free of accident hazards for two Residents (#149 and #88) out of a total sample of 23 residents. Specifically:
1. For Resident #149, the facility failed to implement fall interventions after a fall.
2. For Resident #88, the facility failed to ensure that the Resident was wearing a smoking apron as indicated in the medical record while the Resident was smoking.
Findings include:
1. Resident #149 was admitted to the facility in January 2025 with diagnoses of falls resulting in a vertebral fracture and dementia.
Review of Resident #149's most recent Minimum Data Set (MDS) indicated the Resident was unable to complete the Brief Interview for Mental Status (BIMS) and the staff had assessed him/her to have moderate cognitive impairment. The MDS also indicated Resident #149 required substantial to maximal assistance with self-care and mobility tasks.
Review of the incident report dated 2/2/25 indicated the following:
-Witnessed fall in the main dining room. Resident was ambulating with CNA's back to the main dining room after toileting. Resident crossed (his/her) feet while walking and slipped to the floor. CNA assisted resident to the floor, no apparent injuries noted. Resident ambulating at baseline. No c/o (complain of) pain.
Review of Resident #149's fall care plan indicated the following interventions:
-Rehab evaluate and treat as ordered or PRN (as needed), initiated 1/14/25.
-Ensure proper placement of feet prior to ambulation, initiated 2/2/25.
Review of the therapy screen log book for 2025 failed to indicate therapy had screened Resident #149 after this fall.
During an interview on 4/8/25 at approximately 2:30 P.M. the Director of Rehabilitation said she was unaware Resident #149 sustained a fall on 2/2/25 and never received a referral from nursing to evaluate the Resident.
Review of the Nurse Practitioner note dated 2/6/25 failed to indicate the Nurse Practitioner was notified of this fall.
Review of the incident report dated 3/23/25 indicated the following:
-Resident fell off the wheelchair, assessed for injuries, sweelings (sic) and bruises and non (sic) found. (He/she) was helped off the floor and back into the wheelchair.
Review of Resident #149's fall care plan indicated the following interventions:
-Rehab evaluate and treat as ordered or PRN (as needed), initiated 1/14/25.
-1:1 (one to one) supervision when out of bed, initiated 3/27/25.
-1:1 supervision for 24 hours. Increase close supervision. MD evaluation. Fall, initiated 3/23/25.
-Resident to be in common areas when awake, initiated 3/23/25.
Review of the 1:1 log book for Resident #149 indicated the following:
-The book failed to indicate 1:1 supervision was completed on four days from 3/27/25 - 3/30/25.
-On 3/31/25, 1:1 supervision was only completed from 11:00 P.M. to 11:45 P.M.
-On 4/5/25, 1:1 supervision was only completed from 3:00 P.M. to 11:00 P.M.
-On 4/6/25, 1:1 supervision was only completed from 12:00 A.M. to 9:00 A.M., and 3:00 P.M. to 11:00 P.M.
-On 4/7/25, 1:1 supervision was not completed from 9:45 A.M. to 3:00 P.M.
-On 4/8/25, 1:1 supervision was not completed from 9:45 A.M. to 3:00 P.M.
During an interview on 4/9/25 at 8:34 A.M., Nurse Practitioner (NP) #1 said she was not made aware of Resident #149's fall on 2/2/25. NP #1 said she would expect all residents to be screened by therapy services when a fall occurs and was unaware Resident #149 was not screened by therapy after the fall on 2/2/25. NP #1 said she would expect all fall interventions to be in place at all times to prevent further falls.
During an interview on 4/9/25 at 11:58 A.M., the Director of Nursing (DON) said after a resident falls at the facility, the staff must complete a fall assessment and implement a new care plan intervention for prevention of further falls immediately. The DON said the nursing staff must also notify the physician or nurse practitioner of the fall and therapy must provide a screen for every fall. The DON said she expects all fall care plan interventions to be in place at all times to prevent further falls from occurring.2. Review of the facility policy titled Smoking Policy - Residents, dated and revised March 2024, indicated the following:
- Prior to, and upon admission if the facility is a smoking facility, residents shall be informed of the facility smoking policy, including designated smoking areas and smoking times.
- The resident will be evaluated upon admission and/or when a resident chooses to smoke, to determine the resident's ability to smoke safely.
Review of the document titled Resident Smoking Guidelines, undated, indicated the following:
- Anyone considered to be a smoking risk will be required to utilize appropriate safety devices. If a resident refuses to use safety devices smoking privileged will be revoked.
- admission and quarterly smoking assessments will be done for safety.
- Protective aprons will be worn per resident smoking assessment.
Resident #88 was admitted to the facility May 2024 with diagnoses including atrial fibrillation, coronary atherosclerosis and post-traumatic stress disorder.
Review of Resident #88's most recent Minimum Data Set Assessment (MDS) dated [DATE] indicated the Resident has a Brief Interview for Mental Status score of 15 out of 15 indicating intact cognition.
The surveyor made the following observation:
- On 4/6/25 at 1:23 P.M., Resident #88 was observed in the courtyard smoking. Resident #88 was not wearing a protective apron while smoking.
- On 4/7/25 at 9:09 A.M., Resident #88 was observed in the courtyard smoking. Resident #88 was not wearing a protective apron while smoking.
Review of Resident #88's Kardex (a form indicating the level of care a resident needs) indicated the following under the safety section: Apron use while smoking if indicated.
Review of Resident #88's most recent Smoking Evaluation dated 2/18/25 indicated the following:
- Protective Smoking Equipment (describe): Apron.
Review of Resident #88's smoking care plan, dated 5/22/24 indicated the following intervention: Apron use while smoking if indicated.
During an interview on 4/7/25 at 2:27 P.M., the Activities Director said residents get evaluated for smoking by nursing. The Activities Director said residents will have care plans if they smoke and they should be implemented. The Activities Director said we have aprons outside, but residents do not want to wear them, including Resident #88. She then said the Director of Nursing said we cannot force residents to wear aprons since this is their home.
During an interview on 4/8/25 at 2:13 P.M., the Director of Nursing said if a resident is evaluated to wear a smoking apron while smoking they should be wearing them. The DON then said the resident refuses to wear one then staff need to be documenting the refusal.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0692
(Tag F0692)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview, the facility failed to maintain acceptable parameters of nutritional status f...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview, the facility failed to maintain acceptable parameters of nutritional status for one Resident (#12) out of a total sample of 23 residents. Specifically, the facility failed to a. obtain weekly weights to monitor the weight for Resident #12 as ordered and b. provide the dietary supplements as indicated by the Registered Dietitian.
Findings include:
Review of the facility policy titled Weight Management, dated and revised April 2019, indicated the following:
- Weights will be obtained weekly X 4 after admission. Subsequent weights will be monthly, unless physician's orders or the resident's condition warrants more frequently as determined by the Interdisciplinary Team (IDT).
- If a resident refuses weighing or circumstances prevent weighing the resident, the IDT will document the reason in the resident's medical record and care plan. Make attempt to weigh resident at another time.
Resident #12 was admitted to the facility in January 2019 with diagnoses including chronic respiratory failure, chronic obstructive pulmonary disease dysphasia and Barrett's Esophagus without dysplasia.
Review of Resident #12's most recent Minimum Data Set Assessment (MDS) indicated that the Resident has a Brief Interview for Mental Status score of 15 out of 15 indicting intact cognition. Further review of the MDS indicated that the Resident requires partial/moderate assistance with eating
a. Review of Resident #12's physician's order dated 1/29/25, indicated the following:
- weight every 7 days one time a day every 7 days please weigh on Mondays update md (Medical Doctor) with weight gain >5 lbs. (pounds)
Review of Resident #12's weight summary log indicated the following:
- 2/27/25: 219.4 lbs.
- 3/3/25: 226.4 lbs.
- 3/3/25: 226.4 lbs.
- 3/12/25: 224.0 lbs.
- 3/13/25: 229.0 lbs.
- 3/19/25: 224.9 lbs.
Review of Resident #12's February 2025 Treatment Administration Record (TAR) sheet failed to indicate any documented weights for the entire month.
Review of Resident #12's March 2025 TAR indicated that the Resident was weighed on 3/5/25, 3/12/25 and 3/19/25. The Resident was not weighed on 3/26/25.
Review of Resident #12's medical record indicated that weekly weights were not obtained four times since the physician's order was implemented on 1/29/25.
Review of Resident #12's [NAME] (a form indicating the level of care a resident needs) indicated the following under the Monitors section:
- Monitor/record/report to MD PRN (as needed) s/sx (signs/symptoms) of malnutrition: emaciation, muscle wasting, significant weight loss: 3lbs. in 1 week, >5% in 1 month, >7.5% in 3 months, >10% in 6 months.
During an interview on 4/7/25 at 2:10 P.M., the Registered Dietitian (RD) said she works in the facility two days per week. The RD said the Certified Nursing Assistants (CNA) are supposed to obtain the weights and nursing should validate that weights are being obtained. The RD and surveyor reviewed Resident #12's medical record and the RD said Resident #12's weights are not being obtained as ordered.
During a follow up interview on 4/8/25 at 1:34 P.M. after the surveyor notified the RD of Resident #12's weekly weights not being completed, the RD weighed Resident #12, and he/she weighed 219.8 lbs., 5.1 pounds less than the most recent reweigh on 3/19/25. The RD said she will start adding a soft sandwich to his/her meals.
During an interview on 4/8/25 at 2:13 P.M., the Director of Nursing (DON) said Resident #12 should be weighed as ordered and if the Resident refuses then staff should be documenting it in the medical record.
b. Review of Resident #12's physician's order dated 3/10/25 indicated the following:
- Frozen Nutritional Treat (or magic cup) with meals 2 each all meals
The surveyor made the following observations:
- On 4/6/25 at 8:44 A.M., Resident #12 was eating breakfast in his/her bed. There were no Magic Cups on his/her tray.
- On 4/6/25 at 12:34 P.M., Resident #12 was eating lunch in his/her bed. There were no Magic Cups on his/her tray.
- On 4/7/25 at 12:30 P.M., Resident #12 was eating breakfast in his/her bed. There were no Magic Cups on his/her tray.
- Review of a progress note written by the Registered Dietitian dated 2/20/25 at 2:39 P.M., indicated the following: Several interventions in place to increase his/her kcal/pro (calorie/protein) intake: magic cup/frozen nutrition treat BID (twice daily). Recommend to continue all other supplement interventions as ordered.
Review of Resident #12's Medical Nutrition Therapy Assessment completed by the Registered Dietitian (RD) dated 3/10/25, indicated the following:
- Recommended to Start: Increase FNT (Frozen Nutrition Treat - Magic Cup) to 2 each with all meals.
- Summary of Nutrition Assessment: Resident's current weight shows significant loss x 3, and 6 months ago. Reviewed current interventions of Ensure and frozen nutrition treat. Rt (resident) expressed a preference for frozen nutrition treat and required 2 at each meal.
During an interview on 4/8/25 at 1:34 P.M. after the surveyor notified the RD of Resident #12's weekly weights not being completed, the RD weighed Resident #12, and he/she weighed 219.8 lbs., 5.1 pounds less than the most recent reweigh on 3/19/25. The RD said the Resident should be receiving 2 Magic Cups with meals and she will start adding a soft sandwich to his/her meals.
During an interview on 4/8/25 at 1:44 P.M., Certified Nursing Assistant (CNA) #8 said CNA's look at the Resident's meal tickets to make sure everything is on there and if something is missing we will get it for the Resident.
During an interview on 4/8/25 at 2:13 P.M., the Director of Nursing said weight loss interventions should be followed as ordered.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Respiratory Care
(Tag F0695)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, policy review, and record review, the facility failed to provide respiratory care services in...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, policy review, and record review, the facility failed to provide respiratory care services in accordance with professional standards of practice two Residents (#92, and #13) out of a total sample of 23 residents. Specifically:
1. For Resident #92, the facility failed to ensure oxygen was set to the level prescribed by the physician and maintain a clean filter on the oxygen concentrator; and
2. For Resident #13, the facility failed to ensure oxygen was set to the level prescribed by the physician.
Findings include:
Review of the facility policy titled, Oxygen Administration, dated 1/2024, indicated the following:
-Steps in procedure: 6. Adjust the oxygen delivery device so that it is comfortable for the resident and the proper flow of oxygen is being administered.
- Preparation: Verify that there is a physician's order in place. Review the physician's orders or facility protocol for oxygen administration.
1. Resident #92 was admitted to the facility in August 2024 with diagnoses including Chronic Obstructive Pulmonary Disease (COPD).
Review of Resident #92's most recent Minimum Data Set (MDS) dated [DATE], indicated the Resident had a Brief Interview for Mental Status (BIMS) score of 14 out of a possible 15, which indicated he/she is cognitively intact. The MDS also indicated Resident #93 required partial to moderate assistance with functional daily tasks.
On 4/6/25 at 7:41 A.M., the surveyor observed Resident # 92 in bed receiving oxygen via nasal cannula. The oxygen filter was able to be observed from his/her doorway and was covered in gray dust.
On 4/6/25 at 9:34 A.M., Resident #92 was observed lying in his/her bed wearing an oxygen canula. The oxygen concentrator was observed to be set to 5 liters of oxygen. The oxygen filter was observed to be covered in gray dust. Resident #92 said he/she uses oxygen all the time and he/she should receive 4 liters of oxygen. Resident #92 said he/she does not touch the oxygen machine as the nurses set the machine to the level of oxygen he/she should be receiving.
On 4/6/25 at 11:09 A.M., Resident #92 was observed sitting in his/her wheelchair wearing an oxygen canula. The oxygen concentrator was observed to be set to 5 liters of oxygen and the filter was covered in gray dust.
On 4/7/25 at 8:19 A.M., and 10:17 A.M., Resident #92 was observed sitting in his/her wheelchair wearing an oxygen canula. The oxygen concentrator was observed to be set to 5 liters of oxygen and the filter was covered in gray dust.
On 4/8/25 at 8:08 A.M., the surveyor, with Nurse #3, observed Resident #92's oxygen filter on his/her concentrator. Nurse #3 said the oxygen filter is covered with a thick dust and should not be because nursing staff should be cleaning the filter weekly.
On 4/8/25 at 8:25 A.M., the surveyor, with the Corporate Nurse, observed Resident #92's oxygen filter on his/her concentrator. The Corporate Nurse said that the filter was very dirty and should not be.
Review of Resident #92's physician orders indicated the following orders:
- oxygen via nasal canula titrated to maintain O2 (oxygen) sats (saturation) above 90% continuously and PRN (as needed), every shift for hypoxia, initiated 10/22/24
-may titrate oxygen from 3 liters to 2 liters via NC (nose canula) to maintain O2 SAT above 89%, initiated 10/1/24.
Review of Resident #92's respiratory care plan initiated on 10/23/24, indicated the following:
-Administer humidified oxygen as per MD (physician) order.
Review of Resident #92's lab results dated 12/1/24 indicated he/she has a CO2 (carbon dioxide) level of 38 mmol/L (millimoles per liter), which is higher than the normal range of 22-33.
During an interview on 4/7/25 at 10:45 A.M., Nurse #1 said Resident #92 is on continuous oxygen therapy and the oxygen level should be set to what is prescribed by the physician. Nurse #1 then checked the Resident's orders and said the Resident should be on 2-3 liters of oxygen. Nurse #1 said the Resident should not receive more oxygen than ordered due to his/her diagnosis of COPD and more oxygen could create carbon dioxide retention (a rise in his/her carbon dioxide levels). Nurse #1 said she gave Resident #92 his/her medications earlier in the morning and did not check his/her oxygen to ensure it was on the correct setting as ordered.
During an interview on 4/7/25 at 11:45 A.M., the Director of Nursing said oxygen setting should be set to the level prescribed by the physician and the nurses should be checking to ensure the settings are correct at least once a shift. The Director of Nursing said Resident #92 should only be receiving 1-3 liters of oxygen and due to his/her diagnosis of COPD, the Resident should not be receiving oxygen at a higher level due to the risk of CO2 retention.
2. Resident #13 was admitted to the facility in January 2025 with diagnoses including end stage renal disease, obstructive sleep apnea and chronic respiratory failure.
Review of Resident #13's most recent Minimum Data Set Assessment (MDS) dated [DATE] indicated that the Resident has a Brief Interview for Mental Status score of 13 out of 15 indicating intact cognition. Further review of the MDS indicated that the Resident requires oxygen therapy.
The surveyor made the following observations:
- On 4/6/25 at 7:58 A.M., Resident #13 was sitting in his/her wheelchair in his/her room receiving oxygen via nasal cannula. The oxygen machine was set to 4.5 liters.
- On 4/7/25 at 11:12 A.M., Resident #13 was sitting in his/her wheelchair in his/her room receiving oxygen via nasal cannula. The oxygen machine was set to 4.5 liters. Resident #13 said he/she has to receive oxygen every day.
- On 4/8/25 at 7:13 A.M., Resident #13 was sitting on the side of his/her bed receiving oxygen via nasal cannula at 4.5 liters.
Review of Resident #13's physician's order dated 2/12/25, indicated the following:
- Oxygen at 1-3 liters/minute via nasal cannula update md (medical director) with elevated oxygen needs as needed for SOB (shortness of breath).
Review of Resident #13's altered respiratory status/difficulty breathing care plan, dated and revised 2/4/25, indicated the following intervention:
- Oxygen setting as ordered
Review of Resident #13's most recent laboratory results dated [DATE], indicated the following:
- CO2 (carbon dioxide) 37 mmol/L. The reference range for a normal value is indicated to be between 22-33 mmol/L. This result was flagged as being high.
During an interview on 4/8/25 at 9:02 A.M., Nurse #7 said Resident #13 has trouble breathing so he/she is on oxygen. Nurse #7 and the surveyor reviewed Resident #13's orders and she said his/her oxygen should be set between 1-3 liters. Nurse #7 said if Resident #13 receives too much oxygen he/she could retain more CO2. Nurse #7 and the surveyor observed Resident #13's oxygen machine and she said it was set at 4.5 liters and it was too high.
During an interview on 4/8/25 at 2:13 P.M., the Director of Nursing said Resident #13's oxygen setting was set too high and it should be at the setting as indicated in the physician's order.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0698
(Tag F0698)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, and interviews, the facility failed to provide care and services consistent with professional standards ...
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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 care and services consistent with professional standards of practice for one Resident (#13) who required renal dialysis (a life sustaining treatment that helps the body remove extra fluids and waste products from the blood when the kidneys are not able to) out of a total sample of 23 residents. Specifically, for Resident #13, the facility failed to ensure nursing staff documented they obtained blood pressures from his/her arm with the AV fistula (arteriovenous fistula, is when an artery and vein connect directly, allowing blood to flow. This term is interchangeably used with AV shunt.).
Findings include:
Review of the facility policy titled Hemodialysis Access Care, dated and revised November 2017, indicated the following:
- Guidelines: Steps in the procedure:
4. To prevent infection and/or clotting: Do not use access arm to take blood pressure.
Resident #13 was admitted to the facility in January 2025 with diagnoses including end stage renal disease, obstructive sleep apnea and chronic respiratory failure.
Review of Resident #13's most recent Minimum Data Set Assessment (MDS) dated [DATE] indicated that the Resident has a Brief Interview for Mental Status score of 13 out of 15 indicating intact cognition. Further review of the MDS indicated that the Resident requires dialysis therapy.
During an observation on 4/6/25 at 7:58 A.M., the surveyor observed Resident #13 to have a dialysis fistula on his/her left arm. Resident #13 told the surveyor this is where he/she received his/her dialysis.
Review of Resident #13's physician's order indicated the following:
- Dated 3/13/25: No blood pressure/blood draws to be taken in the left arm, every shift.
- Dated 4/4/25: Dialysis three times per week, Monday, Wednesday Friday.
Review of Resident #13's dialysis care plan, dated 1/27/25, indicated the following intervention: Do not draw blood or take B/P (blood pressure) in arm with graft/shunt.
Review of Resident #13's blood pressure vitals history indicated that staff had documented obtaining blood pressure readings on Resident #13's left arm (where the dialysis shunt is) 15 times since the physician's order was given.
During an interview on 4/8/25 at 9:02 A.M., Nurse #7 said staff should not be obtaining blood pressure readings on Resident #13's left arm as they would be making a mistake by doing so.
During an interview on 4/8/25 at 2:13 P.M., the Director of Nursing (DON) said staff should not be obtaining blood pressure on Resident #13's left arm, it should be done on his/her right arm.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0699
(Tag F0699)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure a comprehensive person-centered plan of care was developed f...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure a comprehensive person-centered plan of care was developed for Trauma-Informed Care for two Residents (#57 and #88), who were admitted with the diagnosis of Post-Traumatic Stress Disorder (PTSD), out of a total sample of 23 residents.
Findings include:
Review of the facility policy titled Trauma Informed Care, dated October 2019, indicated: To guide staff in appropriate and compassionate care specific to individuals who have experienced trauma. Trauma-informed care is culturally sensitive and person-centered. Reduce or eliminate unnecessary stimuli.
1. Resident #57 was admitted to the facility in July 2023 with diagnoses that included Post Traumatic Stress Disorder, dementia, frontotemporal neurocognitive disorder, and depression.
Review of Resident #57's most recent Minimum Data Set (MDS) assessment, dated 3/27/25, indicated he/she scored a 00 on the Brief Interview for Mental Status (BIMS) indicating severe cognitive impairments. Further review of the MDS indicated he/she has a diagnosis of PTSD.
Review of Resident #57's social services assessment, dated 3/27/25, indicated Resident has a history of PTSD and behavioral issues, which are being addressed via medication.
Review of Resident #57's PTSD care plan, revised 3/17/25, indicated an intervention put into place on 11/13/23 to Determine best coping strategies that has worked in the past to help the resident cope with traumatic event. Further review of the care plan failed to identify triggers and coping strategies for the Resident.
During an interview on 4/6/25 at 12:40 P.M., Family Member #1 said his/her family member has been through a lot in their life. Family Member #1 said she is more than willing to talk to the facility about their family member.
During an interview on 4/7/25 at 2:00 P.M., the Social Worker said triggers should be on the PTSD care plan so staff know what will set that resident off. The Social Worker said she has not discussed triggers or coping strategies with his/her family who is her responsible party and Guardian.
During an interview on 4/8/25 at 2:14 P.M., the Director of Nursing said a resident who has a diagnosis of PTSD should have a care plan in place with triggers so staff are aware.
2. Resident #88 was admitted to the facility May 2024 with diagnoses including atrial fibrillation, coronary atherosclerosis and post-traumatic stress disorder (PTSD).
Review of Resident #88's most recent Minimum Data Set Assessment (MDS) dated [DATE] indicated the Resident has a Brief Interview for Mental Status score of 15 out of 15 indicating intact cognition. Further review of the MDS indicated Resident #88 has a post-traumatic stress disorder diagnosis.
Review of Resident #88's MDS dated [DATE] indicated that the Resident has a post-traumatic stress disorder diagnosis.
Review of Resident #88's Behavioral Health evaluation completed by the Nurse Practitioner, dated 6/6/24, indicated the following:
- HPI (History of Present Illness): PTSD
Review of Resident #88's Behavioral Health evaluation completed by the Nurse Practitioner, dated 8/8/24, indicated the following:
- HPI: Reports worsening anxiety and depression. Endorses flashbacks and nightmares related to PTSD.
- Psychiatric History: SI (Suicidal Ideation) Details: I think I tried years ago when I was depressed.
- Clinical Assessment: Endorsed nightmares and flashbacks reported to PTSD.
Review of Resident #88's current, active care plans failed to indicate that a personalized, resident-focused care plan was implemented for PTSD.
During an interview on 4/7/25 at 1:55 P.M., the Social Worker said when residents are admitted to the facility the staff do an in-depth evaluation. The Social Worker continued to say a part of that evaluation is asking if the Resident has PTSD or trauma history and if so, a personalized care plan indicating triggers should be developed for the Resident. The Social Worker said she was not aware Resident #88 has endorsed having PTSD and he/she should have a care plan in place.
During an interview on 4/8/25 at 2:13 P.M., the Director of Nursing (DON) said all residents with a known history or diagnosis of PTSD should have a personalized care plan indicating triggers. The DON said she was not aware Resident #88 had PTSD or that a care plan was not in place.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0757
(Tag F0757)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to ensure one Resident (#8) was free from unnecessary psychotropic me...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to ensure one Resident (#8) was free from unnecessary psychotropic medications, out of a total sample of 23 residents.
Findings include:
Review of the facility policy titled, Psychotropic Medication, dated 7/2023, indicated the following:
-To administer and monitor the effects of psychotropic medications when prescribed. Psychotropic medications will be prescribed at the lowest possible dosage and are subject to gradual dose reduction and re-review as needed.
-Dosage is appropriate for the resident and is not in excess of the suggested daily dosage maximum, unless specifically documented by the attending physician.
-The interdisciplinary team assesses and monitors the appropriateness, effectiveness, and side effects associated with psychotropic medications for each resident via resident care plan review period the resident, and one indicated, the family or responsible person, will be included in this process prior to the administration of dose.
Resident #8 was admitted to the facility in August 2019 with diagnoses including unspecified dementia, unspecified severity, without behavioral disturbance, mood disturbance, anxiety.
Review of Resident #8's most recent Minimum Data Set (MDS), dated [DATE], indicated the Resident scored a 3 out of a possible 15 on the Brief Interview for Mental Status (BIMS) which indicated he/she had severe cognitive impairment. The MDS also indicated Resident #8 was dependent on staff for self-care tasks.
Review of Resident #8's physician orders indicated the following order initiated on 7/17/24:
-Zyprexa (an antipsychotic medication) oral tablet 5 MG (milligrams). Give 5 MG by mouth two times a day related to unspecified dementia. Unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance and anxiety; paranoid schizophrenia.
Review of the psychiatrist notes dated 2/13/25, 3/3/25 and 3/27/25 indicated the following:
-Clinical Assessment: MSE (Mental Status Exam) shows Parkinsonian Sx (symptoms) c/w (consistent with) neuroleptic-induced EPS (Extrapyramidal Symptoms are drug-induced movement disorders that occur due to antipsychotic blockade of the nigrostriatal dopamine tracts) SE's (side effects) .Options to reduce EPS at this point include 1) lowering dose of zyprexa, but recent assault makes this untenable; 2) changing to the lowest EPS agent, which would be Seroquel, which has added benefit of lower metabolic SE's; 3) adding Amantadine, which would be preferable to using an ACh agent (neurotransmitter); 4) Adding an ACh agent such as cogentin or benadryl, but this can cause undesirable SE's and increase mortality in elderly .can increase Zyprexa if needed.
-The recommendation section of the note failed to indicate a recommendation to start Resident #8 on Seroquel.
Review of Resident #8's physician orders indicated the following order written on 3/29/25:
-Seroquel (an antipsychotic medication) oral tablet 50 mg (milligrams) give 1 tablet two times a day related to paranoid schizophrenia.
Review of Resident #8's medical record indicated the following:
-Resident #8 has a legal guardian who makes all medical decisions for the Resident
-Resident #8 has a Roger's orders (a judge and legal guardian decide when an antipsychotic medication can be administered). Resident #8's treatment plan did not include Seroquel as an agreed upon medication for the Resident.
-The medical record failed to indicate Resident #8 or his/her legal guardian was informed of the new order for Seroquel and the risks/benefits of the medication in advance of administration of the medicine.
Review of the Nurse Practitioner noted, dated 4/3/25, indicated the following:
-Today, nursing reports (the Resident) is more lethargic. Yesterday (he/she) was at (his/her) baseline, this morning ate less breakfast than usual and has been sleeping most of the morning. No reports insomnia or irregular sleep patterns overnight period (his/her) VS (vital signs) are stable, a febrile, no hypoxia. BS (blood sugar) 154. (He/she) has no complaints of SOB (shortness of breath) cough, urinary problems, or pain, though ROS (review of symptoms) limited due to (his/her) baseline dementia slash schizophrenia. Review of PCC (electronic medical record) - (he/she) was started on Seroquel 50MG BID (twice a day) on 3/29, unclear reason, otherwise no recent Med changes. Per nursing (he/she) is up in dining room waiting for lunch this afternoon.
-Physical exam: Quite sleepy on exam.
-Plan: nursing reports today that member is more lethargic and sleepy when compared to baseline. Physical exam intact other than member is noted to be lethargic. VS stable, no other complaints. (He/she) Was started on Seroquel 50MG BID 3/29 - unclear reason/no note/no psych rec. Plan hold Seroquel.
During an interview on 4/7/25 at 7:48 A.M., Nurse #2 said she regularly works at the facility and is familiar with Resident #8. Nurse #2 said she had no idea why the Resident was started on Seroquel.
During an interview on 4/7/25 at 11:45 A.M., the Director of Nursing said Resident #8's mood and behavior is very unpredictable. The Director of Nursing said the Psychiatrist wanted to start Resident #8 on Seroquel and he must have spoken with the Nurse Practitioner about the med changes. The Director of Nursing said she was unaware of the specifics about the recommendation.
During an interview on 4/8/25 at 11:07 A.M., Nurse Practitioner (NP) #1 said Resident #8 should never have been started on Seroquel. NP #1 said it was a suggestion from the Psychiatrist, but the Psychiatrist never made it a firm recommendation and had acknowledged it was not on the Roger's treatment plan so could not have been started without consent from the court. NP#1 said Seroquel most likely wouldn't have been effective medication for Resident #8 anyways.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Dental Services
(Tag F0791)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review and interviews, the facility failed to follow the recommendations of the dentist to ensure ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review and interviews, the facility failed to follow the recommendations of the dentist to ensure a referral was made to the oral surgeon for one Resident (#92) out of a total sample of 23 residents.
Findings include:
Resident #92 was admitted to the facility in August 2024 with diagnoses including Chronic Obstructive Pulmonary Disease (COPD).
Review of Resident #92's most recent Minimum Data Set (MDS) dated [DATE], indicated the Resident had a Brief Interview for Mental Status (BIMS) score of 14 out of a possible 15, which indicated he/she is cognitively intact. The MDS also indicated Resident #93 required partial to moderate assistance with functional daily tasks.
During an interview on 4/6/25 at 9:34 A.M., Resident #92 said he/she has been waiting to see the dentist. The Resident said he/she was supposed to have teeth pulled and have dentures made and no one from the facility has discussed this with him/her. Resident #92 was observed to have several small, broken and brown teeth on the bottom of his/her mouth. Resident #92 said he/she did not have any pain but would really like to have the dental work completed.
Review of Resident #92's oral health care plan dated 9/9/24, indicated an intervention to refer to dentist as needed.
Review of Resident #92's medical record indicated the Resident was seen by the dentist on 3/10/25 with the following recommendations:
-Action required by nursing staff: Refer to oral surgeon eval for extractions of non-restorable dentition - all remaining maxillary and mandibular teeth, F/F (upper and lower) dentures will be fabricated after initial healing.
Review of Resident #92's nursing and physician notes in March and April 2025 failed to indicate the nursing staff was aware of this recommendation, reviewed this recommendation with the physician and made the referral to the oral surgeon.
During an interview on 4/7/25 at 11:45 A.M., the Director of Nursing said all dental visit notes are emailed to her, and she is responsible for ensuring the recommendations are followed. The Director of Nursing was unaware of the recommendation for Resident #92 to be referred to an oral surgeon and could not say if this referral had been made or not.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0808
(Tag F0808)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview, the facility failed to provide the prescribed, therapeutic diet for two Resid...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview, the facility failed to provide the prescribed, therapeutic diet for two Residents (#12, #4) out of a total sample of 23 Residents. Specifically:
1. For Resident #12, the facility failed to ensure the Resident was receiving Nectar Thickened Liquids as ordered.
2. For Resident #4, the facility failed to ensure that the Resident was receiving a Dysphagia Mechanical Soft diet and Nectar Thick Liquids as ordered.
Findings include:
1. Resident #12 was admitted to the facility in January 2019 with diagnoses including chronic respiratory failure, chronic obstructive pulmonary disease dysphasia and Barrett's Esophagus without dysplasia.
Review of Resident #12's most recent Minimum Data Set Assessment (MDS) indicated that the Resident has a Brief Interview for Mental Status score of 15 out of 15 indicting intact cognition.
Further review of the MDS indicated that the Resident requires partial/moderate assistance with eating.
The surveyor made the following observations:
- On 4/6/25 at 8:44 A.M., Resident #12 was eating breakfast in his/her bed with no staff present. On his/her lunch tray was an unopened packet of powder to make drinks Nectar Thick Consistency. Resident #12 said staff are supposed to put it in his/her coffee but never do. Resident #12 proceeded to drink his/her coffee that was not Nectar Thick consistency.
- On 4/7/25 at 8:02 A.M., Resident #12 was eating breakfast in his/her bed with no staff present. On his/her lunch tray was an unopened packet of powder to make drinks Nectar Thick Consistency. Resident #12 said staff do not open the Nectar Thick Packet most of the time. Resident #12 proceeded to try and open the packet, and he/she was unable to do so. The Resident then took a sip of his/her coffee that was not Nectar Thick consistency.
- On 4/8/25 at 8:26 A.M., Resident #12 was eating breakfast in his/her bed. The packet of Nectar Thick powder was unopened as Resident #12 was eating his/her breakfast.
Review of Resident #12's meal ticket indicated the following: Thick Fluids - Nectar Mildly, Standing orders: 8 fl oz (fluid ounce) coffee decaf Nectar
Review of Resident #12's physician's order dated 3/26/25, indicated the following:
- Nectar Thick Liquids (2 mildly thick) consistency
Review of Resident #12's [NAME] (a form indicating the level of care a resident needs) indicated the following under the Monitors section:
- Monitor/document/report PRN (as needed) s/sx (signs/symptoms) of dysphagia: pocketing, choking, coughing, drooling, holding food in mouth, several attempts at swallowing, appears concerned at meals.
Review of Resident #12's Speech Therapy Evaluation and Plan of Treatment dated from 1/13/25 through 2/9/25, indicated the following:
- Recommendations: Diet Recs - Liquids = Nectar Thick Liquids.
Review of Resident #12's Medical Nutrition Therapy Assessment completed by the Registered Dietitian (RD), dated 3/10/25, indicated the following:
- Recommend to Continue: Nectar Thick Liquids
During an interview on 4/8/25 at 1:34 P.M., the RD said Resident #12 should be receiving Nectar Thick Liquids. The RD said staff should be pouring the Nectar Thick Powder in the Resident's coffee.
During an interview on 4/8/25 at 1:44 P.M., Certified Nursing Assistant (CNA) #8 said CNA's will open the Nectar Thick Packet for the residents and mix it into their coffee. CNA #8 said we look at the meal ticket to make sure everything is correct.
During an interview on 4/8/25 at 2:13 P.M., the Director of Nursing said Resident's diets should be followed as ordered.
2. Resident #4 was admitted to the facility in June 2014 with diagnoses including hemiplegia and hemiparesis, dysphagia and epilepsy.
Review of Resident #4's most recent Minimum Data Set Assessment (MDS) indicated that the resident had a Brief Interview for Mental Status score of 2 out of 15 indicating severe cognitive impairment. Further review of the MDS indicated that the Resident is dependent on staff for activities of daily living and requires partial/moderate assistance with eating.
Review of Resident #4's physician's order dated 12/30/24, indicated the following: Regular diet, Dysphagia Mechanical Soft texture, Nectar Thick Liquids (2 mildly thick) consistency.
The surveyor made the following observation:
- On 4/7/25 at 10:52 A.M., Resident #4 was sitting at a table in the dining room. A Certified Nursing Assistant (CNA) approached him/her and asked if he/she wanted any water and a snack. The CNA proceeded to pour Resident #4 a cup of water from a water container on the nursing cart and give the Resident a bag of a Cheez-It snack (a crunchy, crumbly snack). The CNA proceeded to tell the Resident it is salty and she walked away. Resident #4 proceeded to eat the snack and drink the water with no supervision. The CNA did not check the Resident's diet or make the water a Nectar Thick Consistency.
During an interview on 4/7/25 at 2:10 P.M., the Registered Dietitian (RD) said Cheez-Its are not an appropriate snack for someone on a Dysphagia Mechanical Soft diet and they pose a choking risk. The RD also said Resident #4 should not be drinking any liquid that is not a Nectar Thick Consistency.
During an interview on 4/8/25 at 2:13 P.M., the Director of Nursing said resident's diets should be followed as ordered.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Medical Records
(Tag F0842)
Could have caused harm · This affected 1 resident
Based on observation, record review and interview, the facility failed to accurately document in the medical record for one Resident (#9) out of 23 total sampled residents. Specifically, for Resident ...
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Based on observation, record review and interview, the facility failed to accurately document in the medical record for one Resident (#9) out of 23 total sampled residents. Specifically, for Resident #9, the facility failed to document presence of six bilateral foot wounds in weekly skin evaluations.
Findings include:
Resident #9 was admitted to the facility in November 2024 with diagnoses including diabetes and mild cognitive impairment.
Review of the Minimum Data Set (MDS) assessment, dated 1/23/25, indicated Resident #9 had severe cognitive impairment as evidenced by a Brief Interview for Mental Status (BIMS) score of 4 out of 15. This MDS indicated Resident #9 had two unstageable pressure ulcers. This MDS also indicated Resident #9 was unable to walk and was dependent on staff for turning in bed, hygiene, and transferred.
Review of Resident #9's entire plan of care related to skin, revised 3/24/25, indicated the Resident had left and right heel arterial ulcers. The entire plan of care failed to indicate the Resident had any other wounds.
On 4/7/25 at 10:36 A.M., the surveyor observed Nurse #5 perform the wound dressing change on Resident #9's bilateral heels. During this observation, there were six additional wounds on the bilateral feet. The following additional wounds were observed on Resident #9's left foot: two dime sized wounds on left lateral foot and one dime sized wound on the left ankle. The following additional wounds were observed on Resident #9's right foot: one dime sized wound on the right lateral foot and two dime sized wounds on the anterior foot. Nurse #5 said all six of these wounds appear to be eschar (necrotic tissue that can develop in wounds). Certified Nurse Assistant (CNA) #7 was present during this observation. Nurse #5 and CNA #7 said these six wounds developed shortly after he/she returned from the hospital (Resident #9 was readmitted to the facility from the hospital on 3/17/25). Nurse #5 said there are no wound treatment orders for these six wounds, and she does not know what type of wounds they are. Nurse #5 said the consultant Wound PA had been responsible for assessing these six wounds weekly.
Review of Resident #9's admission assessment, dated 3/17/25, indicated the following wounds:
- Right Heel, Type Pressure, length 6 centimeters (cm) by 6.2 cm.
- Left Heel, Type: Pressure, length 4.8 cm by 6.5 cm.
- Anterior l. (left) foot, Type: Other (specify), length 1.3 cm by 2.1 cm.
- Left late (lateral), Type: Other (specify), length 1.5 cm by 1.5 cm.
- Medial Left Archille [sic], Type: Other (specify), length 2 cm by 1.8 cm.
- Right heel proximal scab, Type: Other (specify), length 2 cm by 2.1 cm.
Review of Resident #9's assessments titled 'Weekly Skin Evaluation', dated 3/20/25, 3/27/25, and 4/3/25, failed to indicate any wounds in addition to the left heel and right heel pressure ulcers.
Review of Resident #9's medical record failed to include any wound treatment orders, mention of, assessment, or measurements of any wounds other than relating to the left heel and right heel pressure ulcers from 3/18/25 until the surveyor's wound observation on 4/7/25.
During an interview on 4/7/25 at 11:42 A.M., The Director of Nursing (DON) the Resident had additional wounds on his/her feet when they were re-admitted from the facility on 3/17/25 and they spoke about the additional foot wounds weekly during risk meeting since his/her readmission. The DON said the six additional foot wounds should have been documented on the weekly skin evaluations but were not.
During a follow up interview on 4/9/25 at 8:07 A.M., the Regional Nurse said she assessed the six additional wounds on Resident #9's bilateral feet and they looked like they were arterial ulcers to her. The Regional Nurse said they should have been documented on the weekly skin evaluations but were not.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected 1 resident
Based on observations, interviews and record review, the facility failed to maintain an infection prevention and control program designed to help prevent the development and transmission of communicab...
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Based on observations, interviews and record review, the facility failed to maintain an infection prevention and control program designed to help prevent the development and transmission of communicable diseases and infections. Specifically, for Resident #9, the facility failed to ensure staff performed hand hygiene before applying and after removing gloves during wound care.
Findings include:
Review of the facility policy titled 'Handwashing/Hand Hygiene', revised July 2024, indicated, but was not limited to the following:
- Policy: The facility considers hand hygiene the primary means to prevent the spread of infections.
6. Use an alcohol-based hand rub containing at least 62% alcohol; or, alternatively, soap and water for the following situations:
e. Before donning (applying) gloves.
i. After handling used dressings, contaminated equipment, etc.
j. After removing gloves.
8. The use of gloves does not replace hand washing/hand hygiene. Integration of glove use along with routine hand hygiene is recognized as the best practice for preventing healthcare-associated infections.
Resident #9 was admitted to the facility in November 2024 with diagnoses including diabetes and mild cognitive impairment.
Review of the Minimum Data Set (MDS) assessment, dated 1/23/25, indicated Resident #9 had severe cognitive impairment as evidenced by a Brief Interview for Mental Status (BIMS) score of 4 out of 15. This MDS indicated Resident #9 had two unstageable pressure ulcers.
On 4/7/25 at 10:36 A.M., the surveyor observed Nurse #5 perform wound dressing change on Resident #9's bilateral heel pressure ulcers. Nurse #5 removed a dressing from right heel wound. Nurse #5 then removed gloves and did not perform hand hygiene prior to applying a new pair of gloves. Nurse #5 cleansed the right heel wound, which had a large amount of tan drainage, with a wound cleanser and gauze. Nurse #5 then removed gloves and did not perform hand hygiene prior to applying a new pair of gloves. Nurse #5 applied skin prep the edges of the wound bed. Nurse #5 then removed gloves and did not perform hand hygiene prior to applying a new pair of gloves. Nurse #5 applied adaptic (wound treatment) and alginate (wound treatment) to the wound bed. Nurse #5 then removed gloves and did not perform hand hygiene prior to applying a new pair of gloves. Nurse #5 applied a dressing to the right heel wound. Nurse #5 then removed gloves and used an alcohol prep pad to clean her hands. Nurse #5 said she forgot hand sanitizer and instead is using alcohol prep pads to sanitize. Nurse #5 then applied new gloves and assisted Resident to reposition in bed. Nurse #5 removed the left heel dressing. Nurse #5 then removed gloves and did not perform hand hygiene prior to applying a new pair of gloves. Nurse #5 cleansed the left heel wound, which had a large amount of tan drainage, with a wound cleanser and gauze. Nurse #5 then removed gloves and did not perform hand hygiene prior to applying a new pair of gloves. Nurse #5 continued to cleanse the left heel wound with wound cleanser. Nurse #5 then removed gloves and used an alcohol prep pad to clean her hands. Nurse #5 applied iodosorb (a wound care gel) and a dressing to the left heel wound. During these wound dressing changes Nurse #5 did not perform any hand hygiene after removing gloves and before applying new ones during six out of eight glove changes. During the other two glove changes, Nurse #5 used alcohol prep pads to sanitize and said this was because she forgot hand sanitizer.
During an interview on 4/7/25 at 11:14 A.M., Nurse #5 said she should have performed hand hygiene during all glove changes but did not.
During an interview on 4/7/25 at 12:06 P.M., the Director of Nursing (DON) said Nurse #5 should have performed hand hygiene by either using an alcohol-based hand rub or washing hands with soap, during all glove changes. The DON said alcohol prep pads are not a substitute for hand hygiene.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Resident Rights
(Tag F0550)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, and interviews, the facility failed to provide a dignified dining experience for the resid...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, and interviews, the facility failed to provide a dignified dining experience for the residents of the facility as well as provide a dignified existence for four Residents (# 52, #14, #57 and #13), out of a total sample of 23 residents. Specifically, the facility failed to:
1) provide a dignified dining experience to the residents on the first and second floor,
2) provide privacy during care for Resident #52,
3) provide dignity while providing incontinence care by using double incontinence briefs for Residents #52, #14 and #57 and
4) provide a dignified environment for Resident #13.
Findings include:
Review of the facility policy titled, :Resident Rights, dated 1/24, indicated the following:
-Employees shall treat all residents with kindness, respect and dignity. a. Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to:
a. a dignified existence
b. be treated with respect, kindness, and dignity
t. privacy and confidentiality.
1. The facility failed to provide a dignified dining experience to the residents on the first and second floor.
The following was observed on the first floor unit during the days of survey:
- On 4/6/25 at 8:37 A.M., a staff member was observed feeding a resident who was lying in bed while standing over them, not at eye level.
- On 4/6/25 at 12:38 P.M., a Certified Nursing Assistant (CNA) was overheard saying is he a feed while passing out lunch trays with other residents nearby.
- On 4/7/25 at 8:13 A.M., a staff member was observed standing over a resident feeding him/her breakfast while he/she was laying in his bed.
- On 4/8/25 at 12:34 P.M., a CNA was overheard saying is he a feeder while passing out lunch trays with other residents nearby.
On 4/6/25 at 8:34 A.M., and 8:38 A.M., staff were overheard referring to residents as feeds in the presence of residents when passing out breakfast trays on the second floor.
The following was observed in the second-floor dining room during lunch on 4/6/25:
-Three residents were seated at a dining table. The first resident was served lunch at 12:24 P.M. The other two residents were served lunch at 12:40 P.M. and 12:42 P.M., 16-18 minutes later.
- Three residents were seated at a dining table. The first resident was served lunch at 12:24 P.M. The other two residents were served lunch at 12:40 P.M. and 12:42 P.M., 16-18 minutes later.
-Three residents were seated at a dining table. The first resident was served lunch at 12:35 P.M. The last resident was served lunch at 12:53 P.M., 18 minutes later.
-Three residents were seated at a dining table. The first resident was served lunch at 12:25 P.M. The last resident was served lunch at 12:52 P.M., 27 minutes later.
-At 12:35 P.M., two staff were overheard referring to residents as feeds in the presence of residents when passing out lunch trays.
The following was observed in the second-floor dining room during breakfast on 4/7/25:
-Three residents were seated at a dining table. The first resident was served breakfast at 7:56 A.M. The last resident was served lunch at 8:09 A.M., 13 minutes later.
-Two residents were seated at a table. The first resident was served breakfast at 7:57 A.M. The second was served at 8:11 A.M., 14 minutes later.
-Two residents were seated at a table. The first resident was served breakfast at 7:57 A.M. The second was served at 8:07 A.M., 10 minutes later.
The following was observed in the second-floor dining room during lunch on 4/7/25:
-Three resident were seated at a dining table. The first resident was served lunch at 12:28 P.M. The last resident was served lunch at 12:39 P.M., 11 minutes later.
-Three resident were seated at a dining table. The first resident was served lunch at 12:27 P.M. The last resident was served lunch at 12:45 P.M., 18 minutes later.
-Three resident were seated at a dining table. The first resident was served lunch at 12:34 P.M. The last resident was served lunch at 12:48 P.M., 14 minutes later.
On 4/8/25 at 8:37 A.M., two staff on the second floor were overheard referring to residents as feeders in the presence of residents when passing out breakfast trays.
During an interview on 4/8/25 at 2:13 P.M., the Director of Nursing said the staff are expected to provide a dignified dining experience for the residents of the facility. The Director of Nursing said staff should be at eye level with residents while assisting them with a meal, should not refer to residents with labels such as feeds or feeders and all residents who are seated at the same table should be served meals at the same time.
2. The facility failed to provide privacy during care for Resident #52.
Resident #52 was admitted to the facility in October 2022 with diagnoses including dementia legal blindness, and failure to thrive.
Review of Resident #52's most recent Minimum Data Set (MDS) dated [DATE], indicated the Resident was unable to complete the Brief Interview for Mental Status (BIMS) and the staff assessed him/her to have moderate cognitive impairment. The MDS also indicated Resident #52 is dependent on staff for toileting tasks.
On 4/6/25 at 8:19 A.M., a staff member was toileting and changing Resident #52's incontinence brief in a hallway bathroom with the door open, visible to anyone walking by.
During an interview on 4/9/25 at approximately 11:30 A.M., Certified Nursing Assistant #3 said privacy should be ensure while providing any personal care by pulling the privacy curtain or closing the door.
3. The facility failed to provide dignity while providing incontinence care by using double incontinence briefs for Residents #52, #14 and #57.
a. Resident #52 was admitted to the facility in October 2022 with diagnoses including dementia legal blindness, and failure to thrive.
Review of Resident #52's most recent Minimum Data Set (MDS) dated [DATE], indicated the Resident was unable to complete the Brief Interview for Mental Status (BIMS) and the staff assessed him/her to have moderate cognitive impairment. The MDS also indicated Resident #52 is dependent on staff for toileting tasks.
On 4/8/25 at 11:32 A.M., Resident #52 was observed to be wearing two incontinence briefs at the same time.
During an interview on 4/8/25 at 11:35 A.M., Certified Nursing Assistant (CNA) #3 said he assisted the Resident with his/her morning care, and he placed two incontinence briefs on the Resident to ensure they would stay in place.
During an interview on 4/8/25 at 2:13 P.M., the Director of Nursing said residents should never have two incontinence briefs on at the same time as it is not dignified.
b. Resident #14 was admitted to the facility in December 2022 with diagnoses that included Alzheimer's disease, dementia, chronic obstructive pulmonary disease, schizophrenia and anxiety.
Review of Resident #14's most recent Minimum Data Set (MDS) assessment, dated 1/23/25, indicated he/she scored a 1 out of 15 on the Brief Interview for Mental Status (BIMS) indicating severe cognitive impairments. Further review of the MDS indicated he/she was dependent on staff for toileting tasks.
On 4/8/25 at 11:39 A.M., Resident #14 was observed to be wearing two incontinence briefs at the same time.
During an interview on 4/8/25 at 11:39 A.M., Certified Nursing Assistant (CNA) #5 said the 11:00 P.M. to 7:00 A.M. shift did his/her morning care. CNA #5 said staff should not be double briefing residents but Resident #14 does have two incontinence briefs on.
During an interview on 4/8/25 at 2:13 P.M., the Director of Nursing said residents should never have two incontinence briefs on at the same time as it is not dignified.
c. Resident #57 was admitted to the facility in July 2023 with diagnoses that included Post Traumatic Stress Disorder (PTSD), dementia, frontotemporal neurocognitive disorder, and depression.
Review of Resident #57's most recent Minimum Data Set (MDS) assessment, dated 3/27/25, indicated he/she scored a 00 out of 15 on the BIMS indicating sever cognitive impairments. The MDS also indicated Resident #57 is dependent on staff for toileting tasks.
On 4/8/25 at 11:43 A.M., Resident #57 was observed to be wearing two incontinence briefs at the same time.
During an interview on 4/8/25 at 11:43 A.M., Certified Nursing Assistant #2 said she assisted the Resident with his/her morning care, and she placed two incontinence briefs on the Resident to ensure they would stay in place.
During an interview on 4/8/25 at 2:13 P.M., the Director of Nursing said residents should never have two incontinence briefs on at the same time as it is not dignified.
4. Resident #13 was admitted to the facility in January 2025 with diagnoses including end stage renal disease, obstructive sleep apnea and chronic respiratory failure.
Review of Resident #13's most recent Minimum Data Set Assessment (MDS) dated [DATE] indicated that the Resident has a Brief Interview for Mental Status score of 13 out of 15 indicating intact cognition.
The surveyor made the following observations:
- On 4/6/25 at 10:50 A.M. and on 4/7/25 at 1:22 P.M., a cork board beside Resident #13's bed was observed to say Fuck this place written in pen.
During an interview on 4/6/25 at 10:50 A.M., Resident #13 said he/she did not write that, it was in the room when he/she moved in and he/she does not like it there.
During an interview on 4/8/25 at 9:02 A.M., Nurse #8 said that should not be written in his/her room and it needs to be removed. Nurse #8 said Resident #13 moved into the room not long ago and it was written by the previous resident. Nurse #8 said it should have been removed before Resident #13 moved into the room.
During an interview on 4/8/25 at 2:13 P.M., the Director of Nursing said that the derogatory language should not be written in Resident #13 room, and all residents should have a dignified experience in the facility.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Safe Environment
(Tag F0584)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Resident #52 was admitted to the facility in October 2022 with diagnoses including dementia legal blindness, and failure to t...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Resident #52 was admitted to the facility in October 2022 with diagnoses including dementia legal blindness, and failure to thrive.
Review of Resident #52's most recent Minimum Data Set (MDS) dated [DATE], indicated the Resident was unable to complete the Brief Interview for Mental Status (BIMS) and the staff assessed him/her to have moderate cognitive impairment. The MDS also indicated Resident #52 is dependent on staff for toileting tasks.
On 4/8/25 at 7:18 A.M., the surveyor observed Resident #52's unmade bed. The mattress had a hole in the top layer of material throughout the middle of the mattress with dark brown stains throughout the mattress.
During an interview on 4/8/24 at 2:12 P.M., the Director of Nursing looked at a picture of Resident #52's mattress and said that the mattress should not have any missing layer of fabric and should be replaced. The Director of Nursing said the maintenance department usually inspects all mattresses and if there is damage to a mattress it will be replaced.
Based on observation and interview, the facility failed to maintain a home-like environment. Specifically,
1. The facility failed to ensure that the second floor was free from odors.
2. For Resident #80, the facility failed to ensure the resident's room did not smell of urine and was free from small black flying insects.
3. For Resident #52, the facility failed to ensure his/her mattress was intact without any missing fabric.
Findings include:
The facility was unable to provide a home-like environment policy.
1. On 4/6/25, the surveyors noted the second floor unit had a strong odor of stale urine and body odor throughout the hallways, and dining area at various times during the day (7:00 A.M. - 3:00 P.M.)
On 4/7/25 and 4/8/25, the surveyors noted the second floor unit had a strong odor of stale urine and body odor throughout the hallways, and dining area at various times during the day (6:45 A.M. - 3:00 P.M.)
During an interview on 4/6/25 at 12:40 P.M., Family member #1 said she comes on different days and different times during the week and the second floor always has a bad smell which is not great for her or the residents.
During the resident group meeting conducted on 4/7/25, 14 out of 16 participating residents complained about the odor of the facility and that there is always a constant bad odor.
During an interview on 4/9/25 at 10:02 A.M., the Activities Director said it has a bad odor on the second floor of the facility at all times.
During an interview on 4/9/25 at 11:13 A.M., the Administrator said he has noticed a smell on the second floor and it is because a resident's foley catheter has leaked into the floor and gotten under the tiles. He said housekeeping does their best to eliminate the odor.
2. Resident #80 was admitted to the facility in February 2024 with diagnoses including hypertension and chronic kidney disease.
Review of the most recent Minimum Data Set (MDS) assessment, dated 1/30/25, indicated Resident #80 was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) score of 13 out of 15.
On 4/6/25 at 7:28 A.M., Resident #80 approached the surveyor in the hallway and said he/she is disgusted with their room because it constantly smells strongly of urine. Resident #80 said it's so bad he/she needs to open the window frequently to help lessen the smell of urine. Resident #80 said he/she spends very little time in the room because of the smell. Resident #80 said he/she has told many staff members about the smell, but nobody does anything about it. Resident #80 further said he/she has expressed concern about cockroaches in the room because staff does not remove old food from the room.
On 4/6/25 at 7:43 A.M, the surveyor entered Resident #80's room which smelled strongly of urine. There was a bag of soiled briefs visible on the roommate's side of the room. There were multiple open food wrappers and open juice containers scattered throughout the room on surfaces and on the floor. There were condiment packets open and leaking onto the floor. There were greater than ten small black flying insects throughout the room.
On 4/6/25 at 12:12 P.M., the surveyor entered Resident #80's room which smelled strongly of urine. There was a bag with a soiled brief visible on the roommate's side of the room. There were greater than ten small black flying bugs throughout the room. There were multiple open food wrappers and open juice containers scattered throughout the room on surfaces and on the floor. There were condiment packets open and leaking onto the floor. A certified nurse assistant (CNA) delivered a meal tray to Resident #80's roommate and swatted her hand as she walked through the small black flying insects.
On 4/7/25 at 8:45 A.M., the surveyor entered Resident #80's room which smelled strongly of urine. There was a bag with a soiled brief visible on the roommate's side of the room. There were multiple open food wrappers and open juice containers scattered throughout the room on surfaces and on the floor. There were condiment packets open and leaking onto the floor. There were greater than ten small black flying bugs throughout the room.
0n 4/8/25 at 9:14 A.M., the surveyor entered Resident #80's room which smelled strongly of urine. There were multiple open food wrappers and open juice containers scattered throughout the room on surfaces and on the floor. There were condiment packets open and leaking onto the floor. There were greater than ten small black flying bugs throughout the room.
During an interview on 4/7/25 at 8:48 A.M., CNA #7 said Resident #80 often opens the window, but said she was unsure why. CNA #7 said Resident #80 complains about bugs being in the room, specifically cockroaches, but that she hasn't seen any bugs herself and thinks it's not true.
During an interview on 4/9/25 at 8:18 A.M., the Director of Nursing (DON) and Regional Nurse said staff should attempt to remove wrappers, food, and trash from Resident #80's room. They said yesterday they removed more than 20 juice containers from his/her room and those probably attracted the small black flying insects. They further said if there is an odor of urine present staff should identify and remove the source of scent if possible, and if unable to identify the source, then housekeeping should be notified because it might be in the mattress or somewhere that needs to be cleaned.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Comprehensive Care Plan
(Tag F0656)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record reviews and interviews, the facility failed to ensure resident centered care plans were developed a...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record reviews and interviews, the facility failed to ensure resident centered care plans were developed and/or implemented for three Residents (#20, #14, #88) out of a total sample of 23 residents. Specifically,
1. For Resident #20, the facility failed to develop a comprehensive pacemaker care plan.
2. For Resident #14, who was assessed to be at moderate risk for falls the facility failed to implement non-skid strips by his/her bed as per the plan of care.
3. For Resident #88, the facility failed to develop a personalized care plan with resident-specific interventions for suicidal indication history.
4. For Resident #88, the facility failed to develop and implement a personalized care plan for use of a hand orthotic as indicated by Occupational Therapy
Findings include:
1. Review of the facility policy titled, Care of a Resident with a Pacemaker, dated 3/18, indicated the following:
-1. For each resident with a pacemaker, document the following in the medical record and on a pacemaker identification care upon admission:
a. The name, address, and telephone number of the cardiologist.
b. Type of pacemaker.
c. Type of leads .
d. Manufacturer and model.
e. Serial Number.
f. Date of implant; and
g. Paced rate.
-2. When the resident's pacemaker is monitored by the Physician, document the date and results of the pacemaker surveillance, including:
a. How the resident's pacemaker was monitored (phone, office, internet);
1. Resident #20 was admitted to the facility in October 2024 with diagnoses that included dementia, presence of cardiac pacemaker, heart failure, asthma, and type 2 diabetes.
Review of Resident #20's most recent Minimum Data Set (MDS) assessment, dated 1/9/25, indicated he/she scored a 3 out of a possible 15 on the Brief Interview for Mental Status (BIMS) indicating severe cognitive impairments.
During an interview on 4/8/25 at 12:20 P.M., Resident #20 said he/she has a pacemaker.
Review of Resident #20's hospital Discharge summary, dated [DATE], indicated AV block status post pacemaker 3/2022. The discharge summary also indicated the pacemaker checks will be remote on 10/23/24, 1/22/25 and 4/29/25.
Review of Resident #20's cardiac care plan, dated 10/6/24, indicated The Resident's Pacemaker information: Manufacturer: (SPECIFY) Model: (SPECIFY) Serial #: (SPECIFY) Date Implanted:(SPECIFY) Name of Cardiologist: (SPECIFY) Side of Chest: (SPECIFY) Pacemaker checked every year: (SPECIFY) via (SPECIFY). Pacemaker check as ordered.
Review of Resident #20's physician note, dated 3/5/25, indicated AV block status post pacemaker.
Review of Resident #20's physician orders failed to indicate orders relating to his/her pacemaker.
During an interview on 4/8/25 at 12:21 P.M., Nurse #4 said Resident #20 does have a pacemaker but she is not sure how it is monitored or any other details of the pacemaker.
During an interview on 4/8/25 at 2:14 P.M. the Director of Nursing said Resident #20 does have a pacemaker and should have a comprehensive care plan in place with details of the pacemaker.
2. Resident #14 was admitted to the facility in December 2022 with diagnoses that included Alzheimer's disease, dementia, chronic obstructive pulmonary disease, schizophrenia and anxiety.
Review of Resident #14's most recent Minimum Data Set (MDS) assessment, dated 1/23/25, indicated he/she scored a 1 out of 15 on the Brief Interview for Mental Status (BIMS) indicating severe cognitive impairments. Further review of the MDS indicated he/she needed supervision/touching assistance for eating. Dependent on toileting hygiene and toileting.
Review of Resident #14's fall care plan, dated 5/9/24, indicated Non-skid strips by the bed.
On 4/6/25 at 8:20 A.M., the surveyor observed Resident #14 in bed, non-skid strips were not in place next to his/her bed.
On 4/7/25 at 7:03 A.M., 8:18 A.M., 11:01 A.M., the surveyor observed Resident #14 in bed, non-skid strips were not in place next to his/her bed.
Review of Resident #14's fall risk evaluation, dated 5/6/24, indicated he/she scored a 12 indicating moderate risk.
During an interview on 4/8/25 at 12:21 P.M., Nurse #4 said Resident #14 is a fall risk and tries to get out of bed at times. Nurse #4 said Resident #20's floor does not have non-skin strips.
During an interview on 4/8/25 at 2:14 P.M. the Director of Nursing said Resident #14 is at risk for falls and his/her fall intervention of non-skid strips should be in place.
3. Resident #88 was admitted to the facility May 2024 with diagnoses including atrial fibrillation, coronary atherosclerosis and post-traumatic stress disorder.
Review of Resident #88's most recent Minimum Data Set Assessment (MDS) dated [DATE] indicated that the Resident has a Brief Interview for Mental Status score of 15 out of 15 indicating intact cognition.
Review of the facility policy titled Suicide Threats, revised and dated November 2017, indicated the following:
- If the resident remains in the facility, staff will monitor the resident's mood and behavior and update care plans accordingly.
Review of Resident #88's Behavioral Health evaluation completed by the Nurse Practitioner, dated 6/6/24, indicated the following:
- Psychiatric History: SI (Suicidal Ideation) Details: I think I tried years ago when I was depressed.
- Clinical Assessment: HX (history) Suicidality.
Review of Resident #88's Behavioral Health evaluation completed by the Nurse Practitioner, dated 8/8/24, indicated the following:
- HPI (History of Present Illness): Expresses passive SI
- Psychiatric History: SI (Suicidal Ideation) Details: I think I tried years ago when I was depressed.
- Clinical Assessment: Passive SI reported to DON (Director of Nursing). HX Suicidality.
Review of Resident #88's current active care plans failed to indicate that a care plan was developed indicating a history of Suicidal Ideations with individualized interventions or plans.
During an interview on 4/7/25 at 1:55 P.M., the Social Worker said when residents are admitted to the facility we do an in-depth evaluation. The social worker continued to say a part of that evaluation is asking if the Resident has had any history or current suicidal ideations and if they have, an individualized care plan should be developed and implemented. The social worker said she was not aware of Resident #88's history of suicidal ideations.
During an interview on 4/8/25 at 2:13 P.M., the Director of Nursing (DON) said the facility should have developed a personalized care plan for Resident #88's history of suicidal ideation.
4. Resident #88 was admitted to the facility in May 2024 with diagnoses including atrial fibrillation, coronary atherosclerosis and post-traumatic stress disorder.
Review of Resident #88's most recent Minimum Data Set Assessment (MDS) dated [DATE] indicated that the Resident has a Brief Interview for Mental Status score of 15 out of 15 indicating intact cognition. Further review of the MDS indicated that the Resident has upper extremity impairment on one side.
Review of Resident #88's admission MDS dated [DATE] indicated that the Resident had upper extremity impairment on one side upon admission to the facility.
During an observation on 4/6/25 at 8:26 A.M., Resident #88 was laying in his/her bed. The surveyor observed his/her right hand in a closed position. When asked if the Resident can flex open his/her right fingers, he/she was unable to open his/her right fingers. Resident #88 said his/her hands have always been like this, the Resident continued to say he/she does not remember seeing therapy recently and does not wear any device for his/her right hand.
Review of Resident #88's current, discontinued, and completed physician's orders since he/she was admitted to the facility, failed to indicate an order for the use of a resting handing splint or for staff to ensure self range of motion exercises were implemented.
Review of Resident #88's Occupational Therapy Evaluation and Plan of Treatment dated 5/23/24, indicated the following:
- Fine Motor Coordination = Impaired (R hand impaired due to contracture of digits.)
Review of Resident #88's Occupational Therapy Discharge summary dated from 5/23/24 through 6/3/24, indicated the following:
- Diagnosis: contracture, right hand, stiffness of right hand
- Discharge Recommendations: Complete self-ROM (range of motion) on R hand daily. Use of R handed splint at night.
The surveyor requested a policy on Occupational Therapy services for the facility, the facility said they do not have an Occupational Therapy policy.
Review of Resident #88's Kardex (a form indicating the level of care a resident needs) indicated the following under the Resident Care section: Provide active assistance ROM (range of motion)/strengthening/fine motor movement exercises as needed.
Review of Resident #88's Activities of Daily Living care plan, dated 5/22/24, indicated the following interventions:
- Provide active assistance ROM/strengthening/fine motor movement exercises as needed
- Refer resident to OT/PT (occupational therapy/physical therapy) as needed
Review of a physician's progress note dated 5/29/24 at 9:30 A.M., indicated the following:
- Neuro patient does have contracture right hand, unable to extend all digits of the right hand.
During an interview on 4/7/25 at 1:10 P.M., the interim Director of Rehab (DOR) said she is in the facility every day and she looks for range of motion changes if she is able. The DOR said the facility's OT is contracted out and is not here every day. The DOR then said the facility's sister buildings are more of a priory for therapy services due to insurance. The DOR then said for residents with range of motion impairments, they would ideally be seen by OT and Resident #88 was only seen last year due to a fall. The DOR said the Resident was admitted to the facility before she started working in the building and he/she should have been seen by OT to assess for range of motion impairments and progress. The DOR said she has only evaluated Resident #88 herself after he/she sustained a fall in the facility last year, not for his/her hand contracture.
During an interview on 4/8/25 at 9:24 A.M., Nurse #8 said Resident #88's right hand has always been contracted and she has never seen him using a splint and she does not remember if he/she has ever been seen by therapy services.
During an interview on 4/8/25 at 10:12 A.M., the Occupational Therapist (OT) said she has not personally evaluated Resident #88. The OT said Resident #88 has a right-hand contracture and he/she has a resting hand splint (a hand splint where the hand will lay flat to prevent the fingers from clenching), but he/she needs a better splint for his/her right hand. The OT said she did not complete the post-fall evaluation from last year on Resident 88, but clinically, if the Resident was able to use a resting hand splint, he/she would be able to fully stretch out his/her hand and now he/she cannot which indicates that it is a worsening contracture. The OT said she will be ordering Resident #88 a hand splint with a roll in it since his/her fingers are clenched.
During a follow up interview on 4/8/25 at 10:46 A.M., the OT said she observed Resident #88's hand and she is ordering him/her a new splint with a roll in the fist as it is more appropriate for Resident #88's hand contracture. The OT then said Resident #88 was unable to fully extend his/her right hand upon her evaluation.
During a follow-up interview on 4/8/25 at 11:15 A.M., Resident #88 said he/she has a hand splint in his/her bedside table drawer. Resident #88 proceeded to dig to the bottom of the drawer to pull out a hand splint in a bag which had many belongings on top of it. He/she said it is too uncomfortable, and he/she does not wear it. Resident #88 said he/she does not remember staff members ever coming in to stretch out his/her hand.
During an interview on 4/8/25 at 11:25 A.M., Certified Nursing Assistant #8 said she has worked in the facility for over 20 years. CNA #8 said she did not know the Resident has a hand contracture and has never stretched out his/her hands for range of motion. CNA #8 continued to say she has never seen a hand splint for Resident #88.
During an interview on 4/8/25 at 2:13 P.M., the Director of Nursing (DON) said Resident #88's interventions from his/her OT Discharge summary should have been followed, he/she should have had his hand stretched out daily and he/she should have been using a hand splint. The DON said there should have been physician's orders in place for these so they can be implemented. The DON said she is not sure how staff can monitor these interventions if there are no physician's orders in for them.
During an interview on 4/9/25 at 10:11 A.M., the Medical Director said the resting hand splint was too uncomfortable for Resident #88. The MD said he would expect staff to encourage him/her to wear it and stretch out his/her hand as able. The MD then said he thinks Resident #88 would have benefited from more therapy services.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0658
(Tag F0658)
Could have caused harm · This affected multiple residents
Based on observation, record review and interview, the facility failed to ensure physician orders were implemented for two Residents (#70 and #4) out of a total sample of 23 residents. Specifically,
...
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Based on observation, record review and interview, the facility failed to ensure physician orders were implemented for two Residents (#70 and #4) out of a total sample of 23 residents. Specifically,
1. For Residents #70, who is at risk for developing pressure ulcers, the facility failed to ensure his/her air mattress was set according to the physician's order.
2. For Resident #4, the facility failed to follow a physician's order to obtain a Urine Analysis in a timely manner.
Findings include:
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.
1. Resident #70 was admitted to the facility in September 2023 with diagnoses that included legal blindness, type 2 diabetes, major depressive disorder, and peripheral vascular disease.
Review of Resident #70's most recent Minimum Data Set (MDS) assessment, dated 3/13/25, indicated he/she scored a 15 out of 15 on the Brief Interview for Mental Status (BIMS) indicating intact cognition. Further review of the MDS indicated that the Resident is at risk for developing pressure ulcers.
On 4/6/25 at 8:05 A.M. and 12:34 P.M., the surveyor observed Resident #70 in bed on an air mattress. The air mattress was set to 300 lbs (pounds).
On 4/7/25 at 7:05 A.M., 8:20 A.M., and 11:01 A.M., the surveyor observed Resident #70 in bed on an air mattress. The air mattress was set to 300 lbs.
On 4/8/25 at 7:41 A.M. and 10:24 A.M., the surveyor observed Resident #70 in bed on an air mattress. The air mattress was set to 300 lbs.
Review of Resident #70's physician order, dated 2/20/24, indicated Low air loss mattress setting 150.
Review of Resident #70's last weight taken was on 3/2/25 and was 136.5 lbs.
Review of Resident #70's Norton Scale (scale for predicting risk of pressure ulcers), dated 3/7/25, indicated he/she scored a 6 indicating high risk for developing pressure ulcers.
On 4/8/25 at 11:45 A.M., the surveyor with Nurse #4 observed Resident #70 in bed on an air mattress. The air mattress was set to 300 lbs. Nurse #4 said the air mattress should be set to 150 per the doctor's order. Nurse #4 said the Resident is on an air mattress because he/she is at risk for skin breakdown.
During an interview on 4/8/25 at 2:14 P.M., the Director of Nursing said Resident #70 is at risk for developing pressure ulcers and his/her air mattress should be set per the physician's order.2. Resident #4 was admitted to the facility in June 2014 with diagnoses including hemiplegia and hemiparesis, dysphagia and epilepsy.
Review of Resident #4's most recent Minimum Data Set Assessment (MDS) indicated that the Resident had a Brief Interview for Mental Status score of 2 out of 15 indicating severe cognitive impairment.
Review of Resident #4's physician's orders indicated the following order dated 4/1/25:
- Obtain UA (urine analysis) C&S (culture and sensitivity) r/o (rule out) jaundice, every shift may d/c (discontinue) when obtained.
During an interview on 4/8/25 at 8:46 A.M., Nurse #7 said the Nurse Practitioner came in to see Resident 4 and she said that he/she looked yellow, so she wanted to obtain a urine sample to rule out Jaundice. Nurse #7 then said Resident #4 every time staff take Resident #4 to the bathroom they should attempt to collect a urine sample. Nurse #7 said this should have been followed up on sooner, 100%.
During an interview on 4/8/25 at 10:27 A.M., Nurse Practitioner (NP) #2 review Resident #4's physician's orders with the surveyor, NP #2 said she was not sure why the order was put in to rule out jaundice as she never mentioned that. NP #2 said when she evaluated Resident #4, he/she pointed to his/her abdomen indicating discomfort, so she wanted to collect a urine sample to get more information. Nurse Practitioner #2 said a urine analysis should be obtained within 24 hours.
Review of the Laboratory binder on the first floor B-side nursing station indicated a laboratory requisition form for Resident #4's urine to be obtained. The Form indicated that urine was collected on 4/6/25 but it was not picked up by laboratory for analysis.
During an interview on 4/8/25 at 2:13 P.M., the Director of Nursing (DON) said when an order for a urine analysis is put in, the urine should be obtained within 24 hours. The DON reviewed the lab requisition form and she said this is the form that is supposed to go with the urine sample when sent out to the lab and she was not sure why the sample was not sent out.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
ADL Care
(Tag F0677)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2c. Resident #34 was admitted to the facility in February 2024 with diagnoses including hemiplegia.
Review of Resident #34's mos...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2c. Resident #34 was admitted to the facility in February 2024 with diagnoses including hemiplegia.
Review of Resident #34's most recent Minimum Data Set (MDS) dated [DATE], indicated the Resident scored 13 out of a possible 15 on the Brief Interview for Mental Status (MDS) which indicated he/she is cognitively intact. The MDS also indicated Resident #34 required partial to moderate assistance for self-feeding tasks.
On 4/6/25 at 8:14 A.M., Resident #34 was observed lying in bed while eating breakfast. There were no staff in the room to provide assistance if needed and the Resident was not visible from the hallway.
On 4/6/25 at 12:45 P.M., Resident #34 was observed eating lunch at a table at the end of the second-floor unit hallway. There were no staff at that end of the hallway and the Resident was not visible from the nursing station. From 12:45 P.M., to 12:59 P.M., the Resident was observed staring at his/her lunch and not eating.
On 4/7/25 at 8:17 A.M., Resident #34 was observed lying in bed while eating breakfast. There were no staff in the room to provide assistance if needed and the Resident was not visible from the hallway.
On 4/8/25 at 8:26 A.M., Resident #34 was observed lying in bed while eating breakfast. There were no staff in the room to provide assistance if needed and the Resident was not visible from the hallway.
Review of Resident #34's Activity of Daily Living care plan, last revised 3/6/35, indicated the following:
-Eating: assist to dependent.
-Self performance may vary depending on cognition, behavioral symptoms and activity tolerance.
-Explain all procedures and purpose prior to performing task and encourage self-performance.
Review of Resident #34's Kardex (a form indicating the level of care needed for self-care tasks) indicated the following:
-Eating: assist to dependent.
Review of the nursing summary dated 3/21/25, indicated Resident #34 was dependent on staff for self-feeding tasks.
During interviews on 4/8/25 at 9:21 A.M., and 11:20 A.M., Certified Nursing Assistant (CNA)#1 said each resident has their own Kardex that explains what each resident need and staff are to follow. CNA #1 said Resident #34 requires assistance with meals at times and when not needing assistance, the Resident definitely needs cueing from staff to continue with the task.
During an interview on 4/8/25 at 2:12 P.M., the Director of Nursing said she expects care plans to be followed as written to ensure the appropriate level of care is provided to the residents. The Director of Nursing said the nursing assistants are aware of checking the Kardex to ensure they are providing the level of assistance needed. The Director of Nursing said Resident #34 does not always require physical assistance with meals and sometimes just requires supervision. The Director of Nursing said any resident who requires supervision or assistance with meals should either be in the dining room for meals or have a staff member in the room with them while they eat.
2d. Resident #48 was admitted to the facility in September 2024 with diagnoses including Alzheimer's Disease and failure to thrive.
Review of Resident #48's most recent Minimum Data Set, dated [DATE], indicated the Resident scored 3 out of a possible 15 on the Brief Interview for Mental Status (BIMS) which indicated severe cognitive impairment. The MDS also indicated Resident #48 required partial to moderate assistance from staff for self-feeding tasks.
On 4/6/25 at 8:42 A.M., Resident #48 was observed alone in his/her room, lying in bed with his/her breakfast on the bedside table in from of him/her. The Resident was not visible from the hallway to staff walking by. The Resident was not eating his/her food.
On 4/8/25 at 9:04 A.M., Resident #48 was observed sitting in his/her wheelchair next to the bed with his/her breakfast tray in front of him/her. The Resident was not eating his/her breakfast and was not visible to be supervised from the hallway.
Review of Resident #48's Activities of Daily Living care plan, last revised 9/9/24, indicated the following interventions:
-Eating: supv/assist (supervision/assistance)
-Self-performance varies due to behaviors, cognition.
Review of Resident #48's Kardex (a form indicating the level of care needed for self-care tasks) indicated the following:
-Eating: supv/assist (supervision/assistance)
-Self-performance varies due to behaviors, cognition.
Review of the nursing summary dated 3/19/25, indicated Resident #48 required continual supervision from staff for self-feeding tasks due to inability to sequence/follow simple directions, is easily distracted, has generalized weakness, is unable to initiate or follow-through with tasks and has decreased strength and endurance.
During interviews on 4/8/25 at 9:21 A.M., and 11:20 A.M., Certified Nursing Assistant (CNA)#1 said each resident has their own Kardex that explains what each resident need and staff are to follow. CNA #1 said Resident #48 requires someone to be with him/her at all meals because the Resident does not like to eat. CNA #1 said Resident #48 has been declining and staff have to either feed him/her or provide numerous cues throughout the meal.
During an interview on 4/8/25 at 2:12 P.M., the Director of Nursing said she expects care plans to be followed as written to ensure the appropriate level of care is provided to the residents. The Director of Nursing said the nursing assistants are aware of checking the Kardex to ensure they are providing the level of assistance needed. The Director of Nursing said Resident #48 does not always require physical assistance with meals and sometimes just requires supervision and cueing to continue to eat. The Director of Nursing said any resident who requires supervision or assistance with meals should either be in the dining room for meals or have a staff member in the room with them while they eat. Based on observations, record review and interviews, the facility failed to provide assistance with Activities of Daily Living (ADLs) for seven Residents (#14, #57, #52, #57, #70, #34, #48 and #4) out of a total sample of 23 residents. Specifically,
1. For Residents #14, #57 and #52, the facility failed to provide incontinent care; and
2. For Residents #57, #70, #34, #48 and #4, the facility failed to provide assistance with meals.
Findings include:
Review of the facility policy titled, Activities of Daily Living (ADLs), dated 11/24, indicated the following:
-Residents who are unable to carry out activities of daily living independently will receive the services necessary for activities of daily living. Appropriate care and services will be provided for residents who are unable to carry out ADLs independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with:
c. Elimination (toileting);
d. Dining (meals and snacks).
1a. Resident #14 was admitted to the facility in December 2022 with diagnoses that included Alzheimer's disease, dementia, chronic obstructive pulmonary disease, schizophrenia and anxiety.
Review of Resident #14's most recent Minimum Data Set (MDS), dated [DATE], indicated he/she scored a 1 out of 15 on the Brief Interview for Mental Status (BIMS) indicating severe cognitive impairments. Further review of the MDS indicated he/she needed supervision/touching assistance for eating. The MDS also indicated Resident #14 is dependent on staff for toileting tasks and is always incontinent of urine and frequently incontinent of bowel.
On 4/7/25 at 8:25 A.M., Resident #14 was observed in bed being assisted with his/her breakfast. From 8:25 A.M. to 1:00 P.M., Resident #14 was observed in his/her room and was not observed to have staff offer to toilet him/her or have incontinent care provided.
On 4/8/25 from 7:27 A.M. to 11:35 A.M., Resident #14 was observed in the dining room and was not observed to have staff offer to toilet him/her or have incontinent care provided.
Review of Resident #14's incontinence care plan, dated 11/1/24, indicated incontinent: check every 2-3 hours and as required for incontinence. Wash, rinse and dry perineum. Apply clean clothes and change clothing PRN after incontinence episodes.
Review of Resident #14's potential skin care plan, dated 11/1/24, indicated Protect skin with incontinent care. Wash, rinse and dry perineum. Change clothing PRN (as needed) after incontinence episodes.
Review of Resident #14's nursing summary, dated 3/21/25, indicated
- Bathing: dependent.
- Continence: 3. Incontinent of both bowel and bladder.
During an interview on 4/8/25 at 11:29 A.M., Certified Nursing Assistant (CNA) #5 said all residents who are incontinent are expected to have incontinent care provided every two hours.
During an interview on 4/8/25 at 11:29 A.M., Nurse #3 said she expects any residents who are incontinent be checked and/or changed every two hours.
During an interview on 4/8/25 at 11:27 A.M., CNA #5 said Resident #14 is on her assignment to provide care to and that the 11:00 P.M to 7:00 A.M. staff gave Resident #14 his/her morning care. CNA #5 said Resident #14 has been up in the dining room since she started her shift and 7:00 A.M. and has not provided him/her with any incontinence care yet.
On 4/8/25 at 11:39 A.M., the surveyor with CNA #3 observed Resident #14's incontinence brief it was heavily soaked with urine.
During an interview on 4/8/25 at 2:12 A.M., the Director of Nursing said incontinence care should include checking and/or changing residents who are incontinent every two hours.
1b. Resident #57 was admitted to the facility in July 2023 with diagnoses that included Post Traumatic Stress Disorder, dementia, frontotemporal neurocognitive disorder, and depression.
Review of Resident #57's most recent Minimum Data Set (MDS), dated [DATE], indicated he/she scored a 00 out of 15 on the Brief Interview for Mental Status (BIMS) indicating severe cognitive impairments. Further review of the MDS indicated he/she was dependent for toileting tasks and is frequently incontinent of both bowel and bladder.
On 4/7/25 at 8:30 A.M., Resident #14 was observed in the dining room eating breakfast. From 8:30 A.M. to 1:34 P.M., Resident #14 was observed in the dining room and was not observed to have staff offer to toilet him/her or have incontinent care provided.
On 4/8/25 from 7:27 A.M. to 11:33 A.M., Resident #14 was observed in the dining room and was not observed to have staff offer to toilet him/her or have incontinent care provided.
Review of Resident #57's activity of daily living care plan, dated 11/26/24, indicated Toilet use: assist
Review of Resident #57's incontinence care plan, dated 11/13/24, indicated Incontinent: Check every 2-3 hours and as required for incontinence.
Review of Resident #57's potential skin care plan, dated 4/1/25, indicated Protect skin with incontinent care. Wash, rinse and dry perineum. Change clothing PRN (as needed) after incontinence episodes.
During an interview on 4/8/25 at 11:29 A.M., Certified Nursing Assistant (CNA) #5 said all residents who are incontinent are expected to have incontinent care provided every two hours.
During an interview on 4/8/25 at 11:29 A.M., Nurse #3 said she expects any residents who are incontinent be checked and/or changed every two hours.
During an interview on 4/8/25 at 11:33 A.M., CNA #2 said she gave Resident #14 care around 7:00 A.M. today and has not provided incontinent care again today. CNA #2 said Resident #14 is always incontinent and should be changed every two hours but was not.
On 4/8/25 at 11:43 A.M., the surveyor with CNA #2 observed Resident #14's incontinence brief it was heavily soaked with urine. CNA #2 said urine leaked out onto Resident #14's pants and they needed to be changed.
During an interview on 4/8/25 at 2:12 A.M., the Director of Nursing said incontinence care should include checking and/or changing residents who are incontinent every two hours.
1c. Resident #52 was admitted to the facility in October 2022 with diagnoses including dementia legal blindness, and failure to thrive.
Review of Resident #52's most recent Minimum Data Set (MDS) dated [DATE], indicated the Resident was unable to complete the Brief Interview for Mental Status (BIMS) and the staff assessed him/her to have moderate cognitive impairment. The MDS also indicated Resident #52 is dependent on staff for toileting tasks.
On 4/7/25 at 8:30 A.M., Resident #52 was observed in the dining room eating breakfast. From 8:30 A.M. to 12:54 P.M., Resident #52 was observed in the dining room and was not observed to have staff offer to toilet him/her or have incontinent care provided.
On 4/8/25 from 7:30 A.M. to 11:32 A.M., Resident #52 was observed in the dining room and was not observed to have staff offer to toilet him/her or have incontinence care provided.
Review of Resident #52's incontinence care plan, last revised 4/7/25, indicated the following interventions:
-Incontinent - check every 2-3 hours and as required for incontinence. Wash, rinse and dry perineum. Change clothing PRN (as needed) after incontinence episodes.
Review of Resident #52's Activity of Daily Living care plan, last revised 4/7/25, indicated the following interventions:
-Toilet use: dependent.
-Incontinent bowel and bladder.
Review of Resident #52's potential for skin impairment care plan, last revised 10/14/24, indicated the following interventions:
-Toileting assistance on toileting schedule or routine,
-Protect skin with incontinent care.
Review of the nursing summary dated 3/19/25, indicated Resident #52 is incontinent of both bowel and bladder.
Review of Resident #52's Kardex (a form indicating the level of assistance needed for daily care) indicated the following:
-Incontinent - check every 2-3 hours and as required for incontinence. Wash, rinse and dry perineum. Change clothing PRN (as needed) after incontinence episodes.
During an interview on 4/8/25 at 11:29 A.M., Certified Nursing Assistant (CNA) #5 said all residents who are incontinent are expected to have incontinent care provided every two hours.
During an interview on 4/8/25 at 11:29 A.M., Nurse #3 said she expects any residents who are incontinent be checked and/or changed every two hours.
During an interview on 4/8/25 at 11:32 A.M., CNA #3 said he provided Resident #52's morning care before breakfast. CNA #3 said all residents who are incontinent should be checked and/or changed every 2 hours, however, he had not checked or toileted Resident #52 since this morning, 4 hours ago.
During an interview on 4/8/25 at 2:12 A.M., the Director of Nursing said incontinence care should include checking and/or changing residents who are incontinent every two hours.
2a. Resident #57 was admitted to the facility in July 2023 with diagnoses that included Post Traumatic Stress Disorder, dementia, frontotemporal neurocognitive disorder, and depression.
Review of Resident #57's most recent Minimum Data Set (MDS), dated [DATE], indicated he/she scored a 00 out of 15 on the Brief Interview for Mental Status (BIMS) indicating severe cognitive impairments. Further review of the MDS indicated he/she requires partial/moderate assistance from nursing staff for eating.
On 4/6/25 from 12:36 P.M. to 12:38 P.M., the surveyor observed Resident #57 in the dining room not initiating self feeding. No staff were assisting the Resident.
On 4/7/25 from 12:40 P.M. to 12:49 P.M., the surveyor observed Resident #57 in the dining room not initiating self feeding, playing with his/her food. No staff were assisting the Resident.
On 4/8/25 from 8:39 A.M. to 8:45 A.M., the surveyor observed Resident #57 in the dining room not initiating self feeding. No staff were assisting the Resident.
During an interview on 4/6/25 at 12:40 P.M., Family member #1 said the facility is always short staffed especially on the weekends. She said her family member does not receive care and does not get fed his/her meal.
Review of Resident #57's activity of daily living care plan, dated 11/26/24, indicated Eating: supervision/cues to assist.
Review of Resident #57's nutrition assessment, dated 3/26/25, indicated Dining assistance: Total Dependence.
During an interview on 4/8/25 at 9:21 A.M., CNA #2 said Resident #57 needs assistance with his/her meals and staff are suppose to sit and assist them once the Resident receives his/her meal.
During an interview on 4/8/25 at 2:13 P.M., the Director of Nursing (DON) said staff should be following the Residents' care plan and receive the supervision or assistance as needed.
2b. Resident #70 was admitted to the facility in September 2023 with diagnoses that included legal blindness, type 2 diabetes, major depressive disorder, and peripheral vascular disease.
Review of Resident #70's most recent Minimum Data Set (MDS), dated [DATE], indicated he/she scored a 15 out of 15 on the Brief Interview for Mental Status (BIMS) indicating intact cognition. Further review of the MDS indicated the Resident needs supervision/touching assistance from staff for eating.
On 4/6/25 at 8:35 A.M., the surveyor observed Resident #70 in bed awake with his/her breakfast tray on his/her tray table next to their bed not set up. No staff were present in the room.
On 4/7/25 from 8:19 A.M. to 8:30 A.M., the surveyor observed Resident #70 in bed with his/her breakfast tray on his/her tray table next to their bed not set up the Resident was observed to struggle to open his/her butter packets. No staff were present in the room.
On 4/7/25 from 12:44 P.M. to 12:47 P.M., the surveyor observed Resident #70 in bed awake with his/her lunch tray on his/her tray table next to their bed not set up. No staff were present in the room.
On 4/8/25 from 8:40 A.M. to 8:48 A.M., the surveyor observed Resident #70 in bed awake with his/her breakfast tray on his/her tray table next to their bed not set up. No staff were present in the room.
On 4/8/25 from 12:55 P.M. to 12:59 P.M., the surveyor observed Resident #70 in bed awake with his/her lunch tray on his/her tray table next to their bed not set up. No staff were present in the room.
Review of Resident #70's activities of daily living, dated 5/21/24, indicated eating: set up, encourage and assist as needed.
Review of Resident #70's active Kardex (a form indicating the level of care needed) indicated eating: set up, encourage and assist as needed.
Review of Resident #70's nutrition therapy assessment, dated 3/10/25, indicated Dining Assistance: Independent, Supervision. Legal blindness.
Review of Resident #70's nursing assessment, dated 3/19/25, indicated the Resident was blind.
Eating: continual supervision (ratio 1:8) Dysfunction: 1. Unable to sequence task/follow simple directions.3. Easily fatigued. 10. Decreased ROM (Range of Motion). 11. Generalized weakness.
Review of Resident #60's ADL flow sheet for 4/6/25 he/she was coded as dependent on staff for eating. On 4/7/25 he/he was coded as supervised for eating. On 4/8/25 for breakfast and lunch coded as supervised.
During an interview on 4/8/25 at 12:05 P.M., CNA #4 said she takes care of Resident #70 regularly but does not supervise him/her or assist them with their meals. CNA #4 said that staff should be following the Resident's Kardex and care plan.
During an interview on 4/8/25 at 2:13 P.M., the Director of Nursing (DON) said staff should be following the Residents' care plan and receive the supervision or assistance as needed. The DON said the Resident likes their meal left but staff should be setting up his/her meal tray.
2e. Resident #4 was admitted to the facility in June 2014 with diagnoses including hemiplegia and hemiparesis, dysphagia and epilepsy.
Review of Resident #4's most recent Minimum Data Set Assessment (MDS) indicated that the Resident had a Brief Interview for Mental Status score of 2 out of 15 indicating severe cognitive impairment. Further review of the MDS indicated Resident #4 is dependent on staff for activities of daily living (ADL) and requires partial/moderate assistance with eating.
The surveyor made the following observations:
- On 4/6/25 at 12:05 P.M., Resident #4 was sitting in a dining room and just finished lunch, he/she had various food items all over his/her chest.
- On 4/7/25 at 8:07 A.M., Resident #4 was sitting in a dining room eating breakfast, he/she was observed drinking oatmeal out of a bowl and spilling it on his/her face and chest. Staff did not provide assistance or encourage the Resident to use utensils.
- On 4/7/25 at 12:18 P.M., Resident #4 was sitting in the dining room eating lunch. The Resident was eating food with his/her hands and was observed to wipe his/her hands on the tablecloth as there was significant food residue on his/her hands. Staff were present in the dining room and did not provide assistance.
- On 4/8/25 at 8:19 A.M., Resident #4 was sitting in a dining room eating breakfast and feeding him/herself. There was food residue on his/her chest and lap as well as on the ground below where he/she was sitting. Staff were present in the dining room but did not provide assistance. At 8:44 A.M., while Nurse #7's back was to Resident #4, the Resident attempted to drink from a cup but dropped it and it spilled all over the ground. Resident #4 then proceeded to drink oatmeal from a bowl and spill some on his/her face.
Review of Resident #4's Kardex (a form indicating the level of care a resident needs) failed to indicate what level of feeding assistance he/she needs.
Review of Resident #4's ADL care plan dated and revised 4/26/24 indicated the following intervention: Eating - assist.
During an interview on 4/8/25 at 8:46 A.M., Nurse #7 said Resident #4 only needs supervision with meals and he/she does okay with eating.
During an interview on 4/8/25 at 2:13 P.M., the Director of Nursing (DON) said staff should be following the Residents' Kardex form to the know what level of feeding assistance they need. The DON said Resident #4 should be getting assistance with meals as needed.
Refer to F725.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0725
(Tag F0725)
Could have caused harm · This affected multiple residents
Based on record review and interview, the facility failed to have sufficient nursing staff to provide nursing and related services to assure resident safety and attain or maintain the highest practica...
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Based on record review and interview, the facility failed to have sufficient nursing staff to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. Specifically, the facility failed to meet the facility-determined minimum for certified nurse assistant (CNA) staff on the weekends.
Findings Include:
Review of the facility assessment, reviewed 3/5/25, indicated:
Direct Care Staffing Ratios:
Unit A: Days 3 CNAs, Evenings 3 CNAs, Nights 2 CNAs.
Unit B: Days 3 CNAs, Evenings 3 CNAs, Nights 2 CNAs.
2nd Floor: Days 4 CNAs, Evenings 4 CNAs, Nights 3 CNAs.
Review of this facility assessment indicated total CNA staffing required for facility from 3/5/25 to 4/9/25 should be: Days 10 CNAs, Evenings 10 CNAs, Nights 7 CNAs.
Review of electronic correspondence given to surveyor from the Director of Operations to the Regional Nurse, dated 4/9/25, indicated:
- The facility assessment was updated in December 2024 and reviewed in QAPI 12/18/24. The staffing requirements by unit prior to the updated assessments were:
A-Unit: Days 2 CNAs, Evenings 2 CNAs, Nights 2 CNAs.
B-Unit: Days 3 CNAs, Evenings 3 CNAs, Nights 2 CNAs.
2nd Floor: Days 4 CNAs, Evenings 4 CNAs, Nights 3 CNAs.
Total: Days 9 CNAs, Evenings 9 CNAs, Nights 7 CNAs
- This electronic correspondence indicates CNA staffing required for 10/1/24 to 3/4/25.
During the recertification survey the surveyors observed concerns with incontinence care not being provided and with odors of urine and/or body odor throughout the second floor and in one room on the first floor.
During the initial tour of the facility on 4/6/25 beginning at 7:20 A.M., there were multiple concerns reported to the surveyors by residents. Seven residents and one family member expressed concerns about wishing there were more staff in the building. They said they often have to wait for a long time when they use their call lights. Some of these interviews included:
- One resident who said, I learned to change my own incontinence brief because it takes too long for the call bells to be answered, and I don't want to wait.
- One resident further said there is often not enough staff, especially on the weekends. The call bell takes a long time to answer, usually between a half hour to an hour.
- The family member said the facility is always short staffed especially on the weekends. She said her family member does not receive care and does not get fed his/her meal.
During the Resident Group interview on 4/8/25 at 11:05 A.M., 10 out of 16 residents expressed concerns with low weekend staffing causing long call bell wait times and medications being administered late.
During offsite preparation, the CASPER Payroll-Based Journal (PBJ) Staffing Data Report submitted by the facility for fiscal year (FY) Quarter 1, 2025 (October 1, 2024 - December 31, 2024) was reviewed. The facility's report triggered that the facility reported excessively low weekend staffing.
Review of the weekend staff schedule, dated October 1, 2024, to December 31, 2024, indicated that the facility was staffed below their determined minimum necessary CNAs for 10 weekend shifts. On these days there were no additional nurses scheduled who could assist with CNA duties. The weekend staff schedules indicated the following staffing during this quarter:
- Saturday October 12, 2024: only 6 CNAs on night shift but should have been 7.
- Sunday October 13, 2024: only 5 CNAs on night shift but should have been 7.
- Saturday October 26, 2024: only 8 CNAs on evening shift but should have been 9.
- Saturday November 2, 2024: only 6 CNAs on night shift but should have been 7.
- Sunday November 3, 2024: only 5 CNAs on night shift but should have been 7.
- Saturday November 9, 2024: only 6 CNAs on night shift but should have been 7.
- Sunday November 10, 2024: only 6 CNAs on night shift but should have been 7.
- Sunday November 17, 2024: only 6 CNAs on night shift but should have been 7.
- Sunday November 24, 2024: only 6 CNAs on night shift but should have been 7.
- Sunday December 19, 2024: only 6 CNAs on night shift but should have been 7.
Further review of the weekend staff schedules, dated January 1, 2025, to April 6, 2025, continued to indicate the facility was staffed below their determined minimum necessary CNAs on 9 weekend shifts. On these days there were no additional nurses scheduled who could assist with CNA duties. The weekend staff schedules indicated the following staffing:
- Saturday January 4, 2025: only 6 CNAs on night shift but should have been 7.
- Sunday January 5, 2025: only 8 CNAs on evening shift but should have been 9.
- Saturday February 1, 2025: only 6 CNAs on night shift but should have been 7.
- Sunday February 16, 2025: only 6 CNAs on night shift but should have been 7.
- Sunday February 23, 2025: only 6 CNAs on night shift but should have been 7.
- Saturday March 8. 2025: only 8 CNAs on evening shift but should have been 10.
- Saturday March 29, 2025: only 6 CNAs on night shift but should have been 7.
- Sunday March 30, 2025: only 8 CNAs on day shift but should have been 10.
- Sunday March 30, 2025: only 9 CNAs on evening shift but should have been 10.
During an interview on 4/07/25 at 9:39 A.M., Nurse #6 said sometimes there is trouble with scheduling/rescheduling appointments because of inconsistent staffing.
During an interview on 4/8/25 at 9:45 A.M., Nurse #5 said she sometimes hears CNAs say they have trouble getting all the care completed because of staffing.
During an interview on 4/9/25 at 8:40 A.M., CNA #6 said she works day shift consistently. CNA #6 said when there are ten CNAs on day shift, they can get everything done, but when there is less the CNAs must rush to get the care done.
During an interview on 4/9/25 at 9:48 A.M, the Scheduler said CNA staffing is currently 9 CNAs on the day shift, 9 CNAs on the evening shift, and 7 CNAs on the night shift (instead of what the facility assessment, dated 3/5/25 indicated). The scheduler said sometimes it's not met because of call outs or because he just can't get the staff. The Scheduler said if the facility is short staffed, CNAs say they feel overworked and that they must rush through care.
During an interview on 4/9/25 at 9:57 A.M., the Administrator said he would expect staff levels to be met as determined what was required based on the census. The Administrator said he has been at the facility since January 2024 and had never been notified of not meeting the required staffing levels but would have expected to be. The Administrator said he would expect the facility to follow staffing ratios determined to be necessary to provide care in either the facility assessment or determined ratios.
During an interview on 4/9/25 at 12:35 P.M., the Regional Nurse said the facility assessment was reviewed in December 2024 in regard to staffing level required based on the census. The Regional Nurse gave the surveyor the above mentioned electronic correspondence that indicated from October 1, 2024, to March 4, 2025, the CNA staffing for the facility should have been 9 CNAs on day shift, 9 CNAs on evening shift, and 7 CNAs on night shift. The Regional Nurse said the facility assessment was updated 3/5/24 and the staffing was updated to require more based on the increased facility census and should have been 10 CNAs on day shift, 10 CNAs on evening shift, and 7 CNAs on night shift starting 3/5/25 to present.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0726
(Tag F0726)
Could have caused harm · This affected multiple residents
Based on interviews, record review, staff education review, and Facility Assessment review, the facility failed to ensure the nursing staff were trained and demonstrated the competencies and skill set...
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Based on interviews, record review, staff education review, and Facility Assessment review, the facility failed to ensure the nursing staff were trained and demonstrated the competencies and skill sets necessary to provide the level and types of care and services needed as outlined in the Facility Assessment. Specifically, the facility failed to ensure licensed nursing staff were trained and demonstrated competency related to wound care.
Findings include:
According to the Board of Registration in Nursing, 244 CMR 9.00: Standards of Conduct, a competency is defined as the application of knowledge and the use of affective, cognitive, and psychomotor skills required for the role of a nurse licensed by the Board and for the delivery of safe nursing care in accordance with accepted standards of practice.
Competency is a measurable pattern of knowledge, skills, abilities, behaviors, and other characteristics that an individual needs to perform work roles or occupational functions successfully.
Review of the comprehensive Facility Assessment Tool, revised 3/5/25, included but was not limited to the following:
- Services Provided Based on Resident Assessment and Care Plans: Skin integrity: Pressure injury prevention and care, skin care, wound care (surgical, other skin wounds).
- Staff training/Education and Competencies: The facility uses [an electronic training system] for various training modules, which are assigned and completed throughout the year. Each module includes exam questions at the end to assess the staff's understanding. Additionally, an annual competency fair is conducted, allowing staff to practice and demonstrate required competencies.
- Yearly Education for All Staff: Skin/Wound Care.
Review of the facility's training plan titled 'Annual Licensed Nurse Skills Competencies and Checklists', undated, indicated, but was not limited to:
- Training Plan Description: Developing clinical competency is important for each nurse in order to deliver quality care. This Annual Licensed Nurse training plan is completed with the ADON (Assistant Director of Nursing), Staff Development Coordinator (SDC) or Designee to facilitate the mastery of nursing skills.
- The checklists follow each step of the skill to provide a complete evaluative tool. They are designed to record an evaluation of each step of the procedure as met or not met.
- Training Plan Module List: Clean a Wound and Apply a Dry Non-Sterile Dressing Skills Checklist, Wound Documentation Skills Checklist.
Throughout the recertification survey (4/6/25 through 4/9/25) the surveyors identified multiple concerns regarding wound care.
The surveyor reviewed staff education files for wound competencies for five licensed nurses currently working in the facility:
- 3 out of 5 nurses failed to have evidence of wound care competencies completed in the last year or upon hire.
During an interview on 4/9/25 at 11:09 A.M., the Regional Nurse said all nurses are required to complete annual competencies for wound care. The Regional Nurse said she reached out to the regional office, who was also unable to locate the missing annual/on hire wound competencies for the above mentioned three nurses.
During an interview on 4/11/25 at 11:23 A.M., The Director of Nursing (DON) said annual competencies and training should be monitored to ensure they are completed, but that there has been a lot of turnover in the staff development role. The DON said the staff development role was vacant about a year ago and was briefly filled in May, June, July and again briefly later in the year. The DON said the role has been being covered by herself and various other staff. The DON was unable to provide the name of a person primarily responsible for monitoring that competencies were completed during the times there was not a staff development nurse.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0730
(Tag F0730)
Could have caused harm · This affected multiple residents
Based on personnel file review and interview, the facility failed to ensure annual performance reviews were completed at least every 12 months for 5 of 5 Certified Nurse Aides (CNAs) personnel files r...
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Based on personnel file review and interview, the facility failed to ensure annual performance reviews were completed at least every 12 months for 5 of 5 Certified Nurse Aides (CNAs) personnel files reviewed.
Findings include:
Review of 5 Certified Nurse Aides (CNAs) personnel files, who had been employed by the facility for over 12 months, indicated:
- 5 out of 5 failed to include documentation of an annual performance review.
During an interview on 4/9/25 at 11:34 A.M., the Director of Nursing (DON) said all CNAs are required to have annual performance reviews completed and the documentation of completion should be readily available. The DON said she was unable to locate any of the 5 CNA annual performance reviewed requested by the surveyor.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0761
(Tag F0761)
Could have caused harm · This affected multiple residents
Based on observations, interviews and policy review, the facility failed to ensure staff stored drugs and biologicals in accordance with State and Federal requirements. Specifically, the facility fail...
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Based on observations, interviews and policy review, the facility failed to ensure staff stored drugs and biologicals in accordance with State and Federal requirements. Specifically, the facility failed to ensure a medication cart, treatment carts on the first and second floor and the second floor's medication room were locked while a nurse was not present.
Findings include:
Review of the facility policy titled, Storage of Medications, dated 8/20, indicated the following:
-Medications and biologicals are stored safely, securely, and properly, following manufacturer's recommendations or those of the supplier. The medication supply is accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications. Medication rooms, carts, and medication supplies are locked when they are not attended by persons with authorized access.
On 4/6/25 at 6:47 A.M., the surveyor observed the medication cart on the first floor unlocked and unsupervised. No staff were present at the cart, the surveyor was able to access the cart and medications.
On 4/6/25 at 7:18 A.M., the surveyor observed the medication room on the second floor unlocked and unsupervised. The surveyor was able to access the medication refrigerator that had multiple medications in it.
On 4/6/25 from 7:18 A.M. to 12:54 P.M., the surveyor observed the treatment cart on the second floor unlocked and unsupervised outside of resident rooms. No staff were present at the cart, the surveyor was able to access the cart. The nurse was not present at the nurses station.
On 4/6/25 at 11:45 A.M. the surveyor observed a first floor treatment cart unlocked and unsupervised next to the visitors bathroom and staff bathroom. No staff were present at the cart, the surveyor was able to access the cart.
On 4/7/25 at 7:01 A.M., the surveyor observed the medication room on the second floor unlocked and unsupervised. The surveyor was able to access the medication refrigerator that had multiple medications in it. The nurse was not present at the nurses station.
During an interview on 4/8/25 at 8:08 A.M., Nurse #3 said medication rooms, medication and treatment carts should be locked unless a nurse in the room and at the cart.
During an interview on 4/08/25 at 2:14 P.M., the Director of Nursing said she expects medication rooms, medication and treatment carts should be locked unless a nurse is present in the room or at the carts.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Menu Adequacy
(Tag F0803)
Could have caused harm · This affected multiple residents
Based on observation, record review and interview, the facility failed to serve what was listed on the menu for all meals during the survey period. Specifically, the facility failed to ensure resident...
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Based on observation, record review and interview, the facility failed to serve what was listed on the menu for all meals during the survey period. Specifically, the facility failed to ensure residents received milk with their meals as indicated on the menu.
Findings include:
During the survey period, all surveyors observed residents who did not receive any milk as their meal tickets indicated they should with their meals during the survey period.
Review of the facility menu for the duration of the survey period indicated that milk is to be served with all meals.
During an interview on 4/9/25 at 8:41 A.M., the Foodservice Director (FSD) reviewed the menus with the surveyor. The surveyor asked if milk is part of the menu and if every resident should be served it, the FSD responded by saying milk is typically only provided if the resident gets coffee or tea with their meal.
During an interview on 4/9/25 at 9:10 A.M., the Corporate Registered Dietitian (RD) said milk is built into the nutritional breakdown for all menus, therefore it should be served for all residents unless they do not want it or if they have a dietary restriction.
During a follow up interview on 4/9/25 at 12:10 P.M., the Corporate Registered Dietitian provided the surveyor with an audit that she had just completed, it indicated that four residents on the first floor did not receive milk when they should have and three residents on the second floor did not receive milk when they should have.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0804
(Tag F0804)
Could have caused harm · This affected multiple residents
Based on resident group meeting, interview and test tray results, the facility failed to ensure foods provided to the residents were prepared by methods that conserve palatability and are at appetizin...
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Based on resident group meeting, interview and test tray results, the facility failed to ensure foods provided to the residents were prepared by methods that conserve palatability and are at appetizing temperatures on four of four units.
Findings include:
The facility was unable to provide a policy regarding food temperature palatability.
During the initial Resident screening process, numerous residents voiced concerns and displeasure about the overall food quality, temperature, and variety they are provided.
During the resident council group meeting on 4/8/25, at 11:05 A.M., 10 out of 16 participating residents complained that the food is always cold and does not taste good.
On 4/8/25, the surveyors conducted test tray audits during lunch on all units of the facility, the results were as followed:
On the first floor A-unit side, the meal cart arrived on the unit at 12:00 P.M., the surveyor received the tray at 12:12 P.M., the following was recorded:
- Stuffed shell pasta with cheese was 120 degrees Fahrenheit and was warm, not hot.
- Salad was 79 degrees Fahrenheit and room temperature. No salad dressing was served with it.
- Cranberry juice was 63 degrees Fahrenheit and warm.
- Ice Cream bar was 22 degrees Fahrenheit and melted all over the tray when it was opened.
On the first floor B-unit side, the meal cart left the kitchen at 12:17 P.M., staff began passing out trays to the residents at 12:21 P.M., the surveyor received the test tray at 12:38 P.M., and the following was recorded:
- Cut-up stuffed shell pasta with cheese was 115 degrees Fahrenheit and was slightly warm, not hot.
- Mixed vegetables were 111 degrees Fahrenheit and slightly warm, not hot.
- Salad Dressing was 73 degrees Fahrenheit, no salad was served with this diet texture.
- Coffee was 118 degrees Fahrenheit and not hot.
- Apple Juice was 58 degrees Fahrenheit and warm
- Ice Cream Bar was 23 degrees Fahrenheit and actively melting as it was opened.
On the second-floor A-unit, the following was recorded:
- Stuffed shell pasta with cheese was 120 degrees Fahrenheit and was warm to cool, not hot.
- Salad was warm and not cool.
- Salad dressing was 72 degrees Fahrenheit and very warm.
- Apple juice was 58 degrees Fahrenheit and warm.
- Coffee was 113 degrees and lukewarm, not hot.
- Ice cream bar was very soft and melted upon opening.
On the second-floor B-unit, the following was recorded:
- Stuffed shell pasta with cheese was 132 degrees and lukewarm.
- Salad was warm and not cool.
- Salad Dressing was 71 degrees Fahrenheit and warm.
- Ginger ale was 59 degrees and warm
- Coffee was 109 degrees and lukewarm, not hot.
- Ice Cream bar was melting upon opening it.
Durin an interview on 4/8/25 at 12:54 P.M., the Corporate Dietary Personnel said the food should be hotter or colder and it is likely a combination of both the kitchen and tray passing.
During an interview on 4/9/25 at 8:41 A.M., the Foodservice Director said she would expect Residents to be receiving their food at an appropriate temperature and she acknowledged that temperatures were not acceptable.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Food Safety
(Tag F0812)
Could have caused harm · This affected multiple residents
Based on observation and interview the facility failed to properly follow food handling practices to prevent the risk of foodborne illness in accordance with professional standards for food service sa...
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Based on observation and interview the facility failed to properly follow food handling practices to prevent the risk of foodborne illness in accordance with professional standards for food service safety.
Findings include:
The surveyor made the following observations during the lunch trayline on 4/8/25:
- At 11:38 A.M., the cook began trayline service, the cook had a visible beard approximately one-inch long and was not wearing a beard net.
- At 11:41 A.M., a diet aide removed disposable gloves and then touched her pants with her bare hands, then touched the oven knobs and then put on a new pair of disposable gloves without washing her hands, thus contaminating her gloves. At 11:44 A.M., the diet aide removed her disposable gloves and used oven mits to remove a tray from the oven. She then put on new disposable gloves without washing her hands, contaminating the gloves. The diet aide then put on new gloves and directly touched bread, contaminating the bread.
- At 11:59 A.M., the cook left the tray line, opened a door to leave the kitchen and got a new box of disposable gloves with bare hands. The cook then put on a pair of disposable gloves without washing his hands, contaminating the gloves. The cook then touched ready-to-eat salad with the contaminated gloves.
- At 12:03 P.M., the cook left the trayline to obtain a beard net and put it on with bare hands. The cook then put on new disposable gloves without washing his hands, contaminating the gloves. At 12:05 P.M., the cook touched his shirt with the gloved hands, then removed a tray from trayline and brought it to the dish room wearing the same gloves. The cook then removed the gloves, touched his shirt with bare hands and put on new gloves without washing his hands, contaminating the gloves. The cook then opened the refrigerator with the gloved hands and grabbed salad mix. He then opened the salad mix and touched the ready-to-eat lettuce with the contaminated gloves.
- At 12:14 P.M., the cook touched the telephone with gloved hands and resumed trayline with the contaminated gloves. At 12:15 P.M., the cook removed the gloves and then touched his over-the-ear headphones on his head with bare hands, he then put new gloves on without washing his hands prior, contaminating the gloves, he then resumed trayline.
During an interview on 4/9/25 at 8:41 A.M., the Foodservice Director (FSD) said she expects staff to wash their hands before putting on new gloves and to wash their hands when they leave their station and return. The FSD said staff should have practiced better hand hygiene during the trayline service.
Apr 2024
17 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0552
(Tag F0552)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Resident #76 was admitted to the facility in March 2024 with diagnoses that included end stage renal disease, anxiety and lef...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Resident #76 was admitted to the facility in March 2024 with diagnoses that included end stage renal disease, anxiety and left leg above the knee amputation.
Review of Resident #76 most recent Minimum Data Set (MDS) assessment, dated 3/10/24, indicated he/she was unable to participate in the Brief Interview for Mental Status Exam and was assessed by staff as being severely cognitively impaired.
Review of active physician's orders indicated the following psychotropic medication orders:
-Ativan (a medication used to treat anxiety) 0.5 milligrams every 4 hours as needed, dated 3/19/24.
-Ativan 0.5 milligrams two times a day, dated 3/19/24.
Review of the March 2024 and April 2024 Medication Administration Record indicated that Resident #76 had been receiving Ativan as ordered.
Review of Resident #76's medical record failed to indicate signed consent for the administration of Ativan.
During an interview on 4/1/24 at 2:21 P.M., the Director of Nursing #1 said that consent for the use of psychotropic medications needs to be obtained from the resident or the resident's representative prior to the administration of psychotropic medications.
During an interview on 4/3/24 at 9:24 A.M., Nurse #6 said that consent for the use of psychotropic medications should be obtained prior to the administration of any psychotropic medication. Nurse #6 reviewed Resident #76's medical record and said that Resident #76 did not have a consent for the administration of Ativan.
Based on record review and interviews, the facility failed to obtain consents for psychotropic medications explaining the risks and benefits of treatment, prior to administering psychotropic medication for two Residents (#47 and #76) out of a sample of 20 Residents.
Findings include:
A review of the facility's policy titled Psychotropic Medication, dated July 2023, indicated the following:
-To administer and monitor the effects of psychotropic mediations when prescribed. The interdisciplinary team assesses and monitors the appropriateness, effectiveness, and side effects associated with psychotropic medications for each resident via resident care plan review. The resident, and when indicated, the family or responsible person, will be included in this process prior to the administration of dose. Psychotropic medication management includes:
a. a physician's order and an appropriate diagnosis is required for psychotropic medications.
b. a written informed consent from the resident (or legally authorized individual in the case of resident incompetence) is required for administration of psychotropic medication.
1. Resident #47 was admitted to the facility in October 2022 with diagnoses that included legal blindness, anxiety, dementia, and depression.
Review of Resident #47's most recent Minimum Data Set (MDS), dated [DATE], indicated the Resident had a Brief Interview for Mental Status (BIMS) score of one out of a possible 15, which indicated he/she had severe cognitive impairment. The MDS also indicated Resident #47 was dependent on staff for all care and mobility.
Review of Resident #47's physician orders indicated the following psychotropic medication orders:
-Mirtazapine (an anti-depressant medication) Tablet 15 mg. Give 1 tablet by at bedtime for increased appetite. Dated 1/4/24.
Review of the medical record failed to include signed consent for the administration of Mirtazapine.
During an interview on 4/1/24 at 2:21 P.M., the Director of Nursing #1 said consent for use of psychotropic medications needs to be obtained from the resident or his/her representative prior to the administration of the medication.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0578
(Tag F0578)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to ensure advanced directives related to guardianships were valid and i...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to ensure advanced directives related to guardianships were valid and in place for two Residents, (#16 and #12) out of a total of 20 sampled Residents. Specifically:
1.) For Resident #16, the facility failed to ensure an established Guardianship was reviewed and renewed annually per court order, and;
2.) For Resident #12, the facility failed to establish a health care agent/representative when his/her activated health care proxy was no longer reachable or involved in his/her care.
Findings include:
1. Resident #16 was admitted to the facility in June 2009 with diagnoses including schizoaffective disorder, syncope, and bipolar disorder.
Review of his/her most recent Minimum Data Set Assessment (MDS), dated [DATE], indicated Resident #16 scored 9 out of a possible 15 on the Brief Interview for Mental Status Exam, (BIMS), indicating moderate cognitive impairment.
Review of the clinical record indicated Resident #16 had an established [NAME] Guardianship, (a Guardianship specifically related to the authorizing treatment with anti-psychotic medication), dated 2/2/23. The Guardianship indicated: Authorization treatment with anti-psychotic medication shall be reviewed on or before 2/2/24.
The clinical record failed to indicate the [NAME] Guardian was reviewed and renewed by the courts in 2024.
During an interview on 4/2/24 at 10:05 A.M., the Social Worker said that Resident #16's [NAME] Guardian was not renewed or reviewed by the courts as ordered.
2. Resident #12 was admitted to the facility in February 2016 with diagnoses including Wernicke's encephalopathy, chronic obstructive pulmonary disease, and alcohol dependence.
Review of Resident #12's most recent Minimum Data Set Assessment (MDS), dated [DATE], indicated he/she scored 8 out of a possible 15 on the Brief Interview for Mental Status Exam, indicating moderate cognitive impairment.
Review of the clinical record indicated Resident #12 had an activated healthcare proxy.
Review of Resident #12's clinical progress note dated 1/29/24 indicated: Attempted to contact [health care agent] multiple times to obtain Covid-19 consent or refusal. Phone is no longer in service. Resident was unaware phone was no longer in service and has no contact information for [health care agent]. Certified letter was sent to [healthcare agent] using address on file.
The clinical record failed to indicate any further information regarding Resident #12's health care agent or possible guardianship.
During an interview on 4/3/24 at 10:16 A.M., Director of Nursing (DON) #1 said that the facility had difficulty in contacting Resident #12's health care agent. DON #1 said it's been a long time. We sent a certified letter but was unable to say when the last time Resident #12's health care agent had been reachable or involved in Resident #12's care or medical related decisions. DON #1 said that Resident #12 had no other family or friends involved and that the facility would need to pursue Guardianship. DON #1 could not say why the facility did not proceed with establishing Guardianship for Resident #12 prior to the surveyor's inquiry.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Free from Abuse/Neglect
(Tag F0600)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, policy review and interviews, the facility failed to ensure one Resident (#31) was free fr...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, policy review and interviews, the facility failed to ensure one Resident (#31) was free from involuntary seclusion, out of a total sample of 20 Residents.
Findings include:
Review of the facility policy titled, Abuse: Prohibition, dated December 2017, indicated the following:
-Each resident has the right to be free from verbal, sexual, physical and mental abuse, neglect, corporal punishment, involuntary seclusion, and misappropriation of their property. Every resident in the facility will be treated with respect and dignity at all times.
-Involuntary seclusion: the separation of a resident from other residents or from his/her room or confinement to his/her room (with or without roommates) against the resident's will, or the will of the resident's legal representative.
Resident #31 was admitted to the facility in February 2024 with diagnoses including stroke with paralysis on right side and abnormalities of gait and mobility.
Review of Resident #31's most recent Minimum Data Set (MDS), dated [DATE], indicated the Resident had a Brief Interview for Mental Status (BIMS) score of 8 out of a possible 15, which indicated he/she had moderate cognitive impairment. The MDS also indicated Resident #31 required maximum assistance from staff for bed mobility tasks.
On 4/1/24 at 12:24 P.M., Resident #31 was observed lying in bed in a dark room behind a closed door. There was a pillow placed under the fitted sheet on the left side of the mattress preventing the Resident from moving his/her legs to that side of the bed. Resident #31 said he/she did not know why the pillow was there and he/she was not able to move his/her arms to the pillow to remove it. Resident #31 said he/she would like to get out of bed. There was no chair in the Resident's room for him/her to get into if he/she desired to get out of bed.
Resident #31 was not observed out of bed for the entirety of the 7:00 A.M. to 3:00 P.M. shift on 4/1/24. His/her door to his/her room was always closed and his/her light in the room was never on.
On 4/2/24 at 7:45 A.M., Resident #31 was observed lying in bed in a dark room behind a closed door. There was a pillow placed under the fitted sheet on the left side of the mattress preventing the Resident from moving his/her legs to that side of the bed.
On 4/2/24 at 8:37 A.M., Resident #31 was observed attempting to get out of bed by placing his/her legs over the side of the bed. Resident #31 said he/she would like to get out of bed. There was no chair in the Resident's room for him/her to get into if he/she desired to get out of bed.
On 4/2/24 at 12:00 P.M., Resident #31 was still observed lying in bed in a dark room behind a closed door. Resident #31 said he/she would love to get out of bed to eat lunch and said he/she could not remember the last time he/she was out of bed.
Review of Resident #31's activity of daily living care plan initiated on 2/23/24, indicated the following:
-Transfer: assist to dependent.
-Locomotion: assist with wc (wheelchair).
Further review of Resident #31's complete care plans failed to indicate the Resident prefers to stay in his/her bed or room and refuses to get out of bed.
Review of all nursing progress notes since Resident #31's admission to the facility failed to indicate the Resident refused to get out of bed.
Review of the Physical Therapy evaluation dated 2/24/24 indicated the following:
-Patient goals: I want to walk better but I have no energy.
-Potential for achieving goals: Patient demonstrates good rehab potential as evidenced by decreased need for task segmentation, active participation with plan of treatment, motivated to participate and motivated to return to prior level of living.
-Reason for referral: Pt. (patient) has been non ambulatory x 1 yr (year) since CVA (stroke) and needs further rehab to enable greater (I) (independence) with mobility.
-Resident #31 was able to complete a stand pivot transfer with maximal assistance from the therapist.
-Clinical Impressions: Skilled PT (physical therapy) required to return to PLOF (prior level of function) or develop compensatory methods of mobility such as WC mobility.
-The plan of care was for therapy to treat the Resident 5 times a week for 4 weeks.
Review of the physical therapy notes indicated Resident #31 only received two treatments on 2/27/24 and 3/7/24. The physical therapy notes failed to indicate the physical therapist assistant attempted dynamic sitting training or transfers out of bed. The notes also failed to indicate the therapist provided a chair for the Resident if he/she chose to get out of bed with the nursing staff.
During an interview on 4/2/24 at 11:32 A.M., Nurses #3 and #4 said they work consistently at the building and know Resident #31. Both Nurse #3 and Nurse #4 said they have never observed Resident #31 out of bed. Both nurses said the Resident stays in bed daily and were unaware how the Resident transferred or what type of chair he/she would sit in if out of bed.
During an interview on 4/2/24 at 11:40 A.M., Certified Nursing Assistant (CNA) #1 said she is the primary CNA for Resident #31. CNA #1 said she does not transfer Resident #31 out of bed because the Resident is a high falls risk. CNA #1 said she makes the choice to keep the Resident in bed and does not ask the Resident if he/she would like to get out of bed. CNA #1 said physical therapy is working with the Resident and the therapists are the only staff members who can transfer the Resident out of bed. CNA #1 said safety comes first and it is safer to have to Resident stay in bed.
During interviews on 4/2/24 at 11:18 A.M., and 4/2/24 at 12:46 A.M., the Regional Director of Rehabilitation (DOR) said Resident #31 was only on physical therapy for two treatment sessions and is not currently receiving therapy services. The Regional DOR said Resident #31 did not have a chair to transfer into if he/she wanted to get out of bed and the therapy staff should have provided a chair to the Resident.
During an interview on 4/2/24 at 12:39 P.M., the Regional Nurse said nursing is able to obtain a wheelchair for a resident and is able to get a resident out of bed without waiting for therapy.
During an interview on 4/2/24 at 12:16 P.M., Director of Nursing (DON) #1 said all residents should be asked if they would like to get out of bed daily and throughout the day as needed. DON #1 said all residents should be provided with a chair/method of getting out of bed. DON #1 said nursing can assist residents with transferring out of bed and it is not the responsibility of therapy to get residents out of bed. DON #1 said she is unaware of Resident #31's schedule and if he/she gets out of bed. DON #1 said she was unaware Resident #31 had not been offered to get out of bed.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0604
(Tag F0604)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, policy review and interviews, the facility failed to ensure one Resident (#31) was free fr...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, policy review and interviews, the facility failed to ensure one Resident (#31) was free from restraints out of a total sample of 20 residents. Specifically, the facility failed to identify and assess the use of a pillow under a fitted sheet as a potential restraint for Resident #31.
Findings include:
Review of the facility policy titled, Use of Restraints, dated 1/2024, indicated the following:
-Restraints shall only be used for the safety and well-being of the resident(s) and only after other alternatives have been tried unsuccessfully. Restraints shall only be used to treat the resident's medical symptom(s) and never for discipline or staff convenience, or for the prevention of falls.
-Physical restraints are defined as any manual method, physical or mechanical device, material or equipment attached or adjacent to the resident's body that the individual cannot remove easily, which restricts freedom of movement or restricts normal access to one's body.
-The definition of a restraint is based on the functional status of the resident and not the device. If the resident cannot move remove a device in the same manner in which the staff applied it given that resident's physical condition and this restricts his/her typical ability to change position or place, that device may be considered a restraint.
Resident #31 was admitted to the facility in February 2024 with diagnoses including stroke with paralysis on right side and abnormalities of gait and mobility.
Review of Resident #31's most recent Minimum Data Set (MDS) dated [DATE], indicated the Resident had a Brief Interview for Mental Status (BIMS) score of 8 out of a possible 15, which indicated he/she had moderate cognitive impairment. The MDS also indicated Resident #31 required maximal assistance from staff for bed mobility tasks.
On 4/1/24 at 12:24 P.M., Resident #31 was observed lying in bed. There was a pillow placed under the fitted sheet on the right side of the mattress preventing the Resident from moving his/her legs to that side of the bed. Resident #31 said he/she did not know why the pillow was there and he/she was not able to move his/her arms to the pillow to remove it.
On 4/2/24 at 7:45 A.M., Resident #31 was observed lying in bed. There was a pillow placed under the fitted sheet on the right side of the mattress preventing the Resident from moving his/her legs to that side of the bed.
On 4/2/24 at 8:37 A.M., Resident #31 was observed attempting to get out of bed by placing his/her legs over the side of the bed. Resident #31 said he/she would like to get out of bed.
Review of Resident #31's medical record failed to indicate a restraint assessment had been completed.
During an interview on 4/2/24 at 7:50 A.M., Certified Nursing Assistant (CNA) #1 and the surveyor observed the pillow under Resident #31's fitted sheet. CNA #1 said the staff placed the pillow under the fitted sheet because the Resident attempts to get out of bed. CNA #1 said the Resident is always attempting to get out of bed so the staff place the pillow there so he/she won't get up. CNA #1 said Resident #31 is a high falls risk.
During an interview on 4/2/24 at 7:59 A.M., Director of Nursing #2 and the surveyor observed the pillow under Resident #31's fitted sheet. Director of Nursing #2 said this was considered a restraint and we can't do that.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0658
(Tag F0658)
Could have caused harm · This affected 1 resident
Based on observations, interviews, record review, and policy review, the facility to ensure that services provided met professional standards for one Resident (#13), out of 20 total sampled Residents....
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Based on observations, interviews, record review, and policy review, the facility to ensure that services provided met professional standards for one Resident (#13), out of 20 total sampled Residents. Specifically, the facility failed to implement a daily wound dressing according to the physician's order for five days.
Findings include:
Review of the facility policy titled Medication and Treatment Orders, last revised April 2018, indicated:
-Orders for medications and treatments will be consistent with regulatory standards.
Review of the facility policy titled Dressings, Dry/Clean, revised April 2018, indicated:
-Verify that there is a physician's order for this procedure.
Resident #13 was admitted to the facility in December 2022 with diagnoses that included peripheral vascular disease and obesity.
Review of the most recent Minimum Data Set (MDS) assessment, dated 3/21/24, indicated that Resident #13 had moderate cognitive impairment as evidenced by a Brief Interview for Mental Status (BIMS) score of 10 out of 15. This MDS indicated Resident #13 had an open lesion on his/her foot.
On 4/1/24 at 8:06 A.M., the surveyor observed Resident #13 lying in bed. Resident #13 said the nurses do not change my foot dressing very often. Resident #13 had a dressing on his/her right foot, dated 3/27/24 (5 days prior).
Review of the Resident #13's physician's order, 3/12/24, indicated:
-Clean right distal plantar lateral foot with normal saline, apply A & D ointment, then cover with dry dressing, change daily and PRN.
Review of the March 2024 Treatment Administration Record (TAR), dated 3/27/24, 3/28/24, 3/29/24, 3/30/24, and 3/31/24, indicated the physician's treatment order was documented as completed, (contradicting the surveyors observation).
During an interview on 4/1/24 at 8:52 A.M., the surveyor and Nurse #2 observed Resident #13 lying in bed with a dressing on his/her right foot dated 3/27/24. Nurse #2 said the dressing was not changed since 3/27/24; five days prior. Nurse #2 said that Resident #13's right foot dressing is ordered to be changed daily and wound dressings should be changed at the frequency frequency the physician ordered.
Review of the plan of care related to non-pressure wound of the right distal plantar lateral foot and potential for skin breakdown, dated 1/3/24, failed to indicate Resident #13 refuses dressing changes.
Review of the nursing progress notes, dated 3/5/24 to 4/1/24, failed to indicate Resident #13 refused any dressing changes.
During an interview on 4/2/24 at , the Wound Physician said she was not notified that Resident #13 refused or did not have his/her right foot dressing changed from 3/27/24 until 4/1/24. The Wound Physician said Resident #13 does not usually refuse dressing changes.
During an interview on 4/3/24 at 8:46 A.M., Director of Nursing (DON) #2 said dressings should be changed at the frequency the physician ordered and if refused than the physician should be notified. DON #2 said if a dressing change is not done or refused, the rationale should be documented in the TAR or in a nursing note. DON #2 said if a dressing change is not completed, it should not be documented as completed in the TAR.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
ADL Care
(Tag F0677)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Resident #30 was admitted to the facility in June 2015 with diagnoses that include cerebral infarction (stroke), dysphagia (d...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Resident #30 was admitted to the facility in June 2015 with diagnoses that include cerebral infarction (stroke), dysphagia (difficulty swallowing), dementia and paraplegia.
Review of Resident #30's most recent Minimum Data Set Assessment (MDS), dated [DATE], indicated a Brief Interview for Mental Status (BIMS) score of 15 out of 15 indicating that Resident #30 is cognitively intact. The MDS further indicated that Resident #30 required supervision or touching assistance for eating.
On 4/1/24 at 9:16 A.M. the surveyor observed Resident #30 in bed eating breakfast, sliding down and leaning towards the left. There were no staff present in Resident #30's room.
On 4/2/24 at 8:47 A.M., the surveyor observed a Certified Nurses Aid (CNA) bring Resident #30 his/her breakfast tray, set his/her tray up and leave the room. Resident #30 was observed in bed with the head of the bed elevated at approximately 45 degrees and leaning to the left. The tray table was elevated, and Resident #30 had to reach up and over it to feed his/herself.
On 4/2/24 at 8:53 A.M., the surveyor and Director of Nursing #2 (DON) observed Resident #2 in bed eating alone. DON #2 said that Resident #30 was not in a safe position to eat.
Review of Resident #30's activities of daily living care plan, revised on 3/24/23, indicated eating assistance varies from supervision to total assist.
Review of Resident #30's nutrition care plan, revised on 2/8/24, indicated that Resident #30 has swallowing difficulty due to dysphagia as evidenced by need for mechanically altered diet and to monitor for signs and symptoms of aspiration.
During an interview on 4/2/24 at 2:18 P.M., DON #1 said that she would expect CNA's to supervise Resident #30 as per his/her plan of care with meals.
During an interview on 4/3/24 at 9:11 A.M., CNA #3 said that Resident #30 needs supervision with meals and said someone should always be in the room with him/her while eating.
During an interview on 4/3/24 at 9:15 A.M., CNA #4 said that Resident #30 needs to be supervised with meals because he/she coughs a lot when eating.
Based on observations, record review, policy review and interviews, the facility failed to provide assistance with meals for two Residents (#379 and #30) out of a total sample of 20 residents.
Findings include:
Review of the facility policy titled, Activities of Daily Living (ADLs), Supporting, dated September 2019, indicated the following:
-Residents will be provided with care, treatment and services as appropriate to maintain or improve as able their ability to carry out activities of daily living (ADLs).
-Residents who are unable to carry out activities of daily living independently will receive the services necessary for activities of daily living.
-Appropriate care and services will be provided for residents who are unable to carry out ADLs independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with dining (melas and snacks).
1. Resident #379 was admitted to the facility in October 2023 with diagnoses including pneumonitis due to inhalation of food and vomit and dementia.
Review of Resident #379's most recent Minimum Data Set (MDS), dated [DATE], indicated the Resident had a Brief Interview for Mental Status (BIMS) score of 9 out of a possible 15, which indicated he/she had moderate cognitive impairment. The MDS also indicated Resident #379 required supervision or touching assistace during meals.
On 4/1/24 at 8:40 A.M., Resident #379 was observed eating breakfast while lying in bed. The privacy curtain was drawn, and the Resident was not visible from the hallway. The Resident was observed to have food on his/her chest.
On 4/2/24 at 8:43 A.M., Resident #379 was observed eating breakfast in his/her room alone. The privacy curtain was drawn, and the Resident was not visible from the hallway.
On 4/2/24 at 12:36 P.M., Resident #379 was observed eating lunch in his/her room alone. The privacy curtain was drawn, and the Resident was not visible from the hallway.
Review of Resident #379's activity of daily living care plan, last revised 1/22/24, indicated the following:
-Eating: setup and cue, provide continual supervision/assist prn (as needed).
Review of Resident #379's [NAME] (a form indicating the level of care required) indicated the following:
-Eating: setup and cue, provide continual supervision/assist prn.
During an interview on 4/2/24 at 2:00 P.M., Certified Nursing Assistant #1 said Resident #379 requires supervision while eating.
During an interview on 4/2/24 at 2:18 P.M., Director of Nursing #1 said she would expect the staff would supervise the Resident per his/her activity of daily living care plan.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0679
(Tag F0679)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, policy review and interviews, the facility failed to provide an activity program for three...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, policy review and interviews, the facility failed to provide an activity program for three Residents (#31, #38 and #47) out of a total sample of 20 residents.
Findings include:
Review of the facility policy titled, Activity Evaluation, dated April 2019, indicated the following:
-In order to promote the physical, mental and psychosocial well-being of residents, an activity evaluation is conducted and maintained for each resident at least quarterly and with any change of condition that could affect his/her participation in planned activities.
-Each residence activities care plan relates to his/her comprehensive assessment and reflects his/her individual needs.
-The activity evaluation is used to develop individual activities care plan (Separate from or as part of the comprehensive care plan) that will allow the resident to participate in activities of his/her choice and interest.
1. Resident #31 was admitted to the facility in February 2024 with diagnoses including stroke with paralysis on right side and abnormalities of gait and mobility.
Review of Resident #31's most recent Minimum Data Set (MDS) dated [DATE], indicated the Resident had a Brief Interview for Mental Status (BIMS) score of 8 out of a possible 15, which indicated he/she had moderate cognitive impairment. The MDS also indicated Resident #31 required maximal assistance from staff for bed mobility tasks.
On 4/1/24 Resident #31 was observed in his/her room for the entirety of the 7:00 A.M. to 3:00 P.M. shift. During all observations, the Resident was lying in bed and there was no television or music playing in the room. There were no activity materials observed in the Resident's room.
Activities listed on the activity calendar on this day were: coffee cart and morning greetings, crossword puzzle and Never Have I Ever Game.
On 4/2/24 Resident #31 was observed in his/her room from 7:00 A.M. to approximately 1:30 P.M. During observations made at this time, the Resident was lying in bed and there was no television or music playing in the room. There were no activity materials observed in the Resident's room.
Activities listed on the activity calendar during these hours were: It's Coffee Time, Chit Chat Group, Crossword Puzzle, and You're the Judge.
Review of Resident #31's Recreation admission Assessment, dated 2/23/24, indicated the following:
-Activities of preference: music, reading/writing, spiritual, TV, and talking to others.
-Resident #31 is alert and able to make his/her needs known.
-Resident #31 participates in coffee hour in his/her room and enjoys spending time watching television.
-It is very important to the Resident to have books, newspapers, magazine, music, and religion activities.
-It is somewhat important to the Resident to do things with groups of people.
Review of Resident #31's care plans failed to indicate an activity care plan was developed for the Resident.
Review of Resident #31's Activity of Daily Living care plan initiated on 2/23/24, indicated the following intervention:
-Invite, encourage, remind, escort to activity programs consistent with the resident's interests.
Review of the Documentation Survey Report dated March 2024 and April 2024 failed to indicate the Resident had participated in any activities since admission to the facility.
During an interview on 4/3/24 at 9:02 A.M., the Activities Director said the activity department consists of her and one assistant. The Activities Director said she is often pulled away by other building business and this at times takes away from her ability to complete activities with the residents. The Activities Director said the activity calendar is made based on the residents' preferences and she had the residents fill out a survey of their preferences. The Activities Director said the residents who primarily stay in their rooms depend on visits from the activity staff. The Activities Director said there are activity materials on the floor and nursing should be passing the materials out to the residents throughout the day. The Activities Director said Resident #31 is a tough resident to provide activities for because he/she does not want to be in the facility and stays in his/her room. The Activities Director said she visits Resident #31 in his/her room, and he/she likes to listen to music and watch television. She said the Resident is also very religious and enjoys reading the bible, as he/she used to be a minister. The Activity Director was unaware Resident #31 did not have a radio in his/her room or that the television had not been on for two days. She said she would have expected nursing to put on the television for the Resident. The Activities Director said if the Resident had participated in activities, she would have documented the participation the electronic medical record.
2. Resident #38 was admitted to the facility in June 2019 with diagnoses including Alzheimer's Disease and depression.
Review of Resident #38's most recent Minimum Data Set (MDS) dated [DATE], indicated the Resident had a Brief Interview for Mental Status (BIMS) score of 7 out of a possible 15 which indicated he/she had severe cognitive impairment.
On 4/1/24 at 7:39 A.M., Resident #38 said he/she was bored. The Resident said he/she used to play cards with other residents in the facility and that no longer happens. Resident #38 said he/she likes to listen to music and would like a radio. There were no activity materials observed in the room and the Resident did not have a radio in the room.
On 4/1/24 and 4/2/24 throughout 7:00 A.M. through 3:00 P.M. shift, Resident #38 was not observed participating in any activities.
The activities listed on the activity calendar on 4/1/24 were: coffee cart and morning greetings, crossword puzzle and Never Have I Ever Game.
The activities listed on the activity calendar on 4/2/24 were: It's Coffee Time, Chit Chat Group, Crossword Puzzle, and You're the Judge.
Review of Resident #38's most recent activity assessment dated [DATE] indicated the Resident prefers the radio and television, trivia and coffee social. The assessment indicated the Resident also enjoys reminiscing.
Review of Resident #38's activity care plan last revised 5/15/23 indicated the following interventions:
-Explain importance of activities.
-Introduce to other residents.
-Invite to scheduled activities.
Review of section F of the comprehensive MDS dated [DATE] indicated the following:
-Activities very important to the Resident are listening to music, dingo things with groups of people.
-Activities somewhat important to the Resident are being around animals, and religious services.
Review of the Documentation Survey Report dated March 2024 and April 2024 failed to indicate Resident #38 had participated in any activities since March 1, 2024.
During an interview on 4/3/24 at 9:02 A.M., the Activities Director said the activity department consists of her and one assistant. The Activities Director said she is often pulled away by other building business and this at times takes away from her ability to complete activities with the residents. The Activities Director said the activity calendar is made based on the residents' preferences and she had the residents fill out a survey of their preferences. The Activities Director said the residents who primarily stay in their rooms depend on visits from the activity staff. The Activities Director said there are activity materials on the floor and nursing should be passing the materials out to the residents throughout the day. The Activities Director said Resident #38 used to participate in a poker game group, but she had to stop this group because the residents were gambling. The Activities Director said she did not replace this group with a different type of card game other than poker. The Activities Director said Resident #38 does like to stay in his/her room and listen to music and was unaware there was no radio in the Resident's room. The Activities Director said if the Resident had participated in activities, she would have documented the participation the electronic medical record.
3. Resident #47 was admitted to the facility in October 2022 with diagnoses including dementia, anxiety, and depression.
Review of Resident #47's most recent Minimum Data Set (MDS) dated [DATE] indicated the Resident had a Brief Interview for Mental Status (BIMS) score of 1 out of a possible 15, which indicated he/she had severe cognitive impairment.
On 4/1/24, Resident #47 was not observed participating in any activities on the 7:00 A.M. to 3:00 P.M. shift.
The activities listed on the activity calendar on 4/1/24 were: coffee cart and morning greetings, crossword puzzle and Never Have I Ever Game.
On 4/2/24, Resident #47 was not observed participating in any activities on the 7:00 A.M. to 3:00 P.M. shift.
The activities listed on the activity calendar on 4/2/24 were: It's Coffee Time, Chit Chat Group, Crossword Puzzle, and You're the Judge.
Review of Resident #47's most recent activity assessment date 1/27/24, indicated the following:
-The Resident participated in self-directed activities and one on one activities.
-The Resident likes radio and is supposed to have a radio/cd player to play music and church music at his/her request. The Resident also likes to pray.
Review of the most recent comprehensive MDS indicated the staff did not assess the Resident for his/her preferences.
Review of Resident #47's activity care plan last revised 10/21/23, indicated the following interventions:
-Arrange one on one contacts with resident.
-Offer ongoing structured activity program for intellectual stimulation.
-Offer reality orientation on all possible occasions and contacts.
-Offer schedule of activities for resident to select choices.
-Post personal activity schedule in resident's room.
-Transport resident to activities. Assist in transporting any health-related equipment to activities.
Review of the Documentation Survey Report dated March 2024 and April 2024 indicated Resident #47 had participated in activities twice since March 1, 2024.
During an interview on 4/3/24 at 9:02 A.M., the Activities Director said the activity department consists of her and one assistant. The Activities Director said she is often pulled away by other building business and that at times takes away from her ability to complete activities with the residents. The Activities Director said the activity calendar is made based on the residents' preferences and she had the residents fill out a survey of their preferences. The Activities Director said the residents who primarily stay in their rooms depend on visits from the activity staff. The Activities Director said there are activity materials on the floor and nursing should be passing the materials out to the residents throughout the day. The Activity Director said Resident #47 is very religious and spends most of his/her time in the dining room. The Activity Director said staff should be making music available to him/her but staff often hide his/her radio.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0685
(Tag F0685)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review an interview, the facility failed to follow up on a referral for ophthalmology services for one Resident ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review an interview, the facility failed to follow up on a referral for ophthalmology services for one Resident (#12) out of a total of 20 sampled Residents.
Findings include:
Resident #12 was admitted to the facility in February 2016 with diagnoses including Wernicke's encephalon, chronic obstructive pulmonary disease, and alcohol dependence.
Review of Resident #12's most recent Minimum Data Set Assessment (MDS), dated [DATE], indicated he/she scored 8 out of a possible 15 on the Brief Interview for Mental Status Exam, indicating severe cognitive impairment. The MDS also indicated he/she requires physical assistance from staff with bathing, dressing and toileting.
During an interview on 4/1/24 at 7:59 A.M., Resident #12 said he/she wants to be seen by an eye doctor and wants glasses.
Review of Resident #12's optometry notes indicated:
- 11/8/23: Assessment: Glaucoma suspect, Cataract nuclear, [right] eye. Plan: Cataract surgery recommended. Referral: ophthalmology consult.
- 3/8/24: Assessment: Glaucoma suspect. Open angle with borderline findings. Cataract, mixed, [right] eye. Patient wants to proceed with surgery. Referral: cataract ophthalmology; please make appointment for initial cataract consultation. Please arrange transportation to and from appointment.
Review of clinical record failed to indicate a referral was placed to ophthalmology or an appointment was made for Resident #12, or the recommendation was reviewed with his/her activated health care agent.
During an interview on 4/3/24 at 8:52 A.M., Corporate Nurse #1 said that Resident #12's eye appointment was not made.
During an interview on 4/3/24 at 10:16 A.M., Director of Nursing (DON) #1 said that the facility would have needed to get approval from Resident #12's activated health care proxy to proceed with the referral, but the facility has been unable to get in touch with his/her health care agent for many months. DON #1 said that the facility sent out a certified letter to Resident #12's health care agent.
The clinical record indicated a certified letter was sent to Resident #12's health care agent on 1/29/24 after staff could not reach them regarding vaccination consent or declination. There was no evidence in the clinical record indicating the facility attempted to reach the health care agent regarding vision services for Resident #12.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Respiratory Care
(Tag F0695)
Could have caused harm · This affected 1 resident
Based on observations, record review and interviews, the facility failed to ensure respiratory care was provided consistent with professional standards of care for one Resident (#4) out of a sample of...
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Based on observations, record review and interviews, the facility failed to ensure respiratory care was provided consistent with professional standards of care for one Resident (#4) out of a sample of 20 residents. Specifically for Resident #4, the facility to ensure oxygen was administered in accordance with the physician's orders.
Findings Include:
Review of facility policy titled Oxygen Administration, revised January 2024, indicated to review the physician's orders for oxygen administration and to evaluate oxygen saturation.
Resident #4 was admitted to the facility in March 2018 with diagnoses including chronic obstructive pulmonary disease (COPD, a chronic inflammatory lung disease that causes obstructed airflow from the lungs) and weakness.
Review of Resident #4's most recent Minimum Data Set (MDS) assessment, dated 3/7/24, indicated a Brief Interview for Mental Status (BIMS) score of 13 out of 15 indicating that Resident #4 is cognitively intact. The MDS assessment failed to indicate the use of oxygen.
On 4/1/24 at 7:52 A.M., the surveyor observed Resident #4 lying in bed, oxygen was not being administered.
On 4/1/24 at 1:06 P.M., the surveyor observed Resident #4 sitting on the side of his/her bed. Resident #4 was not utilizing oxygen and there was no portable oxygen concentrator observed in the room.
On 4/1/24 at 2:20 P.M., the surveyor observed Resident #4 lying in bed, oxygen was not being administered and there was no portable oxygen concentrator in the room.
On 4/2/24 at 7:49 A.M. and 11:34 A.M., the surveyor observed Resident #4 sleeping in bed, oxygen was not being administered and there was no portable oxygen concentrator in the room.
Review of Resident #4's active physician's orders, dated 2/23/24, indicated O2 [oxygen] 1-4 liters to maintain [oxygen saturation] >90%, ordered for all shifts.
Review of Resident #4's April 2024 Treatment Administration Record indicated that oxygen was administered on 4/1/24 and 4/2/24.
Review of Resident #4's medical record indicated that the last recorded oxygen saturation was on 3/27/24.
Review of Resident #4's progress notes from March 2024 and April 2024 failed to indicate any assessment of oxygen saturation.
During an interview on 4/2/24 at 2:11 P.M., Nurse #7 said that she had not assessed Resident #4's oxygen saturation on her shift. Nurse #7 reviewed Resident #4's physician's orders and said that the oxygen order would be a continuous order and oxygen saturation should be assessed. Nurse #7 said the last documented oxygen saturation was on 3/27/24. Nurse #7 said that Resident #4 was not currently utilizing oxygen.
During an interview on 4/2/24 at 2:16 P.M., the Director of Nursing (DON) said that Resident #4's oxygen order is a continuous oxygen order. The DON said that she would expect that nurses are assessing oxygen saturation every shift for Resident #4.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0698
(Tag F0698)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review and interviews, the facility failed to ensure services consistent with professional standar...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review and interviews, the facility failed to ensure services consistent with professional standards of practice related to hemodialysis (the process of cleansing the blood by passing it through a special machine, necessary when the kidneys are unable to filter the blood) were provided for one Resident (#65) out of a total sample of 20 residents.
Specifically, for Resident #65 the facility failed to ensure:
1. That a plan of care was developed for his/her AV (aterio-venous) Fistula (dialysis access site).
2. That emergency supplies were at the bedside in accordance with the physician's orders.
Findings Include:
Review of facility policy titled Hemodialysis Access Care, revised November 2017, indicated: care of an AV Fistula includes but is not limited to checking the patency of the site at regular intervals by checking for bruit and thrill (to ensure blood flow through the access site), and monitoring the site for bleeding.
Resident #65 was admitted to the facility in November 2023 with diagnoses that included end stage renal disease requiring hemodialysis and anemia.
Review of Resident #65's most recent Minimum Data Set (MDS) Assessment, dated 1/9/24, indicated a Brief Interview for Mental Status (BIMS) score of 15 out of 15 indicating that Resident #65 is cognitively intact. The MDS assessment further indicated that Resident #65 received dialysis treatment.
1. On 4/1/24 at 8:30 A.M. Resident #65 said that he/she received hemodialysis treatments three times a week. Resident #65 said that he/she has access in his/her chest through a catheter and through an AV Fistula in his/her left arm. Resident #65 said that at the current time he/she is receiving dialysis treatments through the AV Fistula. The surveyor observed both sites were present.
Review of Resident #65's active physician's orders failed to indicate an order to monitor the AV fistula access site.
Review of Resident #65's dialysis care plan, revised 2/12/24, failed to indicate that Resident #65 has an AV fistula.
Review of Resident #65's nursing progress notes from February 2024 through April 2024 failed to indicate any monitoring of left arm AV Fistula.
During an interview on 4/2/24 at 2:05 P.M., Nurse #7 said that Resident #65 received dialysis through a chest wall catheter.
During an interview on 4/2/24 at 2:26 P.M., DON #1 said that she would expect staff to assess an AV Fistula for bruit and thrill and for staff to know how Resident #65 receives dialysis treatments.
During an interview on 4/3/24 at 8:16 A.M., the Dialysis Nurse said that Resident #65 received dialysis through a left arm AV Fistula.
2. On 4/1/24 at 8:30 A.M., the surveyor observed there was no emergency kit at the bedside or observed anywhere in Resident #65's room.
On 4/2/24 at 7:53 A.M., the surveyor did not observe an emergency kit at Resident #65's bedside or in Resident #65's room.
Review of Resident #65's physician's orders, dated 2/12/24, indicated: emergency kit on wall, if bleeding occurs use [NAME] clamp, apply pressure and call 911.
Review of Resident #65's dialysis care plan, revised 2/12/24, indicated: maintain emergency kit at bedside.
During an interview on 4/2/24 at 2:05 P.M., Nurse #7 said there should be an emergency kit at the bedside in the event of bleeding from Resident #65's dialysis access. Nurse #7 checked Resident #65's room and said that there was no emergency kit present.
During an interview on 4/2/24 at 2:26 P.M., the Director of Nurses #1 (DON) said that Resident #65 should have an emergency kit in his/her room. DON #1 checked Resident #65's room and said that there was no emergency kit present.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Drug Regimen Review
(Tag F0756)
Could have caused harm · This affected 1 resident
Based on Record review and interviews the facility failed to act upon irregularities identified in the pharmacist's Medication Regimen Review (MRR) for one Resident (#76) out of a sample of 20 residen...
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Based on Record review and interviews the facility failed to act upon irregularities identified in the pharmacist's Medication Regimen Review (MRR) for one Resident (#76) out of a sample of 20 residents.
Findings include:
Resident #76 was admitted to the facility in March 2024 with diagnoses that included end stage renal disease, anxiety and left leg above the knee amputation.
Review of Resident #76 most recent Minimum Data Set (MDS) assessment, dated 3/10/24, indicated he/she was unable to participate in the Brief Interview for Mental Status Exam and was assessed by staff as being severely cognitively impaired.
Review of Resident #76's physician's orders, dated 3/19/24, indicated Ativan (a psychotropic medication used to treat anxiety) 0.5 milligrams every four hours as needed.
Review of Resident #76's medical record indicated a pharmacist recommendation dated 3/18/24 with the following recommendation regarding physician's orders for Ativan as needed: PRN [as needed] orders for psychotropic medications are limited to 14 days. If the prescribing practitioner believes it is appropriate for the PRN order to be extended beyond the 14 days, they must document their rationale in the resident's medical record and indicate the duration for the PRN order and give order for a specific stop date. PRN orders cannot be open ended. The physician/ prescriber response was to agree with the recommendations, signed and dated 3/26/24.
Review of physician's orders failed to indicate that nursing staff followed through with the pharmacist's recommendations in the MRR after the practitioner agreed to the recommendation.
Review of the most recent practitioner progress note, dated 3/21/24, indicated that the Ativan order should have a 14 day stop date.
During an interview on 4/2/24 at 2:23 P.M., the Director of Nursing #1 (DON) said that she would expect that the recommendations from the pharmacist's MRR were followed.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Medication Errors
(Tag F0758)
Could have caused harm · This affected 1 resident
Based on record review and interviews the facility failed to ensure that PRN [as needed] ordered psychotropic drugs were limited to 14 days for one Resident (#76) out of a total sample of 20 residents...
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Based on record review and interviews the facility failed to ensure that PRN [as needed] ordered psychotropic drugs were limited to 14 days for one Resident (#76) out of a total sample of 20 residents. Specifically, for Resident #76 the facility failed to ensure a 14 day stop date for a PRN Ativan (a psychotropic medication used to treat anxiety) order.
Findings Include:
Resident #76 was admitted to the facility in March 2024 with diagnoses that included end stage renal disease, anxiety and left leg above the knee amputation.
Review of Resident #76 most recent Minimum Data Set (MDS) assessment, dated 3/10/24, indicated he/she was unable to participate in the Brief Interview for Mental Status Exam and was assessed by staff as being severely cognitively impaired.
Review of Resident #76's physician's orders, dated 3/19/24, indicated: Ativan 0.5 milligrams every four hours as needed. The Ativan order failed to indicate a stop date for the medication.
Review of Resident #76's March and April 2024 Medication Administration Record indicated that PRN Ativan had been administered on 3/22/24.
During an interview on 4/2/24 at 2:23 P.M., the Director of Nursing #1 (DON) said that she would expect that a PRN order for Ativan would have a 14 day stop date and then be re-evaluated.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Medical Records
(Tag F0842)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Review of facility policy titled Prevention of Pressure Ulcer/ Injuries, dated November 2017, indicated to conduct a comprehe...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Review of facility policy titled Prevention of Pressure Ulcer/ Injuries, dated November 2017, indicated to conduct a comprehensive skin assessment upon admission and to inspect the skin on a daily basis when performing or assisting with personal care.
Resident #76 was admitted to the facility in March 2024 with diagnoses that included end stage renal disease and left leg above the knee amputation.
Review of Resident #76 most recent Minimum Data Set (MDS) assessment, dated 3/10/24, indicated he/she was unable to participate in the Brief Interview for Mental Status Exam and was assessed by staff as being severely cognitively impaired. The MDS assessment further indicated that Resident #76 had one or more unhealed pressure injuries and is at risk for further pressure injuries. The MDS indicated that Resident #76 has one stage 2 pressure injury (a shallow, open wound that has broken through both the top and bottom layers of the skin) that was present on admission, and that Resident #76 has a surgical wound.
Review of Resident #76's admission skin evaluation, dated 3/5/24, indicated that Resident #76 had a pressure area to the right heel and non-pressure areas to the left knee surgical site with staples, right buttock, and a right knee scabbed area.
Review of weekly skin evaluations indicated the following:
-On 3/11/24 Resident #76 had a stage IV pressure ulcer (an opening in the skin extending into the muscle, tendon, ligament, cartilage or even bone) to his/her coccyx and a right heel pressure ulcer,
-On 3/18/24 Resident #76 had a stage IV pressure ulcer to his/her coccyx, a right heel pressure ulcer and a right heel scabbed wound.
-On 3/25/24 Resident #76 had no skin areas; skin was documented as clean and intact.
-On 4/1/24 Resident #76 had a right heel scab with surrounding non blanchable area, and a sacrum stage 2 pressure ulcer.
Review of Resident #76's skin care plan dated 3/5/24, indicated actual alterations in skin integrity: left thigh surgical site, right buttock denuded area (loss of the top layer of skin), stage 2 right heel, and surgical wound left above the knee amputation.
Review of Resident #76 progress notes since admission failed to indicate documentation on the condition of Resident #76's coccyx wound, sacrum wound or right heel wound.
During an interview and observation on 4/3/24 at 8:01 A.M., the Director of Nurses #1 (DON) and surveyor reviewed the weekly skin evaluations with DON #1, and the DON said that the evaluations were inaccurate as Resident #4 never had a stage 4 pressure ulcer on his/her buttocks.
2. Resident #13 was admitted to the facility in December 2022 with diagnoses including peripheral vascular disease and obesity.
Review of the most recent Minimum Data Set (MDS) assessment, dated 3/21/24, indicated that Resident #13 had moderate cognitive impairment evidenced by a Brief Interview for Mental Status (BIMS) score of 10 out of 15. This MDS indicated Resident #13 had an open lesion on his/her foot.
On 4/1/24 at 8:06 A.M., the surveyor observed Resident #13 lying in bed. Resident #13 said, the nurses don't change my foot dressing very often. Resident #13 had a dressing on his/her right foot, dated 3/27/24.
Review of the Resident #13's physician's order, 3/12/24, indicated:
-Clean right distal plantar lateral foot with normal saline, apply A & D ointment, then cover with dry dressing, change daily and PRN.
Review of the Treatment Administration Record (TAR), dated 3/27/24, 3/28/24, 3/29/24, 3/30/24, and 3/31/24, indicated physician's treatment order was documented as completed to Resident #13's ankle.
During an interview on 4/1/24 at 8:52 A.M., the surveyor and Nurse #2 observed Resident #13 lying in bed with a dressing on his/her right foot dated 3/27/24. Nurse #2 said the dressing was not changed since 3/27/24; five days before the observation. Nurse #2 said that Resident #13's right foot dressing is ordered to be changed daily and wound dressings should be changed at the frequency the physician ordered. Nurse #2 said if a dressing change is not completed than it should not be documented as completed on the TAR.
During an interview on 4/3/24 at 8:46 A.M., Director of Nursing (DON) #2 said dressings should be changed at the frequency the physician ordered. DON #2 said if a dressing change is not completed than it should not be documented as completed on the TAR.
Based on observations, record reviews, policy review and interviews, the facility failed to maintain accurate medical records for three Residents (#31, #13, and #76) out of a total sample of 20 Residents. Specifically: 1) For Resident #31, the facility inaccurately documented the Resident had been transferred out of bed. 2) For Resident #13, the facility documented a daily wound dressing as completed, when it was not completed according to the physician's order for five days; and 3) For Resident #76 the facility failed to accurately document skin assessments on the weekly skin evaluation.
Findings include:
1. Resident #31 was admitted to the facility in February 2024 with diagnoses including stroke with paralysis on right side and abnormalities of gait and mobility.
Review of Resident #31's most recent Minimum Data Set (MDS), dated [DATE], indicated the Resident had a Brief Interview for Mental Status (BIMS) score of 8 out of a possible 15, which indicated he/she had moderate cognitive impairment. The MDS also indicated Resident #31 required maximal assistance from staff for bed mobility tasks.
On 4/1/24 and 4/2/24, Resident #31 was observed in bed throughout the 7:00 A.M. to 3:00 P.M. shift.
During an interview on 4/2/24 at 11:40 A.M., Certified Nursing Assistant (CNA) #1 said Resident #1 stays in bed for safety reasons and the staff do not transfer him/her out of bed.
Review of the document titled, Documentation Survey Report, dated April 2024, indicated the CNAs documented Resident #31 had been transferred out of bed on 4/1/24 and 4/2/24 during the 7:00 A.M. to 3:00 P.M. shift.
During an interview on 4/2/24 at 1:48 P.M., Director of Nursing #1 said the CNAs should not document an activity that did not occur.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0576
(Tag F0576)
Could have caused harm · This affected multiple residents
Based on observation and interview, the facility failed to ensure residents on 3 of 3 units had access to the use of a telephone where calls can be made without being overheard.
Findings include:
Dur...
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Based on observation and interview, the facility failed to ensure residents on 3 of 3 units had access to the use of a telephone where calls can be made without being overheard.
Findings include:
During the Resident Group Interview on 4/2/24 at 2:00 P.M., all participating residents said that staff are unable to provide a telephone in private for Residents to make calls. Residents reported that the facility used to have a portable phone but now any residents who do not own their own cell phone, can only use the phone at the nurses station, where anyone can hear their conversations. Residents said this occurs on all units.
On 4/3/24 at 8:18 A.M., the surveyors observed Resident #16 at the nurses station on the 2nd floor making a phone call. Resident #16 said that he/she used to be able to have the conversations with his/her family on a portable phone in his/her room but did not know where the portable phone went.
On 4/3/24 at 10:13 A.M. the surveyor observed a resident at the nurses station on the 2nd floor making a phone call while staff and residents were in the area and could overhear his/her conversation.
During an interview on 4/3/24 at 8:22 A.M., CNA #1 said that if a resident needs to use the phone, they need to use the phone at the nursing station. CNA #1 said that the residents used to have a cordless phone, but was not sure what happened to it.
During an interview on 4/3/24 at 8:29 A.M., the Activity Director said that residents have to use the phone at the nurses station if they want to make a phone call on the 1st and 2nd floor nursing units. The Activity Director said that the facility used to have a cordless phone they could use but it's no longer available.
During an interview on 4/3/24 at 10:21 A.M., Director of Nursing (DON) #1 said that there is an office residents can use to make a private call. The DON was not aware staff were not assisting residents to the private office to make private phone calls.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Comprehensive Care Plan
(Tag F0656)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Review of the facility policy titled Care of a Resident with a Pacemaker, dated March 2018, indicated
1. For each resident w...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Review of the facility policy titled Care of a Resident with a Pacemaker, dated March 2018, indicated
1. For each resident with a pacemaker, document the following in the medical record and on a pacemaker identification card upon admission:
a. The name, address, and telephone number of the cardiologist.
b. Type of pacemaker.
c. Type of leads.
d. Manufacturer and model.
e. Serial number.
f. Date of implant; and
g. Paced rate.
2. When the resident's pacemaker is monitored by the Physician, document the date and results of the pacemaker surveillance, including:
a. How the resident's pacemaker was monitored (phone, office, internet);
b. Type of the heart rhythm.
c. Functioning of the leads.
d. Frequency of utilization; and
e. Battery life.
Resident #53 was admitted to the facility in September 2023 with diagnoses that included type 2 diabetes, depression, hyperlipidemia, and chronic kidney disease.
Review of Resident #53's most recent Minimum Data Set (MDS), dated [DATE], indicated the Resident scored a 13 out of 15 on the Brief Interview of Mental Status indicating he/she is cognitively intact.
On 4/1/24 at 8:41 A.M., the surveyor observed a Meditronic device plugged in with a green light on. The device was on the floor next to Resident #53's bed. Resident #53 said he/she has a a pacemaker in his/her chest.
On 4/2/24 at 9:00 A.M., the surveyor observed a Meditronic device plugged in with a green light on. The device was on the floor next to Resident #53's bed.
Review of Resident #53's medical record failed to indicate a plan of care for his/her pacemaker.
During an interview on 4/2/24 at 12:24 P.M., the Director of Nurses (DON) said Resident #53 does have a pacemaker Medtronic device plugged in and functioning. The DON said the Resident should have orders in place and a care plan but does not.
During an interview on 4/3/24 at 9:09 A.M., Nurse #6 said Resident #53 has said in the past that he/she does have a pace maker. Nurse #6 said she has noticed the Meditronic device plugged in and said that is used to transmit data to a cardiology office but is unaware of the Resident's cardiology office to contact. Nurse #6 said there should be orders in place for pacemaker checks and identify the Resident's cardiology office.
Based on record review, observations and interviews, the facility failed to ensure resident centered care plans were developed and/or implemented for two Residents (#47, and #53) out of a total sample of 20 Residents. Specifically the facility failed to;
1.) develop a vision, communication and fall risk care plan for Resident #47,
2.) develop a pacemaker care plan for Resident #53.
Findings include:
A review of the facility's policy titled Care Plans, comprehensive Person-centered dated January 2024, indicated the following:
-A comprehensive, person-centered care plan will be developed for each resident. The care plan will include objectives that meet the resident's physical, psychosocial, and functional needs is developed for each resident. Comprehensive care plan development includes:
a. the Interdisciplinary Team (IDT) in conjunction with the resident and his/her family or legal representative, may assist with the development of a comprehensive care plan for each resident.
b. the care plan interventions are derived from the information gathered as part of the comprehensive assessment.
c. the resident comprehensive care plan will identify problem areas and their causes as warranted and developing interventions that are targeted and meaningful to the resident.
1. Resident #47 was admitted to the facility in October 2022 with diagnoses including legal blindness, anxiety, dementia, and depression.
Review of Resident #47's most recent Minimum Data Set (MDS), dated [DATE], indicated the Resident had a Brief Interview for Mental Status (BIMS) score of 1 out of a possible 15, which indicated he/she had severe cognitive impairment. The MDS also indicated Resident #47 required dependence for all care and mobility.
On 4/1/24 at 8:06 A.M., Resident #47 was observed lying in bed. Certified Nursing Assistant (CNA) #1 entered the room while the surveyors were attempting to interview the Resident. CNA #1 said Resident #47 only speak French-Creole and would not be able to understand the interview and the CNA proceeded to interpret for the surveyor. CNA #1 also said Resident #47 is legally blind and requires assistance for all tasks due to the Resident's physical status.
Review of Resident #47's care plans failed to indicate a care plan for communication, vision status or falls risk.
Review of Resident #47's last comprehensive MDS dated [DATE], indicated the Care Area Assessment (CAA) was triggered for visual function and falls which indicated to proceed to care plan to create a care plan for these areas. Further review of the MDS, in the communication section of the MDS (B0700 and B0800) was not assessed.
During an interview on 4/2/24 at 2:42 P.M., the MDS nurse said if a Care Area Assessment is triggered on a comprehensive MDS than a care plan should be developed for any Care Area Assessments triggered. The MDS nurse said she would expect care plans for vision, communication and fall risk to have been developed for Resident #47 since these Care Area Assessments triggered.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0761
(Tag F0761)
Could have caused harm · This affected multiple residents
Based on observations, interviews, and policy review, the facility failed to ensure staff stored all drugs and biologicals in accordance with accepted professional standards of practice. Specifically,...
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Based on observations, interviews, and policy review, the facility failed to ensure staff stored all drugs and biologicals in accordance with accepted professional standards of practice. Specifically,
1. The facility failed to properly secure medications and medication carts on two of four units.
2. The facility failed to ensure medications were labeled and stored according to manufacturer's guidelines in two of four medication carts.
Findings include:
Review of facility policy titled Storage of Medications, revised 1/2024, indicated:
-The facility shall store drugs and biologicals in a safe, secure, and orderly manner.
2. The nursing staff shall be responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner.
6. Compartments (including, but not limited to, drawers, cabinets, rooms, refrigerators, carts, and boxes) containing drugs and biologicals shall be locked when not in use.
1.) The surveyor made the following observations of medication carts left unlocked, unattended, and out of line of vision:
-On 4/1/24 at 8:39 A.M., the surveyor observed the second floor medication cart #2 unlocked and unattended. Nurse #5 said medication carts should be locked when unattended.
-On 4/2/24 at 8:47 A.M. to 8:52 A.M., Nurse #1 left medication cart unlocked while she was in a resident's room. Nurse #1 said medication carts should be locked when unattended.
-On 4/3/24 at 8:15 A.M., the surveyor observed the second floor medication cart #1 unlocked and unattended. Nurse #8 said medication carts should be locked when unattended.
During an interview on 4/3/24 at 8:46 A.M., the Director of Nursing (DON) said medication carts should be locked when unattended.
2a.) During medication administration pass, on 4/2/24, with Nurse #1 assigned to the second floor medication cart #1, the surveyor observed the following:
-At 8:41 A.M., Nurse #1 removed an unlabeled, undated inhaler that was in vital sign machine, which was stored in the hallway. The inhaler was not in a box. This inhaler has 54 doses remaining. Nurse #1 said she was not sure who's inhaler it was. Nurse #1 said she did not put the inhaler in the vital sign machine and that it should not be in the vital sign machine.
-At 8:43 A.M., Nurse #1 placed the inhaler on the top of the medication cart #1 and walked down the hall and around the corner, out of her line of vision.
-From 8:47 A.M., Nurse #1 left medication cart again with the inhaler left on top of medication cart #1 and was in a resident's room. The inhaler was not within Nurse #1's line of vision.
During an interview on 4/2/24 at 8:52 A.M., Nurse #1 said the inhaler should have been locked in the medication drawer, instead of on top of the medication cart.
During an interview on 4/3/24 at 8:46 A.M., Director of Nursing (DON) #2 said inhalers should be labeled with the resident name, the date opened, and stored in the manufacturer box. DON #2 said inhalers should always be locked in the medication cart.
2b. On 4/2/24 at 1:21 P.M., the surveyor observed the following in the A Unit Medication Cart:
- one Combivent inhaler, opened and undated.
- one Albuterol inhaler, opened and undated.
- one Ventolin inhaler, opened and undated.
- one Fluticasone Propionate inhaler, opened and undated.
- one Spiriva inhaler, opened and undated.
- one Solostar Lantus insulin pen, opened and undated.
During an interview and observation on 4/2/24 at 1:22 P.M., Nurse #9 said inhalers and insulin should be dated when they are opened by the nurse and were not.
During an interview on 4/3/24 at 8:46 A.M., Director of Nursing #2 said inhalers should be labeled with the resident name, the date opened, and stored in the manufacturer box.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Food Safety
(Tag F0812)
Could have caused harm · This affected multiple residents
Based on observation, policy review, and interview, the facility failed to store and prepare food in accordance with professional standards for food service safety.
Findings include:
Review of the fac...
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Based on observation, policy review, and interview, the facility failed to store and prepare food in accordance with professional standards for food service safety.
Findings include:
Review of the facility policy titled, Food and Supply Storage, dated June 2018, indicated the following:
- Food, non-food items, and supplies used in food preparation and service shall be stored in such a manner as to maintain safety and sanitation of food or supply for human consumption as outlined in the Federal Drug Administration Food Code, state regulations, and city county/health codes.
- Discard food that exceeds their use by date or expiration date, is damaged, is spoiled, has the time and temperature danger zone requirements, or incorrectly stored such that it is unsafe or its safety is uncertain.
During an initial tour of the kitchen on 4/1/24 at 7:05 A.M., the following was observed:
*A container of cool whip that was opened and undated. The Top of the container was not fully secured and was loosely on the container.
*A container of coleslaw with a discard date of 3/27/24.
*A container of tuna salad with a discard date of 3/31/24.
*A container of cold cuts, undated.
*A prepared salad, undated.
*Three slices of pizza wrapped in tin foil, undated.
During an observation and interview on 4/2/24 at 11:11 A.M., the surveyor perceived a strong musty odor in the basement food storage area. The surveyor observed a white wispy substance consistent with mold and standing water in the bottom of a chest refrigerator containing multiple cases of milk. The surveyor observed two dented cans in the basement food storage area. The Regional Food Service Director said she would expect staff to notify management if the chest refrigerator needs to be drained and cleaned whenever staff use the refrigerator, and that staff use the refrigerator on a regular basis. The Regional Food Service Director said she was not notified but that the refrigerator needs to be drained and cleaned. The Regional Food Service Director said cans will be inspected when they are received, and any dented cans will be set aside in the office to be returned to the vendor. The Regional Food Service Director also said that cans will be checked before they are brought upstairs to the kitchen on the can rack to be used for cooking.
During an interview and observation on 4/2/24 at 11:22 A.M., the surveyor observed two significantly dented cans of chili con carne stored on the can rack in the kitchen. The Regional Food Service Director said the two cans are dented and should have been set aside to be returned, not stored on the can rack.
Jul 2023
1 deficiency
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0557
(Tag F0557)
Could have caused harm · This affected 1 resident
Based on records reviewed and interviews, for one of three sampled residents (Resident #1), who was moderately cognitively impaired, the Facility failed to ensure he/she was treated in a dignified and...
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Based on records reviewed and interviews, for one of three sampled residents (Resident #1), who was moderately cognitively impaired, the Facility failed to ensure he/she was treated in a dignified and respectful manner, when Certified Nurse Aide (CNA) #1 using her personal phone took a video of Resident #1 without his/her knowledge or consent.
Findings include:
Review of the Facility's Residents Rights Policy, dated November 2017, indicated that the Federal and State laws guarantee certain basic rights to all residents of the facility. These rights include the resident's right to:
-A dignified existence.
-Be treated with respect, kindness, and dignity.
-be free from abuse, neglect, misappropriation of property, and exploitation.
Resident #1 was admitted to the Facility in June 2023, and diagnoses included metabolic encephalopathy, dementia with behavioral disturbance, Alzheimer's disease, and heart disease.
Review of Resident #1's most recent Minimum Data Set Assessment, dated 06/18/23, indicated his/her Brief Interview for Mental Status (BIMS) score was 12 out of 15 indicating moderate cognitive impairment (0-7 indicates severe cognitive impairment, 8-12 indicates moderate cognitive impairment, 13-15 indicates cognitively intact), that he/she required staff assistance with activities of daily living, and ambulated with a walker.
Review of the Facility's Internal Investigation Report, dated 6/18/23, indicated that the Administrator received a call on 06/18/23 at 5:30 P.M. from Nurse #1 regarding Resident #1, who was observed on the floor next to his/her bed, with a cable TV cord around his/her neck. The Report indicated the Administrator was informed that Resident #1 was safe, and 911 had been called. The Investigation indicated that at 7:30 P.M., the Administrator received a call from the Police Detective who reported while investigating the incident that Certified Nurse Aide (CNA) #1 had shown him a video (that was on her personal cell phone) of Resident #1, which depicted Resident #1 on the floor next to his/her bed with the cable cord around him/her neck.
During an interview on 07/31/23 at 11:22 A.M., Nurse #1 said that Certified Nurse Aide (CNA) #1 found Resident #1 on the floor next to his/her bed with a cable TV cord around his/her neck and called for assistance. Nurse #1 said that he removed the cable TV cord, and assessed Resident #1. Nurse #1 said Resident #1 was safe and had no visible injuries. Nurse #1 said he placed a pillow under Resident #1's head and told CNA #1 to stay with Resident #1 while he went to call 911. Nurse #1 said he was not aware that CNA #1 had taken a video of Resident #1 on her personal cell phone.
During an interview on 07/31/23 at 1:30 P.M., Certified Nurse Aide (CNA) #1 said that when she walked by Resident #1's room she did not see Resident # 1 in his/her bed, where he/she had previously been sleeping. CNA #1 said she went into the room and found Resident #1 on the floor next to his/her bed with a cable TV cord wrapped around his/her neck, and she immediately called for assistance. CNA #1 said that after Nurse #1 removed the cable cord, and assessed Resident #1, she took a video on her personal cell phone. CNA #1 said in the video, Resident #1 was still lying on the floor and the cord was visible next to him/her on the floor. CNA #1 said she thought it would help the Administrator to understand what happened. CNA #1 said that after she showed the video to the Police, she realized it was a mistake, that she had violated Resident #1 rights and immediately deleted the video.
During an interview on 07/26/23 at 1:30 P.M., the Administrator said that after the Police informed him that Certified Nurse Aide (CNA) #1 had a video on her personal cell phone regarding Resident #1 on the floor and cord around his/her neck, he interviewed CNA #1. The Administrator said that during an interview with CNA #1, she admitted to taking the video and said she had deleted it immediately. The Administrator said CNA #1 was from an Agency, and the Agency Manager was notified regarding CNA #1 actions.
At the time of the survey, the Surveyor was unable to Interview Resident #1 as he/she had been transferred and admitted to the Hospital for medical issues unrelated to the incident.
On 07/26/23, the Facility was found to be in Past Non-Compliance and presented the Surveyor with a plan of correction which addressed the area(s) of concern as evidenced by:
A. On 06/18/23, Resident #1 was immediately assessed by nursing and sent out to the Hospital for further evaluation.
B. On 06/19/23, the Director of Maintenance conducted TV cord and cable cord safety audits of all resident rooms within the Facility.
C. On 06/19/23, since it was determined by the facility that all residents where potentially at risk to be effected by this issue, Clinical and Management staff re-educated all the staff regarding the Facility's Use of personal cell phones and utilization of videos.
D. 06/19/23 through 06/29/23, re-education was provided to all staff by the Administrator and the Staff Development Coordinator (SDC) on the following:
- Resident Rights
-Safety Protocol providing emergency care.
- Employee use of personal cell phones is prohibited in all residents' areas.
- that any posting of the resident's photo on a staff members (employees) social media accounts is a policy violation.
E. Effective 06/19/23, Random staff interviews were conducted by Clinical Management to ensure staff could verbalize understanding of the Facility Abuse Policy, Resident Rights Policy, and to ensure staff compliance related to the restricted use of personal cell phones.
F. The area of concern was reviewed at the June 2023 QAPI meeting, and the committee will continue to review the issue monthly for a minimum of three months, to ensure substantial compliance.
G. The Administrator and Director of Nursing are responsible for overall compliance.
Feb 2023
22 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0552
(Tag F0552)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, policy review and interviews the facility failed to ensure that one Resident (#2D) out of a total sample...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, policy review and interviews the facility failed to ensure that one Resident (#2D) out of a total sample of 16 residents, whose right to be informed of, and participate in his/her treatment plan, was not honored when his/her activated Health Care Agent, declined the administration of an antidepressant and antipsychotic medication and despite the Health Care Agent signed a refusal, the facility continued to administer the antidepressant and antipsychotic medication.
Findings include:
Review of the facility policy titled, Psychoactive Medication, dated as revised April 2018, indicated:
- an informed consent from the resident or legally authorized individual in the case of resident incompetence is required for administration of psychoactive medications.
Resident #2D was admitted to the facility in February 2023 with diagnoses including cognitive impairment, dementia and glaucoma.
Review of the Minimum Data Set Assessment (MDS) dated [DATE], indicated that Resident #2D was rarely understood. The MDS also indicated that Resident #2D scored 2 out of a possible 15 on the Brief Interview for Mental Status Exam (BIMS) indicating severe cognitive impairment.
Review of the physician's order, dated 2/28/23, indicated:
-Quetiapine (antipsychotic medication) 50 milligrams (mg) by mouth once a day for agitation
-Trazodone (antidepressant medication) 50 mg by mouth once a day for agitation.
Review of the Social Services Note, dated 3/1/23, indicated that Resident #2D's health care agent did not want Resident #2D on antipsychotic medications. The note indicated that the health care agent would be accepting to a psychiatric evaluation.
Review of the Social Services Note, dated 3/2/23, indicated that the psychotropic consents were emailed to Resident #2D's health care agent.
Review of the Informed Consent for Psychotropic Administration Form, dated 3/3/23, indicated:
-Quetiapine: that the resident and or resident's legal representative refused consent. Further review indicated additional writing that said 'please do not use any antipsychotic. The consent indicated the facility Assistant Director of Nursing reviewed the form.
-Trazodone: that the resident and or resident's legal representative refused consent. The consent indicated the facility Assistant Director of Nursing reviewed the form.
On 3/30/23, the Assistant Director of Nursing was not available for an interview. The ADON was no longer employed by the facility.
Review of the Medication Administration Record, dated March 2023, indicated both the Quietapine and Trazodone were administered daily.
During an interview on 3/30/23 at 2:10 P.M., the Social Services Director, said that Resident #2D had dementia and he/she was not his/her own person. The SSD said that Resident #2D's health care agent said that he/she didn't want Resident #2D on any antipsychotic mediations. The SSD reviewed the facility psychiatric progress notes and was unable to provide the surveyor with any documentation to support Resident #2D was evaluated.
During an interview on 3/30/23 at 2:00 P.M., the Director of Nursing said that if Resident #2D's health care agent declined the administration of Quetiapine and Trazodone, nursing should not have administered the medications.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0554
(Tag F0554)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview the facility failed to ensure 1 Resident (#2) was assessed for the ability to ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview the facility failed to ensure 1 Resident (#2) was assessed for the ability to self administer medications out of a total sample of 24 Residents.
Findings include:
Review of the facility policy titled 'Safety and Supervision of Residents', dated as last revised April 2018, indicated that Residents have the right to self-administer medications if the interdisciplinary team has determined that it is clinically appropriate and safe for the resident to do so. Further review indicated that the staff and practitioner will periodically (for example, during quarterly MDS reviews) reevaluate a Resident's ability to continue to self-administer medications.
Resident #2 was admitted to the facility in May 2017 with diagnoses including asthma, schizoaffective disorder and anxiety disorder.
Review of the most recent Minimum Data Set assessment dated [DATE], indicated that Resident #2 scored a 15 out of 15 on the Brief Interview for Mental Status exam indicating that Resident #2 is cognitively intact. Further review indicated Resident #2 requires supervision for activities of daily living.
Review of the doctor's orders dated February 2023 indicated an order for ProAir HFA Aerosol Solution 108 (90 base) MCG/ACT (albuterol Sulfate HFA) 2 puffs inhale orally every 4 hours as needed for SOB/WHEEZE. Further review indicated an order for Flovent HFA Aerosol 220 MCG/ACT (Fluticasone Propionate HFA) 2 puffs inhale orally two times a day, rinse mouth out with water after use.
On 2/5/23, at 8:05 A.M., the surveyor observed Resident #2 lying in bed with a plastic bag containing a Pro-air inhaler (used to treat asthma), and a Flovent inhaler (used to treat asthma).
During an interview on 2/5/23, at 8:05 A.M., Resident #2 said that the nurses leave the inhalers with her/him all the time. Resident #2 then said that she/he does not keep the inhalers in a locked drawer but the nurses are supposed to come back and get them.
On 2/5/23, at 8:58 A.M., the surveyor observed a plastic bag on Resident #2's bed containing a Pro-air inhaler and a Flovent inhaler.
On 2/5/23, at 12:20 P.M., the surveyor observed a plastic bag on Resident #2's bed containing a Pro-air inhaler and a Flovent inhaler.
On 2/6/23, at 7:23 A.M., the surveyor observed a plastic bag on Resident #2's bed containing a Pro-air inhaler and a Flovent inhaler.
During an interview on 2/06/23, 7:23 A.M., Resident #2 said that she/he forgot to give the inhalers back to the nurse.
Review of the medical record failed to indicate an assessment for the self administration of medications or a doctor's order for the self administration of medication.
Resident #2's care plans failed to indicate a plan of care for the self administration of medication.
During an interview on 2/6/23, at 11:09 A.M., Nurse #5 said that she could not locate a doctor's order for the self administration of medication or an assessment for the self administration of medication in Resident #2's medical record.
On 2/7/23, at 1:15 P.M., the Director of Nursing gave the surveyor a document titled NSH SELF MEDICATION EVALUATION-V2 and dated 2/6/23 and written at 4:39 P.M. with a lock time of 4:56 P.M. The Director of Nursing then said that the self administration of medication had been completed and is capable of self administering medication while being supervised.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0637
(Tag F0637)
Could have caused harm · This affected 1 resident
Based on record review and interview, the facility failed to complete a significant change Minimum Data Set assessment for 1 Resident (#1) out of a total sample of 24 Residents.
Finding include:
Resi...
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Based on record review and interview, the facility failed to complete a significant change Minimum Data Set assessment for 1 Resident (#1) out of a total sample of 24 Residents.
Finding include:
Resident #1 was admitted in October 2004 with diagnoses including multiple sclerosis, dysphagia and obstructive uropathy.
Review of Resident #1's significant change in status Minimum Data Set assessment, dated 12/14/22, indicated he/she was not receiving hospice care.
Review of the physician's order, dated 10/6/22, indicated hospice consult evaluation and treatment.
Review of long term care status form, dated 10/11/22, indicated Resident #1 was admitted to hospice services.
Review of the Nursing Note, dated 10/11/22, indicated Resident #1 signed onto hospice services.
During an interview on 2/7/23 at 10:49 A.M., the Director of Clinical Reimbursement said that Resident #1's significant change in status MDS was not completed. The Director of Clinical Reimbursement said that the assessment should have been completed within 14 days of his/her change in status.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Assessment Accuracy
(Tag F0641)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview, the facility failed to accurately complete a Minimum Data Set (MDS) assessmen...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview, the facility failed to accurately complete a Minimum Data Set (MDS) assessment for 1 Resident (#1) out of a total sample of 24 Residents. Specifically, for Resident #1, the facility failed to accurately code a) hospice services and b) antibiotic use.
Findings include:
Resident #1 was admitted in October 2004 with diagnoses including multiple sclerosis, dysphagia and obstructive uropathy.
Review of Resident #1's significant change in status Minimum Data Set (MDS) assessment, dated 12/14/22, indicated he/she was not receiving hospice services and he/she received an antibiotic for 7 days.
a) Review of the MDS dated [DATE], indicated he/she was not receiving hospice services.
Review of the physician's order dated 10/6/22 indicated a hospice consult evaluation and treatment.
Review of the long term care status form, dated 10/11/22 indicated Resident #1 was admitted to hospice services.
Review of the nursing note, dated 10/11/22, indicated Resident #1 signed onto hospice services.
b) Review of the MDS dated [DATE], indicated he/she received 7 days of antibiotics.
Review of Resident #1's medication administration record (MAR) and treatment administration record (TAR), dated December 2022, indicated there was no documentation to support he/she was receiving an antibiotic for 7 days during the assessment reference date.
During an interview on 2/7/23 at 8:16 A.M., the Infection Control Nurse said that Resident #1 was not on any antibiotics during the month of December 2022.
During an interview on 2/7/23 at 10:49 A.M., the Director of Clinical Reimbursement said that Resident #1's hospice services should have been coded on the MDS and she said the the antibiotic use should not have been coded for 7 days.
During a follow up interview on 2/7/23 at 1:00 P.M., the Infection Control nurse provided the surveyor a treatment sheet that indicated Resident #1 received topical bacitracin for 6 days during the assessment reference date.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0657
(Tag F0657)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2.) For Resident #1 the facility failed to revise a plan of care for a deep tissue injury (DTI- pressure related injury) when hi...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2.) For Resident #1 the facility failed to revise a plan of care for a deep tissue injury (DTI- pressure related injury) when his/her wound resolved.
Resident #1 was admitted in October 2004 with diagnoses including multiple sclerosis, dysphagia and obstructive uropathy.
Review of Resident #1's significant change in status Minimum Data Set assessment, dated 12/14/22,
indicated that he/she did not have a DTI.
Review of the physician's order dated 1/27/22, indicated for nursing to apply skin prep to left lateral foot DTI daily.
Review of the treatment administration record, (TAR) dated February 2023, indicated that the area was intact.
Review of the Wound Physician's Wound Evaluation and Management Summary, dated 3/8/22, indicated the deep tissue injury of the left lateral foot was resolved.
During an interview on 2/7/23 at 8:30 A.M., the Infection Control Nurse said that the physician's order should have been revised when the DTI resolved.
During an interview on 2/7/23 at 9:54 A.M., the Director of Nursing said that the physician's order should have been revised when the DTI resolved.
Based on observation, interview and record review, the facility failed to revise the plan of care for 2 Residents (#34 and #1) out of a total sample of 24 Residents.
Findings include:
1. For Resident #34 the facility failed to revise a care plan for the level of assistance Resident #34 requires with eating.
Resident #34 was admitted to the facility in June 2015 with diagnoses including quadriplegia, stroke and dementia.
Review of the most recent Minimum Data Set (MDS) dated [DATE], indicated that Resident #34 scored an 9 out of 15 on the Brief interview for Mental Status exam indicating Resident #34 has moderate cognitive impairment. Further review indicated that Resident #34 requires continual supervision with one person physical assist for eating.
Review of the current care plan with the Focus of ADL (Activities of Daily Living) Function, Eating; (intervention dated 2/2/22) - varies from continual supervision to total assist-resident is non-compliant with diet texture; provide education.
On 2/5/23, at 8:57 A.M., the surveyor observed Resident #34 in bed eating. The surveyor also observed that no staff member was in the room providing continual supervision while Resident #34 was eating.
On 2/5/23, at 12 ;35 P.M., the surveyor observed Resident #34 lying in bed eating. The surveyor also observed that no staff member was in the room providing continual supervision while Resident #34 was eating.
On 2/6/23, at 8:30 A.M., the surveyor observed Resident #34 in bed eating. The surveyor also observed that no staff member was in the room providing continual supervision while Resident #34 was eating.
On 2/6/23, at 12:28 P.M. the surveyor observed Resident #34 sitting in a chair next to his/her bed eating. The surveyor also observed that no staff member was in the room providing continual supervision while Resident #34 was eating.
During an interview on 2/6/23, at 12:45 P.M., Nurse #5 said that Resident #34 always eats without continuous staff supervision.
Review of the current care plan with the Focus of Nutrition indicated to provide assistance as need but that Resident #34 is safe to eat independently.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0676
(Tag F0676)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record review, the facility failed to provide the required supervision of activities of da...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record review, the facility failed to provide the required supervision of activities of daily living (ADLs) for one Resident #10 out of a sample of 24 Residents.
Findings include:
Review of the facility policy titled Activities of Daily Living (ADLs), Supporting revised September 2019 indicated the following:
*Appropriate care and services will be provided for residents who are unable to carry out ADLs independently with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with dining (meals and snacks).
Resident #10 was admitted to the facility in June 2020 with diagnoses including dysphagia and dementia.
The most recent minimum data set (MDS) dated [DATE] indicated a brief interview for mental status (BIMS) score of 4 out of a possible 15 indicating severe impairment.
During an observation on 2/5/23 at 8:32 A.M., the surveyor observed Resident #10 in his/her room alone, eating his/her breakfast meal.
During an observation on 2/5/23 at 12:13 P.M., the surveyor observed Resident #10 eating lunch alone in his/her room.
During an observation on 2/5/23 at 1:01 P.M., the surveyor observed certified nursing assistant, (CNA) #2 walk in and out of Resident #10 while feeding him/her leaving Resident #10 to eat alone for periods of time.
During an interview with CNA #2 on 2/5/23 at 1:05 P.M., she said she usually leaves the room for a certain period while Resident #10 is eating alone to assist other residents on the unit, then returns to check on him/her.
Review of Resident #10 activities of daily living (ADL) care plan dated as initiated 2/1/20 indicated the following:
*Eating-extensive assist to total dependence.
Review of Resident #10's nutrition care plan dated as initiated 10/31/22 indicated the following:
*Provide feeding assistance to total assist with eating as needed.
During an observation on 2/6/23 at 8:14 A.M., CNA #2 was observed delivering Resident #10's breakfast meal tray, then exiting the room. Resident #10 was observed trying to eat and open the milk carton on his/her tray with difficulty, CNA #2 returned to the room to assist the Resident after several minutes.
During an observation on 2/6/23 at 12:34 P.M., Resident #10 was observed in the dining room trying to eat lunch on his/her own.
During an interview with CNA #2 on 2/6/23 at 12:40 P.M., she said Resident #10 is totally dependent while eating, she is not able to stay with him/her because she has to run around the unit and assist other residents.
During an interview with the Director of Nurses (DON) on 2/7/23 at 1:35 P.M., she acknowledged that residents who need extensive assistance during meals should not be left alone during meals.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
ADL Care
(Tag F0677)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview, the facility failed to provide assistance with grooming for 2 Residents (#32...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview, the facility failed to provide assistance with grooming for 2 Residents (#32 and #5) out of a total sample of 24 Residents.
Findings include:
Review of the facility policy titled Activities of Daily Living, dated as revised September 2019, indicated the following:
*Appropriate care and services will be provided for residents who are unable to carry out activities of daily living independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with hygiene (bathing, dressing, grooming, and oral care).
1. Resident #32 was admitted in March 2020 with diagnoses including diabetes.
Review of the Minimum Data Set (MDS) dated [DATE] indicated Resident #32 scored a 14 out of a possible 15 on the Brief Interview for Mental Status (BIMS), which indicated the Resident is cognitively intact. The MDS also indicated that Resident #32 requires one person physical assistance for personal hygiene.
During an interview on 2/5/23 at 8:10 A.M., Resident #32 said he/she feels his/her nails are too long, and had asked staff to trim them a month ago.
During an observation on 2/6/23 at 11:05 A.M., Resident #32's nails were untrimmed, with visible debris beneath the nails.
Review of Resident #32's medical record failed to indicate that the Resident has a history of refusing assistance with personal hygiene.
During an interview on 2/6/23 at 11:16 A.M., Certified Nursing Assistant (CNA) #3 said that if a Resident is observed with unkempt nails or facial hair that the CNA should offer assistance. CNA #3 said that Resident #32 should have been offered to have his/her nails trimmed as they were too long.
2. Resident #5 was admitted in August 2008 with diagnoses including weakness, and psychosis.
Review of the Minimum Data Set (MDS) dated [DATE] indicated that Resident #5 scored a 5 out of a possible 15 on the Brief Interview for Mental Status (BIMS), which indicates severe cognitive impairment. The MDS also indicated that Resident #5 requires one person physical assist for personal hygiene.
During an interview on 2/5/23 at 8:18 A.M., Resident #5 said that he/she feels his/her facial hair is too long, and would like to have it trimmed.
During an observation on 2/6/23 at 11:00 A.M., Resident #5's facial hair was untrimmed and greater than 1 inch in length.
During an interview on 2/6/23 at 11:16 A.M., Certified Nursing Assistant (CNA) #3 said that if a resident is observed with unkempt nails or facial hair the CNA should offer assistance. CNA #3 said that Resident #5 never refuses assistance with grooming and should have been offered to have his/her facial hair shaved as it is long.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Quality of Care
(Tag F0684)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviewed and interviews, for 1 of 24 sampled Residents (#36), the facility failed to ensure nursing provided car...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviewed and interviews, for 1 of 24 sampled Residents (#36), the facility failed to ensure nursing provided care and services that met professional standards of practice, related to monitoring and identifying changes in skin. Specifically, when nursing did not complete comprehensive weekly skin assessments and there was no documentation to support when a pressure injury developed to Resident #36's left heel.
Findings include:
Resident #36 was admitted to the facility in February 2022 with diagnoses including dementia, dysphagia and post-traumatic stress disorder.
Review of Resident #36's quarterly Minimum Data Set assessment dated , 11/2/22, indicated that he/she did not have behaviors, he/she required assistance for bed mobility and dressing, and had a history of weight loss.
Review the physician's order, dated 2/10/22, indicated for nursing to conduct a weekly skin check every evening on Thursdays.
Review of the medical record indicated that on 10/6/22 nursing completed a comprehensive skin check completed under evaluation section. Further review indicated that there was no documentation to support that any comprehensive skin checks were completed until 2/6/23.
Review of the Norton Scale assessment dated [DATE] indicated Resident #36 was a high risk for developing pressure ulcers.
Review of the wound physician's note, dated 12/6/22, there was no documentation to support that Resident #36 had a wound on his/her left heel.
Review of the podiatry note, dated 12/9/22, indicated Resident #36 had a dry superficial left plantar heel eschar (dead tissue) measuring 5 centimeters (cm) x 5 cm.
During an interview on 2/7/23 at 1:12 P.M., Medical Records Coordinator said she receives the podiatry notes from the podiatrist and she sends them to the Director of Nursing.
The Director of Nursing on 12/9/22 was no longer employed by the facility and she was unable to provide the surveyor with an interview.
Review of the wound physician's note, dated 12/14/22, there was no documentation to support that Resident #36 had a wound on his/her left heel.
Review of the physician's note dated, 1/11/23, did not indicate any skin concerns.
Review of the Nurse Practitioner Note dated, 1/19/23, indicated that facility staff reports no acute concerns at this time.
Review of the assessment titled, NASH Pressure Ulcer Evaluation, dated 1/26/23, indicated he/she had a stage two pressure ulcer that measures 3 centimeters by 3 centimeters which was first observed on 1/20/23, the wound has purplish circular discoloration 3 cm x 3 cm with two thirds of discolored circular area open, skin not intact wound bed pink with scant pink drainage.
Review of the wound physician's note, dated 1/31/23, indicated Resident #36 has a new stage 3 pressure wound of the left heel
During an interview on 2/6/23 at 12:47 P.M., Certified Nurse Aide #3 said that Resident #36 had an area on his/her left heel for a while. CNA#3 said that one day it opened up and the nurse put a dressing on the wound.
During an interview on 2/7/23 at 1:16 P.M., the wound physician said that the facility did not make her aware of skin concerns on Resident #36's left heal until 1/31/23. The wound physician said she was following Resident #36 for wound care and she would would only evaluate areas that facility staff requested her to look at. She said she was not made aware of the eschar the podiatrist documented on 12/9/22 until the surveyor reviewed his note.
During an interview on 2/7/23 at 11:30 A.M., the surveyor reviewed the medical record with the Infection Control Nurse and the Regional Nurse. They were unable to provide the surveyor with any additional documentation about the wound that the podiatrist referenced in the note from 12/9/22. They were unable to provide any additional information as to when the pressure ulcer developed on Resident #36's left heel and were not sure if this was the same wound that the podiatrist referenced. The Infection Control Nurse said that comprehensive skin checks should have been completed but were not.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Accident Prevention
(Tag F0689)
Could have caused harm · This affected 1 resident
Based on record review and interviews, the facility failed to complete a fall evaluation for one (Resident #10) out of a sample of 24 Residents.
Findings include:
Review of the facility policy titled...
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Based on record review and interviews, the facility failed to complete a fall evaluation for one (Resident #10) out of a sample of 24 Residents.
Findings include:
Review of the facility policy titled Falls and fall risk, managing last revised April 2018 indicated the following:
*A fall is defined as unintentionally coming to rest on the ground, floor or other lower level, but not as a result of an overwhelming external force. A fall without injury is still a fall, unless there is evidence suggesting otherwise, when a resident is found on the floor, a fall is considered to have occurred.
*If the resident continues to fall, staff will re-evaluate the situation and whether it is appropriate to continue or change current interventions. As needed, the attending physician will help the staff reconsider possible causes that may not previously have been identified.
Resident #10 was admitted to the facility in June 2020 with diagnoses including paranoid schizophrenia, and dementia.
Review of Resident #10's Minimum Data Set (MDS) completed on 10/26/22 indicated he/she scored 4 out of a possible 15 on the Brief Interview for Mental Status (BIMS) indicating severe cognitive impairment.
During a record review of Resident #10's progress notes dated 11/24/22, the following was indicated:
*Resident was noted lying on the floor with his duvet wrapped around him/her during shift change in the AM. Resident stated he/she felt warm on the floor. Patient stable, denies pain, dizziness, shortness of breath, no nausea and vomiting, no signs and symptoms of hypoglycemia, no bruises or sores noted. Vital signs within normal limits, patient persuaded by two nurses to get back in bed, resident slept afterwards, patient monitored during shift, no complaints or signs and symptoms of pain or distress, will continue to monitor and provide safety, report given to the evening nurse.
Further review of the medical record did not indicate that a fall risk evaluation was completed, the medical record did not indicate that an incident report and an investigation was completed to rule out the incident as a fall. The medical record also failed to indicate that the physician and responsible party were notified after the Resident was found lying on the floor.
During an interview with Nurse #2 on 2/6/23 at 2:01 P.M., she said after a Resident is suspected to have fallen, vital signs and a neurological exam are done immediately, the physician and the responsible party are notified, a fall risk evaluation is completed, and an investigation and incident report are initiated.
During an interview with the Director of Nurses on 2/7/23 at 9:55 A.M., she said a after a suspected fall, a fall risk evaluation needs to be completed by staff, an incident report needs to be initiated, the physician and responsible party needs to be notified of the fall.
The facility failed to complete a fall investigation after Resident #10 was documented to have been found on the floor of his/her room on 11/24/22.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0698
(Tag F0698)
Could have caused harm · This affected 1 resident
Based on interview, record review, and policy review, the facility failed to ensure for 2 Residents (#13 and #49) out of a sample of 2 Residents receiving dialysis care and services, were consistent w...
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Based on interview, record review, and policy review, the facility failed to ensure for 2 Residents (#13 and #49) out of a sample of 2 Residents receiving dialysis care and services, were consistent with professional standards of practice. Specifically, the facility failed to ensure ongoing communication and collaboration with the dialysis center.
Findings include: Review of the facility policy titled End-Stage Renal Disease, Care of a Resident with' dated as last revised 11/2017, indicated that residents with end stage renal disease (ESRD) will be cared for according to currently recognized standards of care. Further review indicated that the contracted ESRD and the facility will agree on how information will be exchanged between the facilities to manage all aspects of the resident's care.
1. Resident #13 was admitted to the facility in January of 2018 with diagnoses including end stage renal disease, anemia, severe protein-calorie malnutrition and paranoid schizophrenia.
Review of the medical record indicated that Resident #13 receives dialysis services every Tuesday, Thursday and Saturday.
Review of the facility dialysis communication book for Resident #13 indicated only 3 documents, in the last 3 months, titled Dialysis/Observation Communication Form on dated 1/26/23, 1/28/23, and 1/31/23.
Review of the Nurse's Notes dated 11/5/22, through 2/6/23 indicated 3 nurse's notes dated 11/12/22, 11/14/22, and 12/28/22, that indicated the facility had communication with the dialysis facility regarding the dialysis treatment of Resident #13.
During an interview on 2/6/23, at 12:45 P.M., Nurse #5 said that the nurse on duty when a resident is to go out for a dialysis treatment is to fill out the communication form in the dialysis communication book (pointing to a document titled Dialysis/Observation Communication Form) and send it with the resident for the dialysis facility to complete the form with any pertinent information the facility might need to know, including weights, labs etc and send it back to the facility.
2. Resident #49 was admitted to the facility in February 2020 with diagnoses including schizoeffective disorder, bipolar disorder and metabolic encephalopathy.
Review of the medical record indicated that Resident #49 receives dialysis services every Tuesday, Thursday and Saturday.
Review of the facility dialysis communication book for Resident #49 indicated only 4 documents, in the last 3 months, titled Dialysis/Observation Communication Form on dated 12/3/22, 12/29/22, 1/17/23 and 2/2/23.
Review of the Nurse's Notes dated 11/5/22, through 2/6/23 indicated 2 nurse's notes dated 11/25/23, and 12/28/22, that indicated the facility had communication with the dialysis unit regarding the dialysis treatment of Resident #49.
During an interview on 2/6/23, at 12:45 P.M., Nurse #5 said that the nurse on duty when a resident is to go out for a dialysis treatment is to fill out the communication form in the dialysis communication book (pointing to a document titled Dialysis/Observation Communication Form) and send it with the resident for the dialysis facility to complete the form with any pertinent information the facility might need to know, including weights, labs etc and send it back to the facility.
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
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure that pharmacy recommendations were reviewed and addressed by...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure that pharmacy recommendations were reviewed and addressed by the attending physician for 1 sampled Resident (#44) out of a total of 24 sampled Residents.
Findings include:
Resident #44 was admitted to the facility in December 2022 with diagnoses including Alzheimer's disease, falling and anxiety.
Review of his/her most recent Minimum Data Set, dated [DATE] indicated he/she is severely cognitively impaired and is totally dependent on staff for bathing, dressing and eating.
Review of the monthly pharmacist recommendation to Resident #44's physician for the month of January 2023 indicated the following:
Resident #44 is currently ordered for the following PRN psychotropic Medication: Lorazepam Concentrate: 2 MG/ML - .5 mg sublingually every 4 hours as needed for increased anxiety
Please review this PRN order and consider if d/c is appropriate or document continued need for therapy and specify stop date.
There was no indication in the clinical record that the recommendation was followed up or reviewed by Resident #44's physician or the nurse practitioner.
Review of Resident #44's Medication Administration Records dated December 2022, January 2023 and February 2023 indicated Resident #44 received 9 doses of Lorazepam.
During an interview with Corporate Nurse #1, the Director of Nursing, and the Administrator they acknowledged that Resident #44's pharmacist recommendation was not reviewed by the physician or the nurse practitioner.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Medication Errors
(Tag F0758)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure an as needed (PRN) anti-anxiety medication was limited to 14...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure an as needed (PRN) anti-anxiety medication was limited to 14 day use for 1 sampled Resident (#44) out of a total of 24 sampled Residents.
Findings include:
Resident #44 was admitted to the facility in December 2022 with diagnoses including Alzheimer's disease, falling and anxiety.
Review of his/her most recent Minimum Data Set, dated [DATE] indicated he/she is severely cognitively impaired and is totally dependent on staff for bathing, dressing and eating.
Review of Resident #44's physician's orders indicated the following: record indicated an order for Lorazepam Concentrate, 2 MG/ML/ give .5 mg sublingually every 4 hours as needed for increased anxiety, 12/29/22. (An anti anxiety medication).
Review of Resident #44's Medication Administration Records dated December 2022, January 2023 and February 2023 indicated Resident #44 received 9 doses of Lorazepam.
During an interview with Corporate Nurse #1, the Director of Nursing, and the Administrator they acknowledged that there was no stop date with the use of an as needed anti anxiety medication as required.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Unnecessary Medications
(Tag F0759)
Could have caused harm · This affected 1 resident
Based on observation, interview and record review, the facility failed to ensure it was free from a medication error rate of greater than 5 percent. Two of five nurses observed made 3 errors in 33 opp...
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Based on observation, interview and record review, the facility failed to ensure it was free from a medication error rate of greater than 5 percent. Two of five nurses observed made 3 errors in 33 opportunities on one of three units resulting in a medication error rate of 9.09%. These errors impacted 2 Residents (#11 and #7) out of 6 residents observed.
Finding include:
Review of the facility policy titled , Administering Medications dated as revised 2/2020, indicated medications will be administered in a safe and timely manner, and as prescribed.
-Medications will be administered in accordance with prescriber order, including any required time frame.
-Medications are administered within one hour before or after their prescribed times.
*During the medication administration pass on the C- Unit on 2/5/23 at 10:28 A.M., the surveyor observed Nurse #4 prepare medications for Resident #11 including:
- clonazepam 0.5 milligrams (mg), 1 tablet
- tramadol 50 mg, 1 tablet
Review of Resident #11's active physician's orders, dated 6/17/21, indicated:
-tramadol tablet 50 mg, administer 50 mg by mouth two times a day for Pain
scheduled twice daily at 8:00 A.M. and 8:00 P.M., administered 1 hour and 28 minutes late
Review of Resident #11's active physician's orders, dated 6/10/21, indicated:
-clonazepam tablet 0.5 mg, administer 0.5 mg by mouth three times a day for Anxiety
scheduled three times daily at 8:00 A.M., 2:00 P.M. and at 8:00 P.M., administered 1 hour and 28 minutes late
During an interview on 2/5/23 at 10:28 A.M., Nurse #4 said she was late administering Resident #11 his/her medications.
*During the medication administration pass on the C- Unit on 2/6/23 at 9:37 A.M., the surveyor observed Nurse #3 prepare medications for Resident #7 including:
-metformin 1000 mg, 1 tablet
Review of Resident #7's active physician's order, dated 6/9/22, indicated:
-metformin tablet 1000 mg, administer by mouth two times a day for diabetes, give with breakfast and dinner scheduled at 8:00 A.M. and 5:00 P.M., administered 1 hour and 37 minutes late and without a meal.
During an interview on 2/6/23 at 9:42 A.M., Nurse #3 said she was late administering Resident #7's medications and said she should have administered the metformin with a meal.
During an interview on 2/7/23 at 10:03 A.M., the Director of Nursing said that nursing should administer medications with in 1 hour of scheduled times and nursing should administer medications with meals as ordered.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Resident Rights
(Tag F0550)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3.) For Resident #1 the facility failed to ensure a dignified existence when his/her indwelling catheter bag was not in a privac...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3.) For Resident #1 the facility failed to ensure a dignified existence when his/her indwelling catheter bag was not in a privacy bag.
Resident #1 was admitted in October 2004 with diagnoses including multiple sclerosis, dysphagia and obstructive uropathy.
Review of Resident #1's Minimum Data Set assessment dated [DATE] indicated he/she required an indwelling catheter.
Review of the physician's order, dated 1/16/22, indicated a privacy bag for catheter drainage bag every shift.
During an observation on 2/5/23 8:15 A.M., and on 2/5/23 at 12:59 P.M, Resident #1's indwelling urinary catheter bag was not in a privacy bag.
During an interview on 2/6/23 at 1:40 P.M., the Infection Control Nurse said that indwelling urinary catheter bags should be stored in privacy bags.
During an interview on 2/7/23 at 9:56 A.M., the Director of Nursing said that indwelling urinary catheter bags should be stored in privacy bags.
4.) For Resident #36 the facility failed to ensure a dignified existence when staff were observed standing over him/her during meals throughout the survey.
Resident #36 was admitted to the facility in February 2022 with diagnoses including dementia, dysphagia and post-traumatic stress disorder.
Review of Resident #36's Minimum Data Set assessment dated [DATE] indicated he/she required assistance with eating.
During an observation on 2/5/23 at 9:32 A.M., Resident #36 was in bed and a staff member was standing over him/her while assisting Resident #36 with his/her breakfast.
During an observation on 2/5/23 at 12:57 P.M., Resident #36 was in bed and a staff member was standing over him/her while assisting Resident #36 with his/her lunch.
During an observation 2/6/23 at 8:49 A.M., Resident #36 was in his/her wheel chair and a staff member was standing over him/her while assisting Resident #36 with his/her breakfast.
During an interview on 2/7/23 at 10:12 A.M., the Director of Nursing said that staff should be seated at eye level while assisting Residents with meals.
2.) For Resident #10, the facility failed to provide dignity during dining and meal service.
Resident # 10 was admitted to the facility in June 2020 with diagnoses including dysphagia and dementia.
The most recent Minimum Data Set (MDS) completed 10/26/22 indicated a Brief Interview for Mental Status (BIMS) score of 4 out of a possible 15 indicating severe cognitive impairment.
During an observation on 2/5/23 at 12:13 P.M., the surveyor observed Certified Nursing Assistant (CNA #1) walking in and out of the Resident's room, feeding him/her while standing.
During an observation on 2/6/23 at 8:14 A.M., the surveyor observed CNA #2 feeding Resident # 10 while standing over him/her.
During an observation on 2/6/23 at 12:21 P.M, Nurse #2 was observed checking meal trays, she was overheard telling the CNAs now we have feeds.
During an interview with CNA #2 on 2/6/23 at 12:25 P.M., she said she should be sitting down while assisting Residents with meals.
During an interview with Nurse #2 on 2/6/23 at 12:32 P.M., she said Residents should not be identified as feeds and CNAs should not feed Residents while standing.5. For Resident #44 the facility failed to provide a dignified dining experience as evidenced by staff standing while feeding him/her with his/her lunch meal.
Resident #44 was admitted to the facility in December 2022 with diagnoses including Alzheimer's disease, falling and anxiety.
Review of his/her most recent Minimum Data Set, dated [DATE] indicated he/she is severely cognitively impaired and is totally dependent on staff for bathing, dressing and eating.
On 2/6/23 at 12:27 P.M., the surveyor observed Resident #44 laying in bed with the bed in the lowest position. A Certified Nurses Aide (CNA) was standing next to the bed bending over him/her and feeding him/her bites of his/her meal.
During an interview on 2/7/23 at 10:12 A.M., the Director of Nursing said that staff should be seated at eye level while assisting Residents with meals.
Based on observation, record review and interview the facility failed to provide a dignified existence for 5 Residents (#49, #44, #10, #1 and #36) out of a total sample of 24 Residents.
Findings include:
Review of the facility policy titled Resident Rights and dated as last revised November 2017 indicated that all employees shall treat residents with kindness, respect and dignity.
1. For Resident #49 the facility failed to assist with eating in a dignified manner.
Resident #49 was admitted to the facility in February 2020 with diagnoses including schizoaffective disorder, bipolar disorder and metabolic encephalopathy.
Review of the most recent Minimum Data Set (MDS) assessment dated [DATE], indicated that Resident #49 requires an extensive assist with eating.
On 2/5/23, at 8:57 A.M., the surveyor observed Resident #49 lying in bed with a meal tray on an over the bed table at the end of Resident #49's bed.
During an interview on 2/5/23, at 8:57 A.M. Resident #49 said he/she was very hungry.
On 2/5/23, the surveyor observed Resident #49 wait, with the meal tray in front of him/her, 22 minutes before a staff member entered the room to assist Resident #49 with eating.
On 2/5/23, at 12:33 P.M., the surveyor observed Resident #49 lying in bed. The surveyor then observed a staff member place a meal tray on an over the bed table next to Resident #49.
During an interview on 2/5/23, at 12 ;33 P.M., Resident #49 said he/she was very hungry.
On 2/5/23, the surveyor observed Resident #49 wait, with the meal tray in front of him/her, 24 minutes before a staff member entered the room to assist Resident #49 with eating.
On 2/6/23, at 8:23 A.M., the surveyor observed a food tray placed at the end of Resident #49's bed.
On 2/6/23, at 8:34 A.M., 11 minutes after tray was put in front of Resident #49, the surveyor observed a staff member enter Resident #49's room to assist him/her with eating.
On 2/6/23, at 12:24 P.M. the surveyor observed a staff member enter Resident #49's room, place a meal tray on an over the bed table and leave.
During an interview on 2/6/23, at 12:24 P.M. Resident #49 said he/she was very hungry.
On 2/6/23, the surveyor observed Resident #49 wait, with the meal tray in front of him/her, 14 minutes before a staff member entered the room at 12:38 P.M., to assist Resident #49 with eating.
During an interview on 2/6/23, at 12:45 P.M., Nurse #5 said that all meal trays are passed to the residents before staff starts feeding residents that need to be fed.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0604
(Tag F0604)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4. Resident #44 was admitted to the facility in December 2022 with diagnoses including Alzheimer's disease, falling and anxiety....
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4. Resident #44 was admitted to the facility in December 2022 with diagnoses including Alzheimer's disease, falling and anxiety.
Review of his/her most recent Minimum Data Set, dated [DATE] indicated he/she is severely cognitively impaired and is totally dependent on staff for bathing, dressing and eating.
On 2/5/23 at 8:22 A.M. the surveyor observed Resident #44 laying sideways in bed. The bed was in the lowest position pushed against the wall with the side rails in the down position. There was a pillow covering the side rails. Resident #44 was restless and moving around in bed. He/she was attempting to put his/her legs over the siderail and onto the floor.
Review of Resident #44's clinical record indicated the following:
*A physician's order dated 12/15/22, for 2 1/4 side rails up in bed to help promote bed mobility, safety and positioning.
*An side rail evaluation indicating the use of 1/4 side rails for mobility.
*A consent form for the use of side rails indicating the risk of entrapment left blank and unsigned by Resident #44's activated health care proxy.
On 2/6/23, at 7:10 A.M., the surveyor observed Resident #44 in bed. The bed was in the lowest position pushed against the wall with the side rails in the down position.
On 2/7/23, at 7:17 A.M., the surveyor observed Resident #44 in bed. The bed was in the lowest position pushed against the wall with the side rails in the down position. There were two pillows under the mattress. The surveyor then asked Nurse #1 to observe the side rails and pillows. Nurse #1 said that the siderails were down to keep Resident #44 from falling and that his/her family wanted them that way. Nurse #1 said she was not aware that Resident #44's family did not sign the consent form. Initially Nurse #1 said that the siderails could not be moved to an up position, but then did move them in the up position as indicated in the physician's orders.
The Assistant Director of Nursing then entered and acknowledged that the siderails were in the down position and noted that the pillows under the mattress could be placed for positioning. Nurse #1 said she asked a CNA to place the pillows for Resident #44 because he/she was getting restless but the CNA should not have placed them under the fitted sheet.
On 2/7/23, at 8:36 A.M., the surveyor observed Resident #44 laying sideways in bed. The bed was in the lowest position pushed against the wall with the side rails in the down position. He/she was restless and was attempting to put his/her legs over the siderails onto the floor.
During an interview with the Director of Nursing (DON) on 2/7/23, at 9:41 A.M. she said that when Resident #44's 1/4 rails are in the down position they are a little long. The DON acknowledged Resident #44's inability to get out of bed due to the siderails.
Additional review of Resident #44's clinical record failed to indicate an assessment of the use of the siderails as a possible restraint.
Based on observation, record review and interview, the facility failed to ensure 4 Residents (#19, #34 #49 and #44) were free from restraints out of a total sample of 24 residents. Specifically for Residents # 19, #34, #49 and #44 the facility failed to assess the use of 1/2 siderails as a potential restraint.
Findings include:
Review of the facility policy titled 'Use of Restraints' and dated as last revised 11/2019, indicated:
*Restraints shall only be used for the safety and well-being of the resident(s) and only after other alternatives have been tried unsuccessfully.
*Physical restraints are defined as any manual method or physical or mechanical device, material or equipment attached or adjacent to the resident's body that the individual cannot remove easily
*If the device restricts a resident from changing position or place it is considered a restraint.
*Prior to placing a device that could act as a restraint, a pre-restraining assessment will be completed.
Review of the facility's Proper Use of Side Rails Policy, with a revised date of 4/4/19 indicated:
*Siderails are considered a restraint when they are used to limit the resident's freedom of movement (prevent the resident from leaving his/her bed.)
Observations throughout the survey revealed that the side rails the facility uses act as a 1/4 rail when in the up position. The 1/4 side rails in the down position acts as a 1/2 rail as the rail remained above the mattress.
1. Resident #19 was admitted to the facility in November 2015 with diagnoses including dementia with agitation, traumatic brain injury and difficulty walking.
Review of the most recent Minimum Data Set (MDS) dated [DATE], indicated that Resident #19 scored an 11 out of 15 on the Brief interview for Mental Status exam indicating Resident #19 has moderate cognitive impairment. Further review indicated that Resident #19 requires an extensive assist of two people for bed mobility and an extensive assist of one person for ambulating in his/her room and hallway.
On 2/5/22, at 8:14 A.M. the surveyor observed Resident #19 lying in bed with 1/2 side rails on both sides of the bed extending from upper torso to the knees and a pillow on the left side of the bed extending from the top of the side rail to Resident #19's head.
During an interview on 2/5/22, at 8:14 A.M. Resident #19 said staff put the siderails down and the pillow there to prevent him/her from falling out of bed.
On 2/5/23, at 2:39 P.M., the surveyor observed Resident #19 lying in bed with side rails on both sides of the bed extending from the upper torso to the knees and a pillow on the left side of the bed extending from the top of the side rail to Resident #19's head.
On 2/6/23, at 7:50 A.M. the surveyor observed Resident #19 lying in bed with side rails on both sides of the bed extending from the upper torso to the knees.
Review of the care plan indicated that Resident #19 uses 2 1/4 side rails as an enabler for positioning.
Review of the doctor's orders indicated an order for the use of 2 1/4 side rails up while in bed as an enabler for bed mobility.
Review of the medical record failed to indicate a pre-restraining evaluation to determine if the use of 1/2 side rails acts as a restraint for Resident #19 or if the use of 1/2 side rails is the least restrictive.
2. Resident #34 was admitted to the facility in June 2015 with diagnoses including quadriplegia, stroke and dementia.
Review of the most recent Minimum Data Set (MDS) dated [DATE], indicated that Resident #34 scored an 9 out of 15 on the Brief interview for Mental Status exam indicating Resident #34 has moderate cognitive impairment. Further review indicated that Resident #34 requires an extensive assist of two people for bed mobility.
On 2/5/23, at 8:10 A.M., the surveyor observed Resident #34 sitting up in bed with side rails in the down position, positioned from upper torso to the knees and the mattress at the the end of the bed elevated.
On 2/6/23, at 7:55 A.M., the surveyor observed Resident #34 laying down in bed with side rails in the down position, positioned from upper torso to the knees and the mattress at the end of the bed elevated.
Review of the February 2023 doctor's orders indicated an order for 2, 1/4 rails up while in bed as an enabler for bed mobility.
Review of the care plan intervention, last revised as dated 11/3/20, indicated that Resident #34 used 1/2 rails up while in bed as an enabler for bed mobility.
Review of the Minimum Data Set (MDS) dated [DATE], failed to indicate that side rails were used.
During an interview on 2/5/23, at 8:45 A.M., Certified Nurse's Aide (CNA) #6 said that she thought Resident #34 was supposed to have both side rails down so he/she wouldn't fall out of bed.
Review of the medical record failed to indicate a pre-restraining evaluation to determine if the use of 1/2 side rails acts as a restraint for Resident #34 or if the use of 1/2 side rails is the least restrictive.
3. Resident #49 was admitted to the facility in February 2020 with diagnoses including schizoaffective disorder, bipolar disorder and metabolic encephalopathy.
Review of the most recent Minimum Data Set (MDS) assessment dated [DATE], indicated that Resident #49 requires an extensive assist of 2 people for bed mobility.
Review of the doctor's orders dated February 2023 indicated an order for may have 2, 1/4 side rails when in bed for bed mobility and positioning.
On 2/5/23, at 8:02 A.M.,10:43 A.M., and 12:33 P.M., the surveyor observed Resident #49 laying down in bed with side rails in the down position, positioned from upper torso to the knees.
On 2/6/23, at 8:18 A.M. and 12:35 P.M., the surveyor observed Resident #49 laying down in bed with side rails in the down position, positioned from upper torso to the knees.
Review of the care plan intervention dated as last revised 5/13/21, indicated 2 1/4 rails use for bed mobility due to size of resident. Further review indicated that Resident #49 will be assessed quarterly to determine if the continued use of the side rails is still warranted.
Review of the medical record failed to indicate a side rail assessment.
Review of the medical record failed to indicate a pre-restraining evaluation to determine if the use of 1/2 side rails acts as a restraint for Resident #49 or if the use of 1/2 side rails is the least restrictive.
During an interview on 2/6/23, at 12:45 P.M., Nurse #5 said that she had worked at the facility before and Resident #49 had 2 side rails down because he/she would get agitated and was at risk of falling out of bed.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Comprehensive Care Plan
(Tag F0656)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4.) For Resident #42, the facility failed to ensure weekly skin checks were completed as ordered by the physician.
Resident #42...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4.) For Resident #42, the facility failed to ensure weekly skin checks were completed as ordered by the physician.
Resident #42 was admitted to the facility in September, 2021 with diagnoses including toxic metabolic encephalopathy, weakness, and moderate protein calorie malnutrition.
Review of the Minimum Data Set (MDS), dated [DATE], indicated that Resident #42 was unable to participate in the Brief Interview for Mental Status (BIMS) due to being rarely/never understood. The MDS also indicated Resident #42 was at risk for pressure injuries, requires 2 person extensive assist with bed mobility, transfers, toileting and 1 person assist with personal hygiene.
Review of Resident #42's physician's orders indicated an active order for weekly skin checks, initiated 9/23/2022.
Review of Resident #42's electronic medical record indicated that the most recent skin check evaluation was completed on 11/29/22, which documented redness on the Resident's coccyx. The previous skin check evaluation, dated 11/23/22 indicated that Resident #42's skin was intact.
Further review of the medical record indicated the following:
*No weekly skin checks for the month of December 2022.
*No weekly skin checks for the month of January 2023,
*No weekly skin checks for the month of February 2023.
*A total of 9 weeks of skin checks were not present in Resident #42's medical record.
Review of a nursing progress note, dated 1/26/23, indicated Resident #42 had an unstageable pressure injury on his/her coccyx.
Review of the consulting wound physician note, dated 1/31/23, indicated that Resident #42 had an unstageable (due to necrosis) pressure injury on the coccyx.
During an interview on 2/7/23 at 1:15 P.M., the consulting wound physician confirmed that Resident #42's wound was a pressure injury, that this was a new wound, and that the Resident is at risk for developing pressure injuries due to his/her clinical condition.
During an interview on 2/7/23 at 1:45 P.M., the Infection Preventionist (IP) Nurse said that for residents ordered for weekly skin checks a full skin evaluation is expected to be completed weekly which could also be documented in nursing evaluations. The IP Nurse confirmed that the most recent skin evaluation was completed on 11/29/22, and the most recent nursing evaluation was completed on 11/2/22. The IP Nurse said that Resident #42's weekly skin evaluations should have been completed.
5.) For Resident #61, the facility failed to develop and implement a care plan related to suicidal ideation.
Review of the facility policy titled Suicide Threats, revised 11/2017, indicated the following:
*Resident suicide threats will be taken seriously and addressed appropriately.
*If the resident remains in the facility, staff will monitor the resident's mood and behavior and update care plans accordingly.
Resident #61 was admitted in August 2022 with diagnoses including nontraumatic subarachnoid hemorrhage, and dementia with behavioral disturbances, psychosis, and hallucinations.
Review of the Minimum Data Set (MDS), dated [DATE], indicated that Resident #61 scored a 7 out of a possible total score of 15 on the Brief Interview for Mental Status (BIMS), which indicates moderate cognitive impairment.
Review of the Psychology Services note, dated 9/1/22, indicated Resident #61 was seen after reporting suicidal ideations to staff.
Review of Resident #61's electronic medical record failed to indicate that a care plan addressing suicidal ideations was developed.
During an interview on 2/6/23 at 11:27 A.M., the Director of Social Services said that she would expect a care plan to be developed for a resident with suicidal ideations, and that a care plan for suicidal ideations will be developed for Resident #61.
2.) For Resident #1 the facility failed to a.) develop a care plan related to hospice services and b.) ensure his/her air mattress was on the appropriate settings.
Resident #1 was admitted in October 2004 with diagnoses including multiple sclerosis, dysphagia, and obstructive uropathy.
Review of Resident #1's significant change in status Minimum Data Set assessment dated [DATE], indicated he/she was not receiving hospice care.
a.) Review of his/her plan of care on 2/5/23, indicated there was no documentation to support facility staff developing a hospice plan of care with goals and individualized interventions.
During an interview on 2/6/23 at 1:32 P.M., the Infection Control Nurse said Resident #1 was receiving hospice and there was plan of care in his/her medical record. The IC Nurse said that nursing should have developed a plan of care related to hospice.
During an interview on 2/7/23 at 9:58 A.M., the Director of Nursing said nursing should have developed a hospice plan of care.
b.) During observations on 2/5/23 at 8:15 AM, 2/5/23 at 12:59 P.M., 2/6/23 at 6:40 A.M., 2/6/23 at 11:57 A.M., and on 2/6/23 1:40 P.M., Resident #1 was in his/her bed with the air mattress set to 200 pounds.
Review of Resident #1's plan of care related to pressure ulcer prevention, dated as revised 1/4/21 indicated for air mattress as ordered.
Review of the physician's order, dated 1/16/22, low air loss mattress check settings,placement and function every shift should be set at 150 pounds, may adjust for resident comfort every shift
During an interview and observation on 2/6/23 at 1:40 P.M., the Infection Control Nurse said the air mattress should be set according to the physician's order.
During an interview on 2/7/23 at 9:49 A.M., the Director of Nursing said the air mattress should be set according to the physician's order.
3.) For Resident #36, the facility failed to implement interventions per his/her plan of care related to his/her left hand contracture.
Resident #36 was admitted to the facility in February 2022 with diagnoses including dementia, glaucoma and post-traumatic stress disorder.
Review of Resident #36's quarterly Minimum Data Set assessment dated , 11/2/22, indicated: he/she had a functional limitation in range of motion impairment on one side.
Review of the physician's order dated, 9/2/22, indicated:
-left hand contracture, roll up paper towel/napkin to create barrier and protect skin of palm.
During observations on 2/5/23 at 8:18 A.M., 2/5/23 at 12:57 P.M., 2/6/23 at 6:42 A.M., 2/6/23 at 8:52 A.M., and 2/7/23 at 6:51 A.M., Resident #36 was observed with nothing in his/her left hand according to the physician's orders.
During an interview on 2/7/23 at 7:00 A.M., CNA #4 said that Resident #36 does not use anything in his/her left hand.
During an interview on 2/7/23 at 7:02 A.M., Nurse #6 said that Resident #36 does not use anything in his/her left hand.
During an interview on 2/7/23 at 8:10 A.M., the Infection Control Nurse said the physician's order for the left hand contracture needed to be clarified.
Based on observation, record review, and interviews, the facility failed to develop and implement the plans of care for 5 Residents (#46, #1,#36, #42, and #61), out of a total of 24 sampled Residents.
Findings include:
1.) For Resident #46, the facility failed to implement physician's orders regarding the use of ace wraps his/her edema.
Resident #46 was admitted to the facility in May 2020 with diagnoses including hemiplegia and hemiparesis affecting the left non-dominant side.
Review of his/her most recent Minimum Data Set Assessment (MDS) completed on 11/24/22 indicated a score of 15 out of a possible 15 on the Brief Interview for Mental Status (BIMS) indicating intact cognition.
During an observation on 2/5/23 at 8:16 A.M., Resident #46 was observed in bed with kerlix (gauze rolls used for wound care) wrapped around his/her legs with socks on to hold the kerlix in place. Resident #46 told the surveyor that he/she is supposed to have ace wraps on both his/her legs every morning.
During an observation on 2/6/23 at 8:24 A.M., Resident #46 was observed in bed with kerlix wrapped around both his/her legs with socks on to hold the kerlix up. Resident #46 told the surveyor a nurse is supposed to put ace wraps on his/her legs, but no one has done it in a while.
Review of Resident #46's physicians orders indicated the following:
*Ace wraps to bilateral feet on in the AM and off in the PM, once a day for pedal edema.
During an interview with Nurse #3 on 2/6/23 at 11:43 A.M., she said Resident #46 should have ace wraps on in the morning as ordered, kerlix wrapped on her/his feet does not replace ace wraps.
During an interview with the Director of Nursing on 2/6/23 at 1:44 P.M., she said kerlix wrapped around Resident's feet is not equivalent to ace wraps, Resident #46 should have ace wraps on bilateral feet in the morning, off in the evening, as ordered by the physician.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0700
(Tag F0700)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview, the facility failed to obtain consent for the use of siderails prior to their...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview, the facility failed to obtain consent for the use of siderails prior to their installation for 4 sampled Residents (#44, #19, #34 and #49) out of a total of 24 sampled Residents.
Findings include:
Review of the facility's Proper Use of Side Rails Policy, with a revised date of 4/4/19 indicated:
*Before the use of side rails, the staff shall inform the resident and/or legal representative about the benefits and potential hazards associated with siderails.
Observations throughout the survey revealed that the siderails the facility uses act as a 1/4 siderail when in the up position. The 1/4 side siderails in the down position acts as a 1/2 siderail as the rail remained above the mattress.
1. Resident #44 was admitted to the facility in December 2022 with diagnoses including Alzheimer's disease, falling and anxiety.
Review of his/her most recent Minimum Data Set, dated [DATE] indicated he/she is severely cognitively impaired and is totally dependent on staff for bathing, dressing and eating.
On 2/5/23 at 8:22 A.M., the surveyor observed Resident #44 laying in bed with side rails in the down position.
Review of Resident #44's clinical record indicated the following:
*A physician's order dated 12/15/22 for 2 1/4 side rails up in bed to help promote bed mobility, safety and positioning.
*An side rail evaluation indicating the use of 1/4 side rails for mobility.
*A consent form for the use of side rails indicating the risk of entrapment left blank and unsigned by Resident #44's activated health care proxy.
On 2/6/23 at 7:10 A.M., the surveyor observed Resident #44 in bed with siderails in the down position.
On 2/7/23 at 8:36 A.M., the surveyor observed Resident #44 in bed with the siderails in the down position.
During an interview with Corporate Nurse #1, the Director of Nursing and the Administrator on 2/6/23 at 1:22 P.M., the surveyor informed them that there was no signed consent form for the use of siderails for Resident #44.
2. Resident #19 was admitted to the facility in November 2015 with diagnoses including dementia with agitation, traumatic brain injury and difficulty walking.
Review of the most recent Minimum Data Set (MDS) dated [DATE], indicated that Resident #19 scored an 11 out of 15 on the Brief interview for Mental Status exam indicating Resident #19 has moderate cognitive impairment. Further review indicated that Resident #19 requires an extensive assist of two people for bed mobility and an extensive assist of one person for ambulating in room and hallway.
On 2/5/22, at 8:14 A.M. the surveyor observed Resident #19 lying in bed with 1/2 side rails on both sides of the bed.
Review of Resident #19's clinical record indicated the following:
*A physician's order for the use of 2 1/4 side rails up while in bed as an enabler for bed mobility.
*No signed consent form for the use of siderails
On 2/5/23, at 2:39 P.M., the surveyor observed Resident #19 lying in bed with siderails on both sides of the bed.
On 2/6/23, at 7:50 A.M., the surveyor observed Resident #19 lying in bed with siderails on both sides of the bed.
During an interview on 2/5/22, at 8:14 A.M. Resident #19 said staff put the siderails down and the pillow there to prevent him/her from falling out of bed.
3. Resident #34 was admitted to the facility in June 2015 with diagnoses including quadriplegia, stroke and dementia.
Review of the most recent Minimum Data Set (MDS) dated [DATE], indicated that Resident #34 scored an 9 out of 15 on the Brief interview for Mental Status exam indicating Resident #34 has moderate cognitive impairment. Further review indicated that Resident #34 requires an extensive assist of two people for bed mobility.
On 2/5/23, at 8:10 A.M., the surveyor observed Resident #34 sitting up in bed with side rails in the down position
Review of Resident #34's clinical record indicated the following:
*A physician's order for 2, 1/4 rails up while in bed as an enabler for bed mobility.
*No signed consent form for the use of siderails
On 2/6/23, at 7:55 A.M., the surveyor observed Resident #34 laying down in bed with side rails in the down position.
During an interview on 2/5/23, at 8:45 A.M., Certified Nurse's Aide (CNA) #6 said that she thought Resident #34 was supposed to have both siderails down so he/she wouldn't fall out of bed.
4. Resident #49 was admitted to the facility in February 2020 with diagnoses including schizoeffective disorder, bipolar disorder and metabolic encephalopathy.
Review of the most recent Minimum Data Set (MDS) assessment dated [DATE], indicated that Resident #49 requires an extensive assist of 2 people for bed mobility.
On 2/5/23, at 8:02 A.M.,10:43 A.M., and 12:33 P.M., the surveyor observed Resident #49 laying down in bed with side rails in the down position.
Review of Resident #49's clinical record indicated the following:
*A physician's order for 2 1/4 side rails when in bed for bed mobility and positioning.
*No signed consent form for the use of siderails.
On 2/6/23, at 8:18 A.M. and 12:35 P.M., the surveyor observed Resident #49 laying down in bed with siderails in the down position.
During an interview on 2/6/23, at 12:45 P.M., Nurse #5 said that she had worked at the facility before and Resident #49 had 2 siderails down because he/she would get agitated and was at risk of falling out of bed.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0761
(Tag F0761)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview the facility failed to 1. store medications securely for 1 Resident (#2) and 2. label medicat...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview the facility failed to 1. store medications securely for 1 Resident (#2) and 2. label medications appropriately in 1 of 1 medication rooms and 2 of 2 medication carts.
Findings include:
1. Resident #2 was admitted to the facility in May 2017 with diagnoses including asthma, schizoeffective disorder and anxiety disorder.
Review of the most recent Minimum Data Set assessment dated [DATE], indicated that Resident #2 scored a 15 out of 15 on the Brief Interview for Mental Status exam indicating that Resident #2 is cognitively intact. Further review indicated Resident #2 requires supervision for activities of daily living.
Review of the doctor's orders dated February 2023 indicated an order for ProAir HFA Aerosol Solution 108 (90 base) MCG/ACT (albuterol Sulfate HFA) 2 puffs inhale orally every 4 hours as needed for SOB/WHEEZE. Further review indicated an order for Flovent HFA Aerosol 220 MCG/ACT (Fluticasone Propionate HFA) 2 puffs inhale orally two times a day, rinse mouth out with water after use.
On 2/5/23, at 8:05 A.M., the surveyor observed Resident #2 lying in bed with a plastic bag containing a Pro-air inhaler (used to treat asthma), and a Flovent inhaler (used to treat asthma).
During an interview on 2/5/23, at 8:05 A.M., Resident #2 said that the nurses leave the inhalers with him/her all the time. Resident #2 then said that he/she does not keep the inhalers in a locked drawer but the nurses are supposed to come back and get them.
On 2/5/23, at 8:58 A.M., the surveyor observed a plastic bag on Resident #2's bed containing a Pro-air inhaler and a Flovent inhaler.
On 2/5/23, at 12:20 P.M., the surveyor observed a plastic bag on Resident #2's bed containing a Pro-air inhaler and a Flovent inhaler.
On 2/6/23, at 7:23 A.M., the surveyor observed a plastic bag on Resident #2's bed containing a Pro-air inhaler and a Flovent inhaler.
During an interview on 2/06/23, 7:23 A.M., Resident #2 said that he/she forgot to give the inhalers back to the nurse.
2. On 2/7/23, at 9:00 A.M., the surveyor observed the following in the second floor medication cart:
A. 1 orange capsule in a medication cup on top of the medication cart, the cart unlocked and no nurse within eye sight of the medication cart.
B. 1 medication cup in the top drawer with 20 different pills in it, marked with the name of [NAME] and the number 20 on the cup.
C. 1 bottle of Brimonedine Tartrate eye drops without a date opened.
D. 1 bottle of Latanoprost eye drops without a date opened and a dispensed date of 12/17/22.
E. 1 bottle of Atropine 1% eye drops without a date opened and a dispensed date of 1/8/23.
F. 1 bottle of Dorzol/Timolol eye drops without a date opened and a dispensed date of 12/17/22.
During an interview on 2/7/23, at 9:15 A.M., Nurse #8 acknowledged the un-labeled eye drops, the medication on top of the medication cart and the unlocked medication cart. Nurse #8 said that the pre-poured medications in the top drawer of the medication cart were there because a resident had refused to take them and he was going to go back later and administer them.
3. On 2/7/23, at 9:20 A.M., the surveyor observed the following in the second floor medication room:
A. 1 bottle of Trusopt eye drops opened and without a date.
B. 1 bottle of Cosopt eye drops opened and without a date.
C. 1 bottle of Alphagan eye drops opened and without a date.
D. 1 vial of Novolog insulin opened, without a date and a date dispensed of 12/17/22.
During an interview on 2/7/23, at 9:25 A.M., Nurse #8 acknowledged the unlabeled medication.
4. On 2/7/23, at 9:40 A.M., the surveyor observed the following in the A unit medication room:
A. 1 tube of antifungal topical ointment in with oral medication.
B. 1 tube of Clotrimazole topical ointment in with oral medication.
C. 1 bottle of Latanoprost eye drops open, without a date opened and a dispensed date of 12/16/22.
D. 2 bottles of artificial tears open, without a date opened.
E. 1 albuterol inhaler open without a date and without a date dispensed.
F. 1 bottle of Oxcarbazepine open, without a date opened, and a dispensed date of 12/17/22. Review of the manufacturer's directions indicated that the medication expires 7 weeks after opening.
During an interview on 2/7/23, at 9:40 A.M., Nurse #9 acknowledged the un-labeled medication.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Food Safety
(Tag F0812)
Could have caused harm · This affected multiple residents
Based on observation, interview, and policy review the facility failed to maintain proper sanitation practices related to 1.) food storage, and 2.) food handling.
Findings include:
1) Review of the ...
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Based on observation, interview, and policy review the facility failed to maintain proper sanitation practices related to 1.) food storage, and 2.) food handling.
Findings include:
1) Review of the facility policy titled, Food and Supply Storage, revised June 2018 indicated the following:
*Food, non-food items, and supplies used in food preparation and services shall be stored in such a manner as to maintain safety and sanitation of the food or supply for human consumption as outlined in the Federal Drug Administration Food Code, state regulations, and city/county health codes.
*Food and food supplies are stored to minimize exposure to splash, dust, or other contamination.
*Refrigerated Time/Temperature Control for Safety (TCS), ready to eat foods (foods which are especially susceptible to encourage the growth of bacteria that can cause sickness if consumed, such as Eggs, Dairy, Meat products, and cooked vegetables) prepared on site that is held longer than 24 hours should be properly labeled with the common name, the preparation date (day 1), and use by date (maximum 7 days).
During the initial walkthrough of the kitchen on 2/5/23 at 7:29 A.M., the following observations were made:
*The fan/ceiling of the reach-in refrigerator was coated in a black, fuzzy substance. 2 partially uncovered containers with hot dogs and mushrooms were stored directly below the fan.
*A container labeled pasta sauce 1/18, in the reach-in refrigerator.
*A container labeled tomato sauce 1/28, in the reach in refrigerator.
*A container labeled chopped mushrooms 1/24, in the reach in refrigerator.
*A container with cooked pork chops, labeled 1/31, in the reach in refrigerator.
*A container labeled rice 1/29, in the reach in refrigerator
During an interview on 2/5/23, at 7:40 A.M., the Food Service Director (FSD) said food items should be labeled with the preparation/open date, and discarded after 5 days. The FSD identified the substance on the reach-in refrigerator ceiling/fan as mold, and said that the mold has been a persisting and reoccurring issue.
2) Review of the facility policy titled Personal Hygiene for Food Handlers, June 2018 indicated the following:
*Hair Restraints:
-Hair restraints such as hats, hair coverings or nets, and beard restraints are worn at all times when in the kitchen.
-Hair is to be fully contained inside the covering
Review of the facility policy titled, Handwashing, Bare Hand Contact, and glove Use, revised 06/2018, indicated the following:
*When to wash hands:
-after changing tasks
-after touching anything else that may contaminate gloves, such as dirt equipment, work surfaces, cloths, or blood and bodily fluids
*When to change gloves:
-when soiled
-before beginning a new task
-after touching contaminated surface
-after contaminating gloves in a manner that would require handwashing of ungloved hands
During the initial walkthrough of the kitchen on 2/5/23 at 7:29 A.M., the Food Service Director was observed in the food preparation area without a hair restraint.
During the tray line observation on 2/6/23 at 7:50 A.M., the following observations were made:
*The cook was observed contaminating her gloves by touching utensils, an oven door, the steamer handle, and a cloth oven holder to remove a tray of bacon from the oven, then using the same gloved hands to cut pancakes, toast, and an English muffin. The cook then used her contaminated gloved hands to scoop the cut up, ready to eat food directly on resident plates.
During an interview on 2/6/23, at 9:12 A.M., the Foodservice Director (FSD) said that typically food is pre-cut to avoid food handling issues, the FSD also acknowledged that she was not wearing a hair restraint during the initial tour of the kitchen.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Medical Records
(Tag F0842)
Could have caused harm · This affected multiple residents
2.) For Resident #1 the facility failed to maintain a complete and accurately documented medical record for a) when nursing documented they changed an indwelling urinary catheter (foley) urinary drain...
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2.) For Resident #1 the facility failed to maintain a complete and accurately documented medical record for a) when nursing documented they changed an indwelling urinary catheter (foley) urinary drainage bag and b) maintain a complete and accurately documented medical record related to intake and outputs.
Resident #1 was admitted in October 2004 with diagnosis including multiple sclerosis, dysphagia and obstructive uropathy.
Review of Resident #1's significant change in status Minimum Data Set assessment, dated 12/14/22,
indicated he/she required a indwelling catheter.
a. During an observation on 2/5/23 at 8:15 A.M., the Foley catheter bag was dated 1/12/23.
Review of the physician's order dated 8/10/22, indicated for staff to change Foley bag and privacy
bag every two weeks on the 11:00 P.M. to 7:00 A.M. shift (label with date bag with changes) every night shift every 2 weeks on Wednesdays.
Review of the Treatment Administration Record, dated January 2023, indicated the Foley bag was changed on 1/11/23 and 1/25/23.
During an observation on 2/6/23 at 1:40 P.M., the surveyor accompanied by the Infection Control Nurse observed the date on the Foley catheter bag dated 1/12/23. The Infection Control Nurse said that the bag should have been changed on 1/25/23.
During an interview on 2/7/23 at 9:49 A.M., the Director of Nursing said Foley catheter bag should have been changed on 1/25/23.
b. Review of the physician's order dated 1/16/22 , indicated for staff to monitor intake and output every shift.
Review of the Medication Administration Record, dated February 2023, indicated there was only one area for staff to document both the the intake and output.
During an interview on 2/7/23 at 8:18 A.M., the Infection Control Nurse said that the order needs to be clarified. The Infection Control Nurse said that there should be a location for nursing to document the intake and the output separately.
During an interview on 2/7/23 at 9:51 A.M., the Director of Nursing said the order for intake and outputs needed to be clarified. The DON said that nursing did not accurately document in the medical record his/her intake and outputs.
3.) For Resident #36 facility failed to maintain a complete and accurately documented medical record related to the dose of senno
tablet (medication used to treat constipation).
Review of the facility policy titled, Administering Medications, dated as revised 2/2020, indicated for the person administering the medication to verify the right dose before administering the medication.
Resident #36 was admitted to the facility in February 2022 with diagnoses including dementia, dysphagia and post-traumatic stress disorder.
Review of the physician's order dated 7/5/22, indicated:
-senno tablet, administer two tablets by mouth in the evening for constipation.
Further review indicated that there was no dose, as required.
During an interview on 2/7/23 at 8:12 A.M., the Infection Control Nurse said that the senno tablet ordered failed to indicate a dosage and required clarification.
4.) For Resident #64 the facility failed to keep an accurate medical record related to the form of aspirin that nursing was administering.
Resident #64 was admitted to the facility in January 2023 with diagnosis including diabetes, anemia and neoplasm of the pancreas.
Review of his/her physician's order dated 1/20/23, indicated for nursing to administer aspirin oral capsule 81 milligrams one time a day for hypertension. (aspirin capsules are a form of aspirin that is designed to release aspirin in the first part of the intestine which will reduce stomach erosions and ulcers that sometimes occur with regular tablets of aspirin.)
During an observation and interview on 2/6/23 at 12:41 P.M., Nurse #7 said she administered aspirin tablets to Resident #64. She said that she had never seen Asprin capsules.
During an interview on 2/7/23 at 8:25 A.M., the Infection Control Nurse said the aspirin form needed to be clarified.
Based on observation, record review and interview, the facility failed to maintain an accurate medical record for 4 Residents (#49, #1, #36, and #64) out of a total sample of 24 Residents.
Findings include:
1. Resident #49 was admitted to the facility in February 2020 with diagnoses including schizoaffective disorder, bipolar disorder and metabolic encephalopathy.
On 2/5/23, at 7:50 A.M., the surveyor observed Resident #49 lying in bed with a dry protective dressing on his/her left upper arm.
During an interview on 2/5/23, at 7:50 A.M.,Resident #49 said that the dressing on his/her left upper arm was because of dialysis.
Review of the doctor's orders dated February 2023 indicated that Resident #49 receives dialysis Tuesdays, Thursdays and Saturdays. Further review indicated 2 different orders for checking the function of the arteriovenous (AV) fistula created for Resident #49 to receive dialysis.
1. AV Fistula: X Brachial R check thrill and bruit each shift. Document + if present, - if not present every shift.
2. Check bruit and thrill on left arm notify NP/MD with changes to fistula every shift.
Review of the Medication Administration Record (MAR) February 2023 indicated that for 13 out of 15 shifts, the AV Fistula Right Brachial was documented as having a positive bruit and thrill.
During an interview on 2/6/23, at 2:20 P.M., Nurse #5 said that Resident #49's dialysis access fistula is on the left upper arm (left Brachial). Nurse #5 then said that she documented incorrectly on the MAR, positive bruit and thrill for the Right brachial for Resident #49. Nurse #5 said that she did not thoroughly read the doctor's order.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected multiple residents
Based on observations and interviews, the facility failed to wear Personal Protective Equipment (PPE) appropriately to prevent the potential spread of infection on 2 out of 3 units.
Findings include:...
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Based on observations and interviews, the facility failed to wear Personal Protective Equipment (PPE) appropriately to prevent the potential spread of infection on 2 out of 3 units.
Findings include:
On 2/5/23, at 8:00 A.M., the surveyor observed Certified Nurse's Aide (CNA) #5 in the hallway of the first floor unit with her mask beneath her nose standing next to and talking to another CNA.
On 2/6/23 at 7:59 A.M., the surveyor observed a CNA walking down the hallway on the second floor, wearing gloves and holding bag of soiled linen. The surveyor then observed the CNA to open the door to the soiled linen cute, remove her gloves in the hallway and without performing hand hygiene entered the dining area.
On 2/7/23, at 8:17 A.M., the surveyor observed a CNA walking down hallway on the second floor wearing gloves and carrying dirty linen.
On 2/07/23, at 11:25 A.M., the surveyor and the Infection Control Nurse, observed Certified nurse's Aide #5 walking down the hallway on the first floor with 2 gloves on carrying a clean shirt and a protective brief. The surveyor also observed CNA #5 with her mask beneath her nose.
During an interview on 2/7/23, at 11:25 A.M., CNA #5 said that the reason that she was wearing gloves was because her hands were dirty.
During an interview on 2/7/23, at 11:25 A.M., the Infection Control Nurse (ICN) said that CNAs are not allowed to wear 2 gloves in the hallway, only one that is carrying a bag with soiled linen. The ICN then said that masks are supposed to be worn above the nose and gloves are never to be put on over dirty hands.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Safe Environment
(Tag F0584)
Could have caused harm · This affected most or all residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** During observations on 2/7/23 at 7:30 A.M., the surveyor observed the following on the 1st floor nursing unit:
room [ROOM NUMBER...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** During observations on 2/7/23 at 7:30 A.M., the surveyor observed the following on the 1st floor nursing unit:
room [ROOM NUMBER]: There were scuff marks and cracks on the wall by the foot of B bed. There was paint chipping on the outside of the doorframe.
room [ROOM NUMBER]: There were black streaks under the bed. There was paint chipping off the outside of the doorframe.
room [ROOM NUMBER]: There was paint chipping off the outside of the doorframe.
The bathroom connected to room [ROOM NUMBER]: The ceiling was stained and discolored.
room [ROOM NUMBER]: There was paint chipping off the outside of the doorframe.
room [ROOM NUMBER]: There was paint chipping off the outside of the doorframe.
room [ROOM NUMBER]: There were black streaks on the floor by B bed, and peeling paint on and under the windowsill. There was paint chipping off the outside of the doorframe.
room [ROOM NUMBER]: There were black streaks on the floor under the B bed. There was paint chipping off the outside of the doorframe.
The bathroom connected to room [ROOM NUMBER]: There was a crack and peeling paint on the ceiling.
room [ROOM NUMBER]: There was a chunk of floor tile missing between the room and the bathroom posing a tripping hazard, the shelf inside the bedside table by B bed was broken.
room [ROOM NUMBER]: There were scuff marks and paint chipping on the wall by A bed. There was paint chipping off the outside of the doorframe.
The bathroom connected to room [ROOM NUMBER]: The bathroom sink was full of water and unable to drain.
room [ROOM NUMBER]: There was a crack in the paint above the doorframe from the inside of the room, paint was chipping on the windowsill and walls. There was paint chipping off the outside of the doorframe.
room [ROOM NUMBER]: There was paint chipping off the outside of the doorframe.
room [ROOM NUMBER]: There were chunks of floor tile missing, and the Residents footboard was broken. There was paint chipping off the outside of the doorframe.
The bathroom connected to room [ROOM NUMBER]: There were tiles missing from the wall.
Unlabeled door to the right of room [ROOM NUMBER]: There was paint chipping off the outside of the doorframe.
room [ROOM NUMBER]: There were scuff marks and chipped paint near the A bed wall.
room [ROOM NUMBER]: There were black streaks under both resident beds.
room [ROOM NUMBER]: There was paint chipping on the wall.
room [ROOM NUMBER]: There were cracks in the paint by the door and by the window, and the A bed remote did not work consistently. There was paint chipping off the outside of the doorframe.
room [ROOM NUMBER]: There was paint chipping off on the wall.
room [ROOM NUMBER]: There was paint chipping off the outside of the doorframe.
The bathroom connected to room [ROOM NUMBER]: There was rust on the floor heating panel and cracks in the ceiling. There was paint chipping off the outside of the doorframe.
room [ROOM NUMBER]: There was paint chipping near the door on the inside of the room.
room [ROOM NUMBER]: There was paint chipping off the outside of the doorframe.
The elevator: There was paint chipping off of the inside of the door.
During an interview with the Maintenance Director on 2/6/23 at 2:27 P.M., he said he has been trying to do needed repairs and updates to the building one room at a time, but he is dependent on staff to alert him when things need to be fixed and staff do not always tell him when maintenance issues arise.
Based on observation and interview, the facility failed to maintain a comfortable home like environment on 2 of 2 Resident units.
Findings include:
During observations on 2/5/23 at 8:16 A.M., the surveyor observed the following on the 2nd floor nursing unit:
room [ROOM NUMBER] Bathroom: There was a hole in the wall above the sink. The water faucet on the left was stuck in the on position but no water was coming out.
room [ROOM NUMBER]: There was no functional heat system. The Residents had to be moved out of the room as the outdoor temperatures had been below 0 degrees Fahrenheit.
During an interview with the Maintenance Director on 2/6/23 at 2:44 P.M., he said that he was not aware that the heat was not working in room [ROOM NUMBER].
During observations on 2/7/23 at 7:49 A.M., the surveyor observed the following:
room [ROOM NUMBER]: There were gouges on the bathroom door. The thermostat on the wall was missing a plate cover. There were patches of plaster without paint on the wall behind the door and the overbed table by the window had deep gouges and indentations in the wood. The privacy curtains were stained and visibly dirty.
room [ROOM NUMBER]: There were cracks in the linoleum flooring with gouges and scratches in the wall. The dressers and nightstands were visibly worn and scratched.
The shared bathroom between rooms [ROOM NUMBERS]: There was a rusted metal plate on the wall and toilet paper hanging from a rusted metal towel holder.
room [ROOM NUMBER]: There were no closet doors. The windowsill was visibly dirty with dirt and debris. The curtains were soiled and stained. There were large deep gouges in the headboard and behind the bed by the window. There were cracks in the linoleum flooring.
room [ROOM NUMBER]: A portion of the window frame was missing. The dressers were scratched and worn. There was a Styrofoam cooler on the floor with a large hole on the top.
In the shared closet area between room [ROOM NUMBER] and room [ROOM NUMBER] by the bathroom, the surveyor found a large piece of wood with multiple nails sticking out of it, (which appeared to be the missing portion of room [ROOM NUMBER]'s window) which could easily be accessed by wandering/behavioral residents with dementia in either of the rooms. The Surveyor immediately notified the Maintenance Director who removed the item and said that that item should have been removed by staff and that it was not safe as it was accessible to residents with dementia and behaviors.
The shared closet space also had a large hole in the wall near the door to the bathroom noted by the Maintenance Director who said that he was not aware of it.
Shared bathroom between room [ROOM NUMBER] and 218: The radiator was visibly dirty and dusty. The linoleum flooring was cracked and broken.
room [ROOM NUMBER]: There was a fall mat with large brown stains of an unknown substance on the floor.
room [ROOM NUMBER]: There was a cover plate missing from thermostat on the wall. There were stained bed sheets and the walls were scuffed.
room [ROOM NUMBER]: The windowsill was damaged and had visible water damage along the bottom. There were broken and missing pieces of linoleum flooring. by the door.
The shared bathroom between room [ROOM NUMBER] and 221: The radiator was rusted and visibly dirty. The tiles behind and under the toilet were cracked and coming off the the wall. The light fixture was yellowed and had visible debris inside of it.
room [ROOM NUMBER]: The bedding and privacy curtains were stained. There linoleum flooring was cracked and broken.
The shared bathroom between room [ROOM NUMBER] and 218: The radiator was rusted and broken. There were pieces of tile that were broken and cracked.
room [ROOM NUMBER]: There were cracks in the leather chair and portions of linoleum flooring missing by the window. The night stand was broken and the dresser was visibly worn and scratched.
The window in the hallway between room [ROOM NUMBER] and 222 had a long strip of black electrical tape running across it. The windowsill had peeling paint and water damage.
room [ROOM NUMBER]: The curtains were stained and the walls had scratches in the paint.
The shared bathroom between room [ROOM NUMBER] and 223: The toilet seat was broken and on the slant. There was a yellow stethoscope and papers on top of the sharps container. The door had deep gouges.
room [ROOM NUMBER]: There were stains on the ceiling, and cracks in linoleum flooring. The window blinds were missing pieces and the dressers were visibly worn and scratched.
There were stains of an unknown substance on the walls in the hallway near room [ROOM NUMBER] and 224.
room [ROOM NUMBER]: There were multiple screws on the windowsill.
Private Bathroom in room [ROOM NUMBER]: The flooring was stained by the radiator and the tiles on the wall were cracked.
Understanding Severity Codes (click to expand)
Life-Threatening (Immediate Jeopardy)
J - Isolated
K - Pattern
L - Widespread
Actual Harm
G - Isolated
H - Pattern
I - Widespread
Potential for Harm
D - Isolated
E - Pattern
F - Widespread
No Harm (Minor)
A - Isolated
B - Pattern
C - Widespread
Questions to Ask on Your Visit
- "Can I speak with families of current residents?"
- "What's your RN coverage like on weekends and overnight?"
Our Honest Assessment
Strengths
- • Licensed and certified facility. Meets minimum state requirements.
Concerns
- • Multiple safety concerns identified: 1 harm violation(s), $110,773 in fines. Review inspection reports carefully.
- • 67 deficiencies on record, including 1 serious (caused harm) violation. Ask about corrective actions taken.
- • $110,773 in fines. Extremely high, among the most fined facilities in Massachusetts. Major compliance failures.
- • Grade F (20/100). Below average facility with significant concerns.
Bottom line: Trust Score of 20/100 indicates significant concerns. Thoroughly evaluate alternatives.
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About This Facility
What is Melrose Healthcare's CMS Rating?
CMS assigns MELROSE HEALTHCARE 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 Melrose Healthcare Staffed?
CMS rates MELROSE HEALTHCARE's staffing level at 2 out of 5 stars, which is below average compared to other nursing homes. Staff turnover is 46%, compared to the Massachusetts average of 46%. This relatively stable workforce can support continuity of care. RN turnover specifically is 65%, which is notably high. RNs provide skilled clinical oversight, so turnover in this role can affect medical care quality.
What Have Inspectors Found at Melrose Healthcare?
State health inspectors documented 67 deficiencies at MELROSE HEALTHCARE during 2023 to 2025. These included: 1 that caused actual resident harm and 66 with potential for harm. Deficiencies causing actual harm indicate documented cases where residents experienced negative health consequences.
Who Owns and Operates Melrose Healthcare?
MELROSE HEALTHCARE 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 NEXT STEP HEALTHCARE, a chain that manages multiple nursing homes. With 106 certified beds and approximately 96 residents (about 91% occupancy), it is a mid-sized facility located in MELROSE, Massachusetts.
How Does Melrose Healthcare Compare to Other Massachusetts Nursing Homes?
Compared to the 100 nursing homes in Massachusetts, MELROSE HEALTHCARE's overall rating (1 stars) is below the state average of 2.9, staff turnover (46%) is near the state average of 46%, and health inspection rating (1 stars) is much below the national benchmark.
What Should Families Ask When Visiting Melrose Healthcare?
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 Melrose Healthcare Safe?
Based on CMS inspection data, MELROSE HEALTHCARE 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 Melrose Healthcare Stick Around?
MELROSE HEALTHCARE has a staff turnover rate of 46%, 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 Melrose Healthcare Ever Fined?
MELROSE HEALTHCARE has been fined $110,773 across 2 penalty actions. This is 3.2x the Massachusetts average of $34,187. Fines at this level are uncommon and typically indicate a pattern of serious deficiencies, repeated violations, or failure to correct problems promptly. CMS reserves penalties of this magnitude for facilities that pose significant, documented risk to resident health or safety. Families should request specific documentation of what issues led to these fines and what systemic changes have been implemented.
Is Melrose Healthcare on Any Federal Watch List?
MELROSE HEALTHCARE 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.