ROYAL NORWELL NURSING & REHABILITATION CENTER LLC
For profit - Corporation
86 Beds
ROYAL HEALTH GROUP
Data: November 2025
2 Immediate Jeopardy citations
Trust Grade
0/100
#319 of 338 in MA
Photo by Any A
Photo by Any A
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Last Inspection: October 2024
Within standard 12-15 month inspection cycle. Federal law requires annual inspections.
Overview
Royal Norwell Nursing & Rehabilitation Center has received a Trust Grade of F, indicating significant concerns about the quality of care provided. It ranks #319 out of 338 facilities in Massachusetts, placing it in the bottom half of nursing homes in the state, and #25 out of 27 in Plymouth County, suggesting very limited better local options. Although the facility is showing some improvement, reducing issues from 8 in 2024 to 2 in 2025, it still faces serious concerns, including $114,868 in fines, which is higher than 91% of Massachusetts facilities. Staffing is an average strength with a 3/5 rating, but a turnover rate of 56% is concerning compared to the state average of 39%. Notably, there were critical incidents where residents did not receive proper care for their peripherally inserted central catheters (PICC), leading to serious health complications, highlighting ongoing issues with adherence to care protocols. While there are some positive aspects, such as good RN coverage, families should weigh these serious deficiencies carefully.
- Trust Score
- F
- In Massachusetts
- #319/338
- Safety Record
- High Risk
- Inspections
- Getting Better
- Staff Stability ⚠ Watch
- 56% turnover. Above average. Higher turnover means staff may not know residents' routines.
- Penalties ○ Average
- $114,868 in fines. Higher than 58% of Massachusetts facilities. Some compliance issues.
- Skilled Nurses ✓ Good
- Each resident gets 48 minutes of Registered Nurse (RN) attention daily — more than average for Massachusetts. RNs are trained to catch health problems early.
- Violations ⚠ Watch
- 57 deficiencies on record. Higher than average. Multiple issues found across inspections.
0/100
Bottom 6%
Review needed
8 → 2 violations
★☆☆☆☆
1.0
Overall Rating
★★★☆☆
3.0
Staff Levels
★★★★☆
4.0
Care Quality
★☆☆☆☆
1.0
Inspection Score
↔
Stable
2024: 8 issues
2025: 2 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: 56%
Near Massachusetts avg (46%)
Frequent staff changes - ask about care continuity
Federal Fines: $114,868
Well above median ($33,413)
Significant penalties indicating serious issues
Chain: ROYAL HEALTH GROUP
Part of a multi-facility chain
Ask about local staffing decisions and management
Staff turnover is elevated (56%)
8 points above Massachusetts average of 48%
The Ugly 57 deficiencies on record
2 life-threatening 4 actual harm
Jan 2025
2 deficiencies
2 Harm
SERIOUS
(G)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Actual Harm - a resident was hurt due to facility failures
Comprehensive Care Plan
(Tag F0656)
A resident was harmed · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on records reviewed and interviews for one of three sampled residents (Resident #3), whose care plan indicated he/she requ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on records reviewed and interviews for one of three sampled residents (Resident #3), whose care plan indicated he/she required a Hoyer lift (mechanical mobility aid that supports a person's total body weight to allow movement from one surface to another safely) for transfer and Geri-sleeves (stocking like sleeve to protect fragile skin) to both upper extremities to minimize skin injury, the facility failed to ensure staff consistently implemented and followed interventions from his/her care plan, when on 12/07/24, Resident #3, was manually lifted and transferred from his/her bed into a wheelchair by Certified Nurse Aide (CNA) #2 and CNA #3 instead of utilizing the Hoyer lift, he/she also did not have the geri-sleeve on his/her right upper extremity, and as a result he/she sustained a skin tear to the right wrist which required four steri-strips to close the wound.
Findings include:
Review of the Facility Policy titled Comprehensive Person-Centered Care Plan, dated May 2023, indicated that a comprehensive person-centered care plan includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs are developed and implemented for each resident.
The Policy further indicated that the comprehensive, person-centered care plan will include the following;
-Include measurable objectives and timeframe's;
-Describe the services that are to be furnished to attain or maintain the residents highest practicable physical, mental, and psychosocial well-being;
-The facility will ensure that the services provided are arranged are delivered by individuals who are qualified and have the skills, experience and knowledge to do a particular task;
-Aid in preventing or reducing decline in the resident's functional status and/or functional level; and
-Care Plan interventions are chosen after careful data gathering, proper sequencing of events, careful consideration of the relationship between the resident's problem areas and their causes, and relevant clinical decision making.
Resident #3 was admitted to the Facility in February 2022, diagnoses include dementia, adult failure to thrive, history of falls, and anxiety.
Review of Resident #3's Quarterly Minimum Data Set (MDS) dated [DATE], indicated he/she had significantly impaired cognition, severely impaired decision-making ability, rarely able to make self-understood or understand others and was dependent for all care.
Review of Resident #3's Care Plan titled Activities of Daily Living (ADL), dated as last revised 12/03/24, indicated he/she transferred via Hoyer lift with the assistance of two staff members.
Review of Resident #3's Care Plan titled Risk for Impaired Skin Integrity, dated as last revised 12/03/24, indicated to apply geri-sleeves to both upper extremities and they may be removed for care.
Review of Resident #3's CNA Care [NAME], indicated he/she required the use of a Hoyer lift for transfers and geri-sleeves were to to be applied to both upper extremities.
During an interview on 01/06/25 at 2:42 P.M., CNA #2 said she was consistently assigned to work on Resident #3's unit, was aware of the need and how to access resident care [NAME]'s in the computer, but had not done so that day. CNA #2 said that she had an accident with Resident #3 when she transferred him/her with CNA #3. CNA #2 said she told Nurse #2 that she was not aware that Resident #3 required a Hoyer lift for transfers, that she and CNA #3 manually lifted and transferred him/her from the bed into the wheelchair. CNA #2 said after the transfer was done Resident #3 had a cut on his/her right arm. CNA #2 said Resident #3's left geri-sleeve was put on him/her, but she was unable to find the right arms geri-sleeve.
During a telephone interview on 01/13/25 at 11:22 A.M., CNA #3 said that she was asked to help CNA #2 transfer Resident #3 from the bed to the wheelchair. CNA #3 said she did not ask CNA #2 how Resident #3 transferred and said she thought CNA #2 knew how he/she transferred.
CNA #3 said that after they manually lifted and transferred Resident #3 into his/her wheelchair, they noticed he/she had a skin tear on his/her right wrist. CNA #3 said that Resident #3 did not have a geri-sleeve on his/her right arm, and only had one on his/her left arm.
During an interview on 01/06/25 at 11:26 A.M., Nurse #2 said that she was administering medications when CNA #2 and CNA #3 brought Resident #3 out of his/her room and notified her of the skin tear he/she sustained during the transfer. Nurse #2 said that she could not recall how the CNA's said they transferred Resident #3 into his/her wheelchair, but said she obtained statements from each of the CNA's at that time.
Review of the Facility Incident Report file, dated 12/07/24, indicated that although the report reflected that Resident #3 sustained a skin tear during at transfer, there were no statements from CNA #2 or CNA #3 included in the report file.
During an interview on 01/06/25 at 3:03 P.M., the Director of Nurses (DON) said that she was unaware that Resident #3 was manually lifted and transferred on the day of the incident by two CNA's and that they had not known that he/she required a Hoyer lift. The DON said that Resident #3 should have been transferred via the Hoyer lift according to his/her care plan and as indicated on the CNA [NAME].
The DON said that it is the Facility's expectation that all certified and licensed nursing staff must be aware of each of their assigned residents' physical status before assisting them with ADL care.
On 01/06/25, the Facility presented the Surveyor with a plan of correction that addressed the areas of concern identified in this survey, the Plan of Correction provided is as follows:
A. 12/07/24, Nursing immediately assessed Resident #3 for injuries, four Steri-strips were applied to his/her right wrist.
B. 12/09/24, The DON initiated re-education for Certified Staff on the requirement to review the CNA [NAME], how to locate a residents physical status and how they are to be transferred.
C. 12/09/24, the DON and Administrator initiated the requirement for completion of new competencies for all certified staff on the proper use of the mechanical lifts.
D. 12/09/24, the Administrator revised the Policy titled Using a Mechanical lift, to include that at least two trained (certified and competent) staff members are required to safely use a mechanical lift.
E. 12/10/24, the DON, Administrator and Nursing Managers were educated on individual staff members scopes of practice. If the staff member is not certified (completed new competency) to use a mechanical lift, they are not able to assist any staff member with a transfer.
F. 12/13/24, the DON/designee will audit CNA competency through visualization and validate quizzes. Audits will occur weekly x 4 weeks, monthly x 3 months, and quarterly thereafter until compliance is reached.
G. 12/17/24, the DON and Unit Managers added that staff will complete competency/training upon hire, and annually on the use of the mechanical lift device, including the inspection of slings for integrity and clasps prior to transfer.
H. 12/19/24, the areas of concern and data collected were presented at the Facility's Quality Assurance Performance Improvement (QAPI) Committee Meeting.
I. The Administrator and Director of Nurses will be responsible for overall compliance.
SERIOUS
(G)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Actual Harm - a resident was hurt due to facility failures
Accident Prevention
(Tag F0689)
A resident was harmed · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on records reviewed and interviews for two of three sampled residents (Resident #1 and #3), who both required a Hoyer Lift...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on records reviewed and interviews for two of three sampled residents (Resident #1 and #3), who both required a Hoyer Lift (mechanical mobility aid that supports a person's total body weight to allow movement from one surface to another safely) with the assistance of two staff members, the facility failed to ensure that necessary assistive devices were utilized properly and appropriately during transfers in order to maintain resident safety and prevent incidents/accidents resulting in injuries.
1) On 12/09/24, Certified Nurse Aide (CNA) #1 and Activity Assistant (AA) #1 (who was not a certified nurse aide or competent in mechanical lift transfers) did not check to see if the lower straps of the Hoyer lift sling/pad were properly connected to the Hoyer lift device, and during the transfer Resident #1 slid onto the floor, hitting his/her head. Resident #1 was transferred to the Hospital Emergency Department (ED) for evaluation and was diagnosed with a laceration (open wound) to the back of his/her head related to the fall, which required one (1) staple to close.
2) On 12/07/24, CNA #2 and CNA #3, manually lifted and transferred Resident #3, instead of using a Hoyer lift as required, he/she sustained a skin tear to his/her right wrist during the transfer, which required four (4) steri-strips to close the wound.
Findings include:
Review of the Facility Policy titled, Mechanical Lift, dated 05/2023, indicated the following:
-At least two (2) staff are needed to safely move a resident with a mechanical lift; and
-Staff must be trained and demonstrate competency using the specific machines or devices utilized by the Facility.
Further review of the Policy indicated the following steps (not all-inclusive) are essential in proper use of a mechanical lift;
-Measure the resident for proper sling size and purpose;
-Test the lift controls, ensure the emergency release feature works;
-Place the appropriate sling beneath the resident;
-Attach the sling straps to the sling bar;
-Make sure the sling is securely attached to the clips and that is it properly balanced;
-Before resident is lifted, double check the security of the sling attachment;
-Examine all hooks, clips, and fasteners; and
-Check the stability of the straps and ensure that the sling bar is securely attached.
1) Resident #1 was admitted to the Facility in 09/2015, diagnoses include right sided hemiparesis (weakness) related to a cerebral vascular accident (CVA), vascular dementia, chronic pain, and seizure disorder.
Review of Resident #1's Quarterly Minimum Data Set (MDS), dated [DATE], indicated he/she had moderate cognitive impairment and was dependent with all transfers, including to and from his/her bed to his/her wheelchair.
Review of Resident #1's Care Plan titled Activities of Daily Living, reviewed and renewed with his/her November 2024 MDS, indicated he/she required a Hoyer lift for all transfers.
Review of the Facility Incident Report, dated 12/09/24, indicated that at approximately 9:53 A.M. during a mechanical lift transfer from bed to wheelchair, the Hoyer lift pad became unattached from the device, Resident #1 fell out of the Hoyer pad onto the floor and struck his/her head.
The Report further indicated that he/she required transport to the Hospital ED for evaluation and treatment of a head laceration and required one (1) staple to close the wound.
During a telephone interview on 01/10/25 at 10:10 A.M., Certified Nurse Aide (CNA) # 1 said that on 12/09/24, Resident #1 was on her assignment, and she had placed the Hoyer pad beneath him/her to prepare for the transfer from his/her bed to the wheelchair.
CNA #1 said she went into the hallway to find a staff member to ask for assistance. CNA #1 said that she saw Activity Aide (AA) #1 and asked her to assist with the Hoyer lift transfer. CNA #1 said she did not know that the second staff member assisting with a Hoyer lift transfer had to be certified (completed a competency) in using the mechanical lift device.
CNA #1 said that she had already attached the Hoyer pad to the actual Hoyer lift and said she had instructed AA #1 to guide Resident #1's legs as they transferred him/her out of the bed. CNA #1 said she had not noticed that one of the sling straps was not connected correctly and said as she was lowering Resident #1 down towards the wheelchair, one of the lower straps on the pad unlatched and Resident #1 slid to the floor hitting his/her head.
During an interview on 01/06/25 at 10:03 A.M., Activity Aide (AA) #1 said that she had been on the unit passing out newspapers when CNA #1 came out of Resident #1's room and asked for help. AA #1 said she did not ask CNA #1 what she needed assistance with and just went into the room to help. AA #1 said that's when CNA #1 asked her to help with a transfer, that she just needed to hold up and guide Resident #1's legs during the Hoyer lift transfer.
AA #1 said as CNA #1 was turning the Hoyer lift toward the wheelchair, she heard something snap and Resident #1 slid to the floor hitting his/her head. AA #1 said that she had not been certified (had not completed a competency) to use the Hoyer lift.
During an interview on 01/06/25 at 10:59 A.M., Nurse #1 said she was not aware that CNA #1 had asked AA #1 to assist with Resident #1's transfer. Nurse #1 said that only staff who had been certified to use the Hoyer lift can assist in such a transfer.
During an interview on 01/06/25 at 3:03 P.M., the Director of Nurses (DON) said that it is the Facility's expectation that only staff that have passed a competency on working the Hoyer lift are allowed to operate or assist in the transfer utilizing a Hoyer lift, which AA #1 had not done.
2.) Resident #3 was admitted to the Facility in February 2022, diagnoses include dementia, adult failure to thrive, history of falls, and anxiety.
Review of Resident #3's Quarterly Minimum Data Set (MDS) dated [DATE], indicated he/she had significantly impaired cognition, severely impaired decision-making ability, rarely able to make self-understood or understand others and was dependent for all care.
Review of Resident #3's Care Plan titled Activities of Daily Living, dated as last revised 12/03/24, indicated he/she transferred via Hoyer lift with the assistance of two staff members.
Review of Resident #3's CNA Care [NAME], indicated he/she required the use of a Hoyer lift for transfers.
During an interview on 01/06/25 at 2:42 P.M., CNA #2 said she was consistently assigned to work on Resident #3's unit, was aware of the need and how to access resident care [NAME]'s in the computer, but had not done so that day. CNA #2 said that she had an accident with Resident #3 when she transferred him/her with CNA #3. CNA #2 said that when she and CNA #3 manually lifted and transferred him/her from the bed into the wheelchair, after the transfer was done Resident #3 had a cut on his/her right arm. CNA #2 said she was not aware that Resident #3 required the use of a Hoyer lift for transfers.
During a telephone interview on 01/13/25 at 11:22 A.M., CNA #3 said that she was asked to help CNA #2 transfer Resident #3 from the bed to the wheelchair. CNA #3 said she did not ask CNA #2 how Resident #3 transferred, that she thought CNA #2 knew how he/she transferred, and said she did not know Resident #3 was a Hoyer lift transfer. CNA #3 said that after they manually lifted and transferred Resident #3 into his/her wheelchair, they noticed a skin tear on his/her right wrist.
During an interview on 01/06/25 at 11:26 A.M., Nurse #2 said that she was administering medications when CNA #2 and CNA #3 brought Resident #3 out of his/her room and notified her of the skin tear he/she sustained during the transfer. Nurse #2 said that she could not recall how the CNA's said they transferred Resident #3 into his/her wheelchair, but said she got statements from each of the CNA's at that time.
Review of the Facility Incident Report file, dated 12/07/24, indicated that although the report reflected that Resident #3 sustained a skin tear during at transfer, there were no statements from CNA #2 or CNA #3 included in the report file.
During an interview on 01/06/25 at 3:03 P.M., the Director of Nurses (DON) said that she was unaware that Resident #3 was manually lifted and transferred on the day of the incident by two CNA's and that they had not known that he/she required a Hoyer lift. The DON said that it is the Facility's expectation that all certified and licensed staff must be aware of each of their assigned residents physical status and needs before assisting them with care.
On 01/06/25, the Facility presented the Surveyor with a plan of correction that addressed the areas of concern identified in this survey, the Plan of Correction provided is as follows:
A. 12/07/24, Nursing immediately assessed Resident #3 for injuries, four Steri-strips were applied to his/her right wrist.
-12/09/24, Nursing immediately assessed Resident #1 for injuries, 911 was initiated and he/she was transferred to the Hospital ED, he/she required one (1) staple to close the laceration and returned to the Facility.
B. 12/09/24, the Director of Maintenance inspected both Hoyer Lifts for integrity, no abnormal findings or defects noted. The Director will continue to inspect mechanical devices and slings monthly.
C. 12/09/24, the DON measured all residents requiring the use of a Hoyer lift were measured for appropriate sizing. Resident care plans were audited to ensure they were updated with appropriate mode of transfer and with proper pad/sling to use for all residents that require a Hoyer lift.
D. 12/09/24, The DON initiated re-education for Certified Staff on the requirement to review the CNA [NAME], how to locate a residents physical status and how they are to be transferred.
E. 12/09/24, the DON and Administrator initiated the requirement for completion of new competencies for all certified staff on the proper use of the mechanical lifts.
F. 12/09/24, the Administrator revised the Policy titled Using a Mechanical lift, to include that at least two trained (certified and competent) staff members are required to safely use a mechanical lift.
G. 12/10/24, the DON, Administrator and Nursing Managers were educated on individual staff members scopes of practice. If the staff member is not certified to use a mechanical lift, they are not able to assist any staff member with a transfer.
H. 12/13/24, the Administrator/designee will randomly audit maintenance inspection sheets to ensure compliance. Weekly times four weeks, monthly for 3 months, and quarterly thereafter until compliance is achieved.
I. 12/13/24, the DON/designee will audit CNA competency through visualization and validate quizzes. Audit will occur weekly x 4 weeks, monthly x 3 months, and quarterly thereafter until compliance is reached.
J. 12/17/24, the DON and Unit Managers added that staff will complete competency/training upon hire, and annually on the use of the mechanical lift device, including the inspection of slings for integrity and clasps prior to transfer.
K. 12/19/24, the areas of concern and data collected were presented at the Facility's Quality Assurance Performance Improvement (QAPI) Committee Meeting.
L. The Administrator and Director of Nurses will be responsible for overall compliance.
Oct 2024
8 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Resident Rights
(Tag F0550)
Could have caused harm · This affected 1 resident
Based on observation, interview, and record review, the facility failed to promote the rights of one Resident (#60) to have fluids of choice, in a total sample of 18 residents. Specifically, the facil...
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Based on observation, interview, and record review, the facility failed to promote the rights of one Resident (#60) to have fluids of choice, in a total sample of 18 residents. Specifically, the facility restricted the fluids of Resident #60, despite the removal of the order for a fluid restriction three weeks prior.
Findings include:
Resident #60 was admitted to the facility in March 2024 with diagnoses of hard of hearing, polydipsia (excessive thirst), and dementia.
Review of the medical record indicated Resident #60 had an activated Health Care Proxy.
Review of the Minimum Data Set (MDS) assessment, dated 9/18/24, indicated Resident #60 was cognitively intact, scoring 13 out of 15 on the Brief Interview for Mental Status.
Review of the medical record indicated Resident #60 had exhibited behaviors of taking drinks off of the nurse's medication carts, taking cups to fill with water from the faucet or the toilet, and constantly asking for drinks.
Review of the care plans for Resident #60 indicated a Focus for behavior management for a new repetitive behavior of continuously asking for water, drinking excessive amounts of water from the faucet, toilet and other people's cups (initiated 9/13/24) with the following Approaches:
-educate Resident on the importance of drinking from appropriate sources; encourage use of personal tumbler to drink fluids from (initiated 10/11/24)
-encourage self-calming behaviors such as breathing exercises, meditation, guided imagery (initiated 9/13/24)
-ensure my labelled cup is filled with fluids (initiated 10/11/24)
-establish boundaries and limits with the Resident (initiated 9/13/24)
-known to drink out of the toilet, re-direct when this occurs (initiated 9/18/24)
-remind to drink from tumbler filled with liquids when I ask for more water (initiated 10/11/24)
Review of the care plans for Resident #60 indicated a Focus for potential for fluid volume overload related to psychogenic polydipsia (initiated 10/14/24) with the following Approaches:
-educate on the importance of self-limiting fluid intake to minimize the risk of fluid overload (initiated 10/14/24)
-known to be non-adherent with diet orders (initiated 10/14/24)
-monitor for signs and symptoms of fluid overload (initiated 10/14/24)
-family is aware of polydipsia as evidenced by drinking soda when living with them (initiated 10/14/24)
-obtain and monitor laboratory work as ordered (initiated 10/14/24)
-provide Resident with their own tumbler cup labeled with name to encourage drinking from appropriate sources (initiated 10/14/24)
Review of the Physician's Orders indicated as of the time of the survey (10/15/24) the Resident did not have a fluid restriction (discontinued 9/24/24) and was on thin liquids as of 10/14/24.
Review of the nursing progress notes indicated on 9/24/24 the Resident had been seen by the Nurse Practitioner and the Resident had continued to be non-compliant with the fluid restriction. The Nurse Practitioner had discontinued the fluid restriction related to the Resident refusing and the Resident drinking from the toilet.
Following the discontinuation of the fluid restriction on 9/24/24 the following nursing progress notes were written:
-10/5/24: Resident was very behavioral, non-compliant with fluid restriction
-10/9/24: Resident continues excessively drinking water from anywhere, staff are continuously trying to redirect to try to restrict fluid intake
-10/11/24: Nursing provided Resident with a large tumbler labelled with name to encourage drinking from appropriate sources
-10/14/24: meeting with Health Care Proxy, Nurse Practitioner, and nursing with new order to discontinue thickened liquids related to Resident non-compliance and Resident/family wishes for thin liquids
On 10/16/24 at 1:15 P.M., the surveyor observed Resident #60 ask Nurse #2 for ginger ale. Unit Manager #2 provided Resident #60 with a 5-ounce cup of ginger ale. At 1:26 P.M., the surveyor observed Resident #60 ask Nurse #2 for more ginger ale. Nurse #2 told Resident #60 they can have one more small cup of ginger ale, but not until 2:00 P.M. (attempting to set a boundary, as indicated in the care plan) and gave him/her another 5-ounce cup. At 1:43 P.M., the surveyor observed Resident #60 approach Nurse #2 and ask for ginger ale. The Nurse reminded the Resident of the plan to return at 2:00 P.M. and the Resident said he/she did not have a clock in their room.
On 10/16/24 at 4:21 P.M., the surveyor observed Resident #6 approach Nurse #6 and ask for ginger ale. The Nurse informed Resident #60 they would get ginger ale with dinner and said, Not right now. Resident #60 was unable to hear Nurse #6 and continued to ask while telling the nurse that he/she could not hear them. The Nurse was observed to tell Resident #60 that there was no ginger ale.
At 4:24 P.M., Nurse #6 gave Resident #60 a 5-ounce cup of water, the Resident repeatedly asked if there was ginger ale and the nurse responded No, no, no. Can you hear that? The Resident responded, You told me to wait until 4:30 P.M., and the Nurse responded, You have to wait until dinner. At this time, the surveyor observed a drink cart on the unit with a bottle of ginger ale. The Nurse was not observed to check if there was water in the designated tumbler.
At 4:36 P.M., Resident #60 asked a Certified Nursing Assistant (CNA) for a drink and the CNA told the Resident to ask the nurse. The Resident asked Nurse #6 who told the Resident to go watch television. The Resident said, Never mind and walked away. Neither the CNA nor the Nurse were observed to check the Resident's tumbler to make sure it had water.
At 4:52 P.M., the surveyor observed Resident #60 asking Unit Manager #2 for ginger ale. Unit Manager #2 told the Resident No.
At 4:58 P.M., the surveyor observed Nurse #6 to have her medication cart across (blocking) the doorway of Resident #60's room. Unit Manager #2 and Nurse #6 were in the room with Resident #60. Resident #60 asked if he/she could go see what time it was, Unit Manager #2 replied, No, we know what time it is, it's 4:58 P.M., it's not time yet, you have to wait until 5:00 P.M. Unit Manager #2 filled the blue tumbler with water. Resident #60 asked if he/she could have ice in their drink and the Unit Manager replied, Nope, we don't have any. Unit Manager #2 told Nurse #6 that Resident #60 can have any amount of water, but not any amount of ginger ale or juice because he/she was diabetic.
At 5:00 P.M., Resident #60 attempted to leave the room and Unit Manager #2 said, You can't leave. At 5:02 P.M., Resident #60 asked Nurse #6 when dinner was and the Nurse responded, You have to stop asking me, I need to tend to other people. At 5:03 P.M., Unit Manager #2 was observed bringing Resident #60 their dinner meal with ginger ale.
During an interview with observation on 10/17/24 at 2:10 P.M., the surveyor observed Resident #60 having difficulty hearing the surveyor who had to get very close and speak loudly. The Resident said he/she did not have a clock in their room. The surveyor did not observe a clock in the Resident's room.
During an interview on 10/17/24 at 12:39 P.M., CNA #2 and CNA #5 said Resident #60 had behaviors of looking for water and sneaking drinks and that redirection did not work. They said the only thing that worked was giving the Resident what they wanted for a drink.
During an interview on 10/17/24 at 1:49 P.M., the Social Worker said Resident #60 had an increased obsession with drinking water following a stroke. He said the Resident would continuously ask staff for water. He said the family had decided during a meeting to remove the fluid restriction, but he was not sure if this had improved the Resident's behaviors.
During an interview on 10/17/24 at 2:15 P.M., Nurse #4 said he was assigned to care for Resident #60 on this day, but he was unfamiliar with the Resident. He said during the shift there had been a question of if Resident #60 had a fluid restriction, but the Resident did not have any fluid restrictions and the Resident liked to have ice with their water.
During an interview on 10/17/24 at 2:35 P.M., Unit Manager #2 said all Resident #60 wanted to do was drink fluids. She said the fluid restriction was discontinued a couple of weeks prior. She said they give the Resident a cup and fill it with water. She said the staff try to restrict sugary drinks because the resident had a diagnosis of diabetes, but that the Resident was not on a diabetic diet with any restrictions. She said diet ginger ale was available for the Resident. She said she tried to limit the ginger ale intake the previous day because the Resident had had too much already. She said there was no tracking to say how much the Resident had or an order to indicate how much fluid was too much. She said she was telling the Resident not to leave the room yesterday because the Resident did not really want to know what time it was, the Resident wanted to go to the drink cart and grab a drink and was trying to manipulate the staff. She said the Resident did not need to know what time it was because herself and the maintenance man had told the Resident what time it was. She said she had not looked to see if the Resident had a clock in their room. The Unit Manager said the staff cannot stop the Resident from drinking, but the staff had to use common sense on how much they were going to give the Resident to drink.
During an interview on 10/18/24 at 8:00 A.M., the Director of Nurses said the staff were still trying to determine what approaches worked for Resident #60 to decrease the Resident interrupting nurses while passing medications to other residents. She said that although she could not speak directly to why the staff had attempted to limit the drinks for the Resident on 10/16/24 she thinks the staff and the Unit Manager were probably trying to limit the amount of fluids the Resident was having because they knew he/she had too much fluids already. She said there was no fluid restriction and no tracking for fluid intake. She said the best approach right now really came down to quality of life and this was what the staff should be focused on.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0558
(Tag F0558)
Could have caused harm · This affected 1 resident
Based on observations, interviews, and record review, the facility failed to ensure a reasonable accommodation was made for one Resident (#5), of 18 sampled residents. Specifically, the facility faile...
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Based on observations, interviews, and record review, the facility failed to ensure a reasonable accommodation was made for one Resident (#5), of 18 sampled residents. Specifically, the facility failed to ensure the call system was accessible to the Resident to call for staff assistance.
Findings include:
Review of the facility's policy titled Resident Call System, undated, indicated but was not limited to:
-When in their rooms and toilet and bathing areas, residents will have a means of directly contacting caregivers.
Resident #5 was admitted to the facility in March 2017 with diagnoses including dementia and history of falling.
Review of the Minimum Data Set (MDS) assessment, dated 9/4/24, indicated a Brief Interview for Mental Status (BIMS) for Resident #5 was not completed as the Resident is rarely/never understood. Further review of the MDS indicated that the Resident was dependent on staff for activities of daily living and able to ambulate with supervision or touching assistance.
Review of Resident #5's Care Plan indicated, but was not limited to, the following:
-Focus: I am at risk for falls r/t (related to) deconditioning, gait instability, dementia, decreased awareness of safety needs, wandering behavior, and use of antidepressant medication. h/o (history of) epidemic vertigo, muscle weakness
-Approaches: Be sure [Resident #5]'s call light is within reach and encourage [Resident #5] to use it for assistance as needed. [Resident #5] needs prompt response to all requests for assistance.
On 10/15/24 at 10:00 A.M., the surveyor observed Resident #5 lying in bed and the call light cord was gathered and clipped above the bed and out of the Resident's reach.
On 10/16/24 at 10:26 A.M., the surveyor observed Resident #5 lying in bed and the call light cord was gathered and clipped above the bed and out of the Resident's reach.
On 10/16/24 at 11:56 A.M., the surveyor observed Resident #5 lying in bed and the call light cord was gathered and clipped above the bed and out of the Resident's reach.
On 10/16/24 at 4:28 P.M., the surveyor observed Resident #5 lying in bed and the call light cord was gathered and clipped above the bed and out of the Resident's reach.
During an interview on 10/16/24 at 4:40 P.M., Nurse #1 said the call light should not be out of reach and should be where the Resident can reach it at all times.
During an interview on 10/17/24 at 3:00 P.M., the Director of Nursing said that call lights or an alternative means of contacting staff, such as hand bells, should be accessible to residents at all times.
During an interview on 10/17/24 at 4:07 P.M., Unit Manager #2 said that call lights should be within reach for all residents.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Abuse Prevention Policies
(Tag F0607)
Could have caused harm · This affected 1 resident
Based on record review and interviews, for one Resident (#36), of 18 sampled residents, the facility failed to implement policies and procedures for alleged abuse. Specifically, the facility failed to...
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Based on record review and interviews, for one Resident (#36), of 18 sampled residents, the facility failed to implement policies and procedures for alleged abuse. Specifically, the facility failed to investigate and report an allegation of sexual abuse.
Findings include:
Review of the facility's policy titled Abuse Policy, dated May 2023, indicated but was not limited to:
-Identification: Reporting of suspected alleged violations shall be encouraged by staff. Incidents of alleged violations shall be reviewed by the facility's Quality Assessment and Assurance Committee for detection of patterns and trends.
-Reporting: An employee who suspects an alleged violation shall immediately notify the Executive Director (ED) or his/her designee. The ED shall also notify the appropriate State agency in accordance with state law. The results of all investigations must be reported immediately to the ED or his/her designee and to the appropriate State agency, as required by State law with initial report submitted within two hours and follow up within five working days of the violation.
-Policy and Procedure:
A. If a family member, resident or staff reports an incident of abuse/mistreatment/neglect, it is to be reported to the Director of Nursing Services (DNS) or manager immediately and an Incident/Accident report is to be completed.
B. The supervisor is to initiate the following steps:
1. Immediate investigation into the alleged incident.
2. Interview staff member implicated. Get a written statement.
3. Interview other staff members.
4. Interview with resident or resident witnesses.
C. Send initial report to the Department of Public Health (DPH) immediately but no later than two hours.
D. Final reports to be submitted to the Department of Public Health within five business days of the initial report.
Resident #36 was admitted to the facility in June 2018 with the following diagnoses: vascular dementia and post-traumatic stress disorder (PTSD, a mental health condition that is triggered by an event, series of events, or set of circumstances that is experienced by an individual as physically or emotionally harmful or life threatening and that has lasting adverse effects on the individual's functioning and mental, physical, social, emotional, or spiritual well-being).
Review of the Minimum Data Set (MDS) assessment, dated 9/4/24, indicated Resident #36 was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) score of 12 out of 15.
Review of Resident #36's incident report and fall packet, dated 5/16/24, indicated but was not limited to:
-Resident #36 was being assessed after being found on the floor and he/she reported to Nurse #3 that someone had just molested him/her. Nurse #3 indicated that Resident #36 could not provide any additional information.
Review of the Health Care Facility Reporting System (HCFRS, a web-based system that health care facilities must use to report incidents and allegations of abuse, neglect, and misappropriation) failed to indicate the alleged abuse had been reported.
During an interview on 10/17/24 at 12:06 P.M., the Director of Nurses (DON) said the facility did not have a record of a reportable incident for Resident #36 in the last six months.
During an interview on 10/17/24 at 1:22 P.M., Unit Manager #2 said when any form of abuse is alleged or suspected, the facility should ensure the resident is safe, report the allegation to the state agency, and fully investigate the potential abuse. Unit Manager #2 said anytime there is a suspicion or allegation, the facility should follow the policy to investigate and report it.
During an interview on 10/17/24 at 2:29 P.M., the Administrator said she was unaware of the alleged abuse. The Administrator said all allegations of abuse should be investigated and reported to the State agency through HCFRS.
During an interview on 10/17/24 at 2:57 P.M., the Administrator said the alleged abuse had not been investigated or reported.
During an interview on 10/17/24 at 4:20 P.M., the DON said the allegation had not been investigated or reported and it should have been.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Report Alleged Abuse
(Tag F0609)
Could have caused harm · This affected 1 resident
Based on record review and interviews, for one Resident (#36), of 18 sampled residents, the facility failed to ensure an allegation of sexual abuse was reported timely to the state agency as required....
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Based on record review and interviews, for one Resident (#36), of 18 sampled residents, the facility failed to ensure an allegation of sexual abuse was reported timely to the state agency as required.
Findings include:
Review of the facility's policy titled Abuse Policy, dated May 2023, indicated but was not limited to:
-Identification: Reporting of suspected alleged violations shall be encouraged by staff.
-Reporting: An employee who suspects an alleged violation shall immediately notify the Executive Director (ED) or his/her designee. The ED shall also notify the appropriate State agency in accordance with state law. The results of all investigations must be reported immediately to the ED or his/her designee and to the appropriate State agency, as required by State law with initial report submitted within two hours and follow up within five working days of the violation.
-Policy and Procedure:
A. If a family member, resident or staff reports an incident of abuse/mistreatment/neglect, it is to be reported to the Director of Nursing Services (DNS) or manager immediately and an Incident/Accident report is to be completed.
B. The supervisor is to initiate the following steps:
1. Immediate investigation into the alleged incident.
2. Interview staff member implicated. Get a written statement.
3. Interview other staff members.
4. Interview with resident or resident witnesses.
C. Send initial report to the Department of Public Health (DPH) immediately but no later than two hours.
D. Final reports to be submitted to the Department of Public Health within five business days of the initial report.
Resident #36 was admitted to the facility in June 2018 with the following diagnoses: vascular dementia and post-traumatic stress disorder (PTSD, a mental health condition that is triggered by an event, series of events, or set of circumstances that is experienced by an individual as physically or emotionally harmful or life threatening and that has lasting adverse effects on the individual's functioning and mental, physical, social, emotional, or spiritual well-being).
Review of the Minimum Data Set (MDS) assessment, dated 9/4/24, indicated Resident #36 was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) score of 12 out of 15.
Review of Resident #36's incident report and fall packet, dated 5/16/24, indicated but was not limited to:
-Resident #36 was being assessed after being found on the floor and he/she reported to Nurse #3 that someone had just molested him/her. Nurse #3 indicated that Resident #36 could not provide any additional information.
Review of the Health Care Facility Reporting System (HCFRS, a web-based system that health care facilities must use to report incidents and allegations of abuse, neglect, and misappropriation) failed to indicate the alleged abuse had been reported.
During an interview on 10/17/24 at 12:06 P.M., the Director of Nurses (DON) said the facility did not have a reportable for Resident #36 in the last six months.
During an interview on 10/17/24 at 1:22 P.M., Unit Manager #2 said when any form of abuse is alleged or suspected the facility should ensure the resident is safe and report the allegation to the state agency. Unit Manager #2 said anytime there is a suspicion or allegation, the facility should follow the policy to report it.
During an interview on 10/17/24 at 2:29 P.M., the Administrator said she was unaware of the alleged abuse. The Administrator said all allegations of abuse should be reported to the State agency through HCFRS.
During an interview on 10/17/24 at 2:57 P.M., the Administrator said the alleged abuse had not been reported to the State agency.
During an interview on 10/17/24 at 4:20 P.M., the DON said the allegation had not been reported and it should have been.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Investigate Abuse
(Tag F0610)
Could have caused harm · This affected 1 resident
Based on record review and interviews, for one Resident (#36), of 18 sampled residents, the facility failed to ensure allegations of abuse, neglect, exploitation, or mistreatment were thoroughly inves...
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Based on record review and interviews, for one Resident (#36), of 18 sampled residents, the facility failed to ensure allegations of abuse, neglect, exploitation, or mistreatment were thoroughly investigated. Specifically, for Resident #36, the facility failed to ensure an allegation of sexual abuse was investigated.
Findings include:
Review of the facility's policy titled Abuse Policy, dated May 2023, indicated, but is not limited to:
-Identification: Reporting of suspected alleged violations shall be encouraged by staff. Incidents of alleged violations shall be reviewed by the facility's Quality Assessment and Assurance Committee for detection of patterns and trends.
-Reporting: An employee who suspects an alleged violation shall immediately notify the Executive Director (ED) or his/her designee. The ED shall also notify the appropriate State agency in accordance with state law. The results of all investigations must be reported immediately to the ED or his/her designee and to the appropriate State agency, as required by State law with initial report submitted within two hours and follow up within five working days of the violation.
-Policy and Procedure:
A. If a family member, resident or staff reports an incident of abuse/mistreatment/neglect, it is to be reported to the Director of Nursing Services (DNS) or manager immediately and an Incident/Accident report is to be completed.
B. The supervisor is to initiate the following steps:
1. Immediate investigation into the alleged incident
2. Interview staff member implicated. Get a written statement
3. Interview other staff members
4. Interview with resident or resident witnesses
C. Send initial report to the Department of Public Health (DPH) immediately but no later than two hours
D. Final reports to be submitted to the Department of Public Health within five business days of the initial report.
Resident #36 was admitted to the facility in June 2018 with the following diagnoses: vascular dementia and post-traumatic stress disorder (PTSD, a mental health condition that is triggered by an event, series of events, or set of circumstances that is experienced by an individual as physically or emotionally harmful or life threatening and that has lasting adverse effects on the individual's functioning and mental, physical, social, emotional, or spiritual well-being).
Review of the Minimum Data Set (MDS) assessment, dated 9/4/24, indicated Resident #36 was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) score of 12 out of 15.
Review of Resident #36's incident report and fall packet, dated 5/16/24, indicated but was not limited to:
-Resident #36 was being assessed after being found on the floor and he/she reported to Nurse #3 that someone had just molested him/her. Nurse #3 indicated that Resident #36 could not provide any additional information.
During an interview on 10/17/24 at 12:06 P.M., the Director of Nurses (DON) said the facility did not have a reportable for Resident #36 in the last six months.
During an interview on 10/17/24 at 1:22 P.M., Unit Manager #2 said when any form of abuse is alleged or suspected the facility should ensure the resident is safe and fully investigate the potential abuse. Unit Manager #2 said anytime there is a suspicion or allegation, the facility should follow the policy to investigate.
During an interview on 10/17/24 at 2:29 P.M., the Administrator said she was unaware of the alleged abuse. The Administrator said all allegations of abuse should be investigated.
During an interview on 10/17/24 at 2:57 P.M., the Administrator said the alleged abuse had not been investigated.
During an interview on 10/17/24 at 4:20 P.M., the DON said the allegation had not been investigated and it should have been.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0761
(Tag F0761)
Could have caused harm · This affected 1 resident
Based on records reviewed and interviews, the facility failed to ensure staff stored all drugs and biologicals used in the facility in accordance with currently accepted professional principles. Speci...
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Based on records reviewed and interviews, the facility failed to ensure staff stored all drugs and biologicals used in the facility in accordance with currently accepted professional principles. Specifically, the facility failed for one Resident (#21), out of a total census of 70 residents, to ensure safe storage of medications and biologicals according to current standards of practice.
Findings include:
Review of the facility's policy titled Storage of Medications, undated, indicated but was not limited to the following:
-Drugs and biologicals used in the facility are stored in locked compartments under proper temperature, light and humidity controls.
-Compartments (including, but not limited to, drawers, cabinets, rooms, refrigerators, carts, and boxes) containing dugs and biologicals are locked when not in use.
Review of the facility's policy titled Self-Administration of Medications, dated May 2023, indicated but was not limited to the following:
-If the staff determine that a resident cannot safely self-administer medications, the nursing staff will administer the resident's medications.
-Staff shall identify and give to the Charge Nurse any medications found at the bedside that are not authorized for bedside storage, for return to the family or responsible party.
Resident #21 was admitted to the facility in June 2023 with diagnoses including pain, diabetes, and heart failure.
Review of the Minimum Data Set (MDS) assessment, dated 8/28/24, indicated that Resident #21 was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) score of 14 out of 15.
Review of Resident #21's medical record indicated that on 8/6/24, a Self-Administration of Medication evaluation was completed for the Resident. The evaluation indicated that Resident #21 was not approved for self-administration of medications and may not keep medications at the bedside.
On the following dates/times of survey, the surveyor observed two bottles of eye drops on Resident #21's nightstand and three bottles of eye drops and one bottle of acetaminophen (an over-the-counter pain/fever reliever) on the Resident's windowsill:
-10/15/24 at 9:40 A.M.,
-10/16/24 at 12:28 P.M.,
-10/16/24 at 4:49 P.M., and
-10/17/24 at 9:12 A.M.
During an interview on 10/16/24 at 12:28 P.M., Resident #21 said that his/her family provides eye drops and acetaminophen to him/her and that he/she administers his/her own eye drops and acetaminophen. Resident #21 said that he/she does not record the date and time he/she administers the medications anywhere.
During an interview on 10/16/24 at 4:49 P.M., Nurse #1 said that Resident #21 was not able to self-administer medications. Nurse #1 said that the Resident should not have any medications in his/her room and that his/her medications should be stored in the medication cart.
During an interview on 10/17/24 at 9:25 A.M., Unit Manager #2 said that Resident #21 is not able to self-administer medications and should not have any medications in his/her room.
During an interview on 10/17/24 at 4:20 P.M., the Director of Nursing said that no medications should be left out at the bedside. The Director of Nursing said that Resident #21 is not able to self-administer medications and should not have any medications in his/her room.
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 observation, interview, and policy review, for one Resident (#36), of 18 sampled residents, the facility failed to maintain an infection prevention and control program designed to provide a s...
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Based on observation, interview, and policy review, for one Resident (#36), of 18 sampled residents, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and potential transmission of communicable diseases and infections. Specifically, for Resident #36, the facility failed to implement Enhanced Barrier Precautions (EBP, an infection control intervention designed to reduce transmission of multidrug-resistant organisms to residents with increased risk).
Findings include:
Review of the Centers for Medicare and Medicaid Services (CMS) guidance titled Enhanced Barrier Precautions in Nursing Homes, dated 3/20/24, indicated but was not limited to:
-Enhanced Barrier Precautions (EBP) refer to an infection control intervention designed to reduce transmission of multidrug-resistant organisms (MDRO) that employs targeted gown and glove use during high contact resident care activities.
-EBP are used in conjunction with standard precautions and expand the use of personal protective equipment (PPE) to donning (putting on) of gown and gloves during high-contact resident care activities that provide opportunities for transfer of MDROs to staff hands and clothing
-EBP are indicated for residents with any of the following:
a. Infection or colonization with a CDC-targeted MDRO when Contact Precautions do not otherwise apply; or
b. Wounds and/or indwelling medical devices even if the resident is not known to be infected or colonized with a MDRO
-EBP should be used for any residents who meet the above criteria, wherever they reside in the Facility
Review of the facility's policy titled Enhanced Barrier Precautions, undated, indicated but was not limited to:
-Enhanced Barrier Precautions involve gown and glove use during high contact resident care activities for residents known to be colonized or infected with a multidrug-resistant organism as well as those at increased risk of multidrug-resistant organism acquisition (e.g. residents with wounds or indwelling medical devices)
-Enhanced Barrier Precautions require the use of gown and gloves only for high contact resident care activities
Review of the Centers for Disease Control and Prevention (CDC) Enhanced Barrier Precaution sign indicated but was not limited to:
-In addition to standard precautions Staff and Providers must:
-Clean hands prior to entering and when exiting the room
-Wear gloves and a gown for the following high-contact resident care activities: dressing, bathing/showering, transferring, changing linens, providing hygiene, changing briefs or assisting with toileting, device care or use, and wound care.
Resident #36 was admitted to the facility in June 2018 with the following diagnoses: vascular dementia and chronic ulcer of lower extremities.
Review of the Minimum Data Set (MDS) assessment, dated 9/4/24, indicated Resident #36 was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) score of 12 out of 15.
Review of Resident #36's orders indicated but were not limited to:
-Staff to maintain enhanced barrier precautions related to (wounds) every shift for infection control, dated 10/15/24
Review of Resident #36's care plan indicated but was not limited to:
-Staff to maintain enhanced barrier precautions related to auto-immune induced wounds and lower extremity wounds, revised 10/15/24
On the following dates of the survey, an EBP Precaution Sign was posted at the entrance to Resident #36's room:
-10/15/24,
-10/16/24, and
-10/17/24
On 10/16/24 at 9:57 A.M., the surveyor observed Certified Nursing Assistant (CNA) #1 assisting Resident #36 with personal hygiene. CNA #1 was not wearing a gown.
On 10/16/24 at 10:34 A.M., the surveyor observed CNA #1 and CNA #3 transferring Resident #36 from his/her bed to the wheelchair, neither employee was wearing a gown.
On 10/17/24 at 10:10 A.M., the surveyor observed CNA #5 assisting Resident #36 with personal hygiene. CNA #5 was only wearing gloves and had not donned a gown.
On 10/17/24 at 10:36 A.M., the surveyor observed two hospice consultants assisting Resident #36 with personal hygiene, both consultants were only wearing gloves and had not donned a gown.
During an interview on 10/17/24 at 10:17 A.M., CNA #5 said the precaution sign was intended for the nurses during wound care.
During an interview on 10/17/24 at 10:40 A.M., Unit Manager #2 said Resident #36 required EBP for high contact care and included the use of gloves and a gown.
During an interview on 10/17/24 at 4:20 P.M., the Director of Nurses (DON) said Resident #36 required EBP for high contact care activities and staff should have donned gloves and a gown.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0658
(Tag F0658)
Could have caused harm · This affected multiple residents
2. Resident #48 was admitted to the facility in October 2022 with the following diagnoses: dementia, dysphagia (difficulty swallowing), and repeated falls.
Review of the Minimum Data Set (MDS) assess...
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2. Resident #48 was admitted to the facility in October 2022 with the following diagnoses: dementia, dysphagia (difficulty swallowing), and repeated falls.
Review of the Minimum Data Set (MDS) assessment, dated 8/7/24, indicated Resident #48 was severely cognitively impaired as evidenced by a Brief Interview for Mental Status (BIMS) score of 3 out of 15. Further review of the MDS indicated Resident #48 was dependent on staff to eat.
Review of Resident #48's Physician's Orders indicated but was not limited to:
-Air mattress: pressure set per resident's most recent weight; +/- 10 pounds. Document weight. Check placement and function every shift, 10/8/24
-1:1 supervision during oral intake. Ensure complete clearance of mouth prior to next bite. Alternate liquids/solids, encourage to re-swallow if food still present. Position at 90 degrees for 30-40 minutes with meals for dysphagia, 10/17/23
-Fall mat to left side of bed when resident is in bed, every shift for safety, dated 10/3/24
a. Review of the facility's policy titled Prevention of Pressure Ulcers/Injuries, dated May 2023, indicated but was not limited to:
-Select appropriate support surfaces based on the resident's mobility, continence, skin moisture and perfusion, body size, weight, and overall risk factors.
Review of Resident #48's weight record indicated his/her most recent weight was obtained on 10/3/24, and he/she weighed 135 pounds.
On the following dates of survey, the surveyor observed Resident #48 in bed with his/her air mattress set at approximately 350 pounds:
-10/15/24 at 10:37 A.M.
-10/16/24 at 8:28 A.M.
-10/17/24 at 8:47 A.M.
-10/17/24 at 9:06 A.M.
-10/17/24 at 3:31 P.M.
During an interview on 10/17/24 at 3:34 P.M., Certified Nursing Assistant (CNA) #7 said she was not sure how the air mattress settings worked and did not know what Resident #48's air mattress should be set at.
During an interview with observation on 10/17/24 at 3:39 P.M., the surveyor and Nurse #5 observed Resident #48 in bed with his/her air mattress set at approximately 350 pounds. Nurse #5 said the Resident's physician's orders gave instruction for the air mattress. Nurse #5 reviewed Resident #48's record and said his/her most recent weight was 135 pounds and the order indicated the air mattress settings should be set within 10 pounds of his/her weight.
During an interview with observation on 10/17/24 at 4:07 P.M., Unit Manager #2 said Resident #48's air mattress should be set plus or minus ten pounds of their current weight. The surveyor and Unit Manager #2 observed the Resident in his/her bed with the air mattress set at approximately 350 pounds. Unit Manager #2 said the Resident did not weigh 350 pounds and the air mattress setting was incorrect.
During an interview on 10/17/24 at 4:20 P.M., the DON said air mattresses should be set at the correct settings and physician's orders should be followed.
b. On 10/17/24 at 8:47 A.M., the surveyor observed Resident #48 lying in bed with his/her bed positioned between 45 and 60 degrees. Resident #48 was eating his/her breakfast alone and was pulling him/herself forward to grab the food from the breakfast tray. Resident #48 was not observed alternating liquids with solids.
During an interview on 10/17/24 at 9:01 A.M., CNA #4 said Resident #48 required assistance with meals, should have been positioned at 90 degrees, and should not have been eating his/her breakfast alone.
During an interview on 10/17/24 at 9:03 A.M., Nurse #4 said Resident #48 required 1:1 supervision and assistance with meals. Nurse #48 said he/she should be sitting upright at a 90-degree angle and should not have been left alone with his/her breakfast.
During an interview on 10/17/24 at 4:07 P.M., Unit Manager #2 said Resident #48 had a history of dysphagia and required 1:1 supervision with meals and should be positioned at 90 degrees when eating and for at least 30 minutes after.
During an interview on 10/17/24 at 4:20 P.M., the DON said all physician's orders should be followed including those for feeding and assisting residents with meals.
c. On the following dates of survey, the surveyor observed Resident #48 in bed with no fall mat on the side of his/her bed:
-10/15/24 at 10:37 A.M.
-10/16/24 at 8:28 A.M.
-10/17/24 at 8:47 A.M.
-10/17/24 at 9:06 A.M.
-10/17/24 at 3:31 P.M.
During an interview on 10/17/24 at 3:34 P.M., CNA #7 said interventions to keep Resident #48 safe while in bed included a low bed and making sure the call light was within reach. CNA #7 did not know about an intervention for a floor mat to the left side of the bed.
During an interview with observation on 10/17/24 at 3:39 P.M., the surveyor and Nurse #5 observed Resident #48 in his/her bed with no floor mat on the side of the bed. Nurse #5 said she was not aware of an order to keep a floor mat on the side of Resident #48's bed. Nurse #5 and the surveyor reviewed the physician's orders and Nurse #5 said there was an order for a fall mat to the left side of the bed and one should have been in place.
During an interview on 10/17/24 at 4:07 P.M., Unit Manager #2 said Resident #48 should have a floor mat on the left side of the bed when he/she was in bed per physician's orders.
During an interview on 10/17/24 at 4:20 P.M., the DON said Resident #48 had an order for a floor mat to the left side of his/her bed as a fall intervention and the floor mat should have been in place when he/she was in bed. The DON said all physician's orders should be followed.
Based on observation, interview, and record review, the facility failed to follow professional standards of practice specific to following physician's orders for two Residents (#19 and #48) in a sample of 18 residents. Specifically, the facility failed:
1. For Resident #19, to follow physician's orders to discontinue an antipsychotic medication timely; and
2. For Resident #48, to ensure staff implemented physician's orders for:
a. air mattress settings;
b. 1:1 (one to one) supervision with oral intake; and
c. fall mat to side of his/her bed.
Findings include:
1. Review of the facility's policy for Medication and Treatment Order and Administration Policy, undated, indicated the following:
-orders for medications and treatments will be consistent with principles of safe and effective order writing
-verbal orders must be recorded immediately in the resident's chart by the person receiving the order
Resident #19 was admitted to the facility in May 2018 with a diagnosis of dementia.
Review of the medical record indicated Resident #19 had an order for Abilify (an antipsychotic) 2.5 milligrams (mg) one time a day, start date 6/7/24.
Review of a Psychiatric Nurse Practitioner's Progress Note, dated 9/15/24, indicated a recommendation to stop the Abilify.
Review of a nursing progress note, dated 9/19/24, indicated the antipsychotic was no longer needed, as recommended by the Psychiatric Nurse Practitioner and the medical Nurse Practitioner and the Health Care Proxy were aware and in agreement.
Review of the medical record indicated the order to discontinue the Abilify was not implemented until 10/11/24, three weeks later.
During an interview on 10/17/24 at 10:35 A.M., Unit Manager #2 said she had written the nursing progress note on 9/19/24. She said the process was the team would have meetings with the Psychiatric Nurse Practitioner and recommendations would be made. She said the Director of Nurses (DON) would then tell her what to write in a progress note and the DON would be the one to physically discontinue the order in the electronic medical record.
During an interview on 10/17/24 at 12:05 P.M., the DON said recommendations were made from behavior rounds regarding antipsychotic medications and if approved by the primary physician, the orders would be implemented. She said she was responsible for making the changes in the electronic medical record. She said she had not been at the behavior meeting on 9/13/24 and that was why the changes had not been implemented timely.
Sept 2023
30 deficiencies
2 IJ
CRITICAL
(J)
Immediate Jeopardy (IJ) - the most serious Medicare violation
Deficiency F0658
(Tag F0658)
Someone could have died · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, document review, policy review, and interview, the facility failed to follow professional standards of p...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, document review, policy review, and interview, the facility failed to follow professional standards of practice in nursing for the care and monitoring of a peripherally inserted central catheter (PICC) and/or midline catheter. Specifically, the facility failed:
1. To obtain physician's orders and provide appropriate nursing interventions for 2 out of 2 PICC lines and 2 out of 2 midline catheter devices for one Resident (#20), out of a total sample of three residents with peripheral lines in place during the timeframe of 10/10/22 through 11/3/22. This resulted in the Resident experiencing pain and swelling in his/her left arm and an extended hospital stay from 11/3/22 through 11/8/22 with a diagnosis of acute extensive bilateral upper extremity deep vein thromboses (DVT- blood clot in a deep vein) with extension into the subclavian vein and an occlusive left arm DVT involving one of the brachial veins and left axillary vein surrounding the PICC; and
2. For one Resident (#39), out of a total sample of two residents currently residing in the facility with a PICC or midline device in place, to provide care and treatment of the PICC. Specifically, the facility failed to ensure the PICC dressing change was performed correctly, three of three lumens of the PICC were flushed correctly, the needleless connector of one of three lumens was primed before being changed according to facility policies and PICC protocol/standards of practice. The facility also failed to have complete orders in place for care of the Resident's PICC.
It was determined the Immediate Jeopardy began on 10/10/22 and was identified on 9/13/23. The Department of Public Health sent a Notice of Determination of Immediate Jeopardy (IJ) and the IJ templates to the Facility Administrator on 9/13/23.
Findings include:
1. Review of the facility's policy titled Central Line Policy, revised June 2022, indicated but was not limited to the following:
-The purpose of this procedure is to outline the protocol when caring for residents that have a midline (thin, soft tube that is placed into a vein at the level of the armpit) used for IV treatments or peripherally inserted central catheters (PICC- long, thin tube inserted through a vein in your arm and passed through to the larger veins near your heart).
-Enter standing orders including but not limited to:
a. monitoring the site for signs and symptoms of IV related complications
b. catheter lumen flushing
c. dressing orders
d. tubing change frequency
Review of the facility's document titled, Pharmscript Infusion Intravenous (IV) Access Line Maintenance Protocol, dated December 2018, indicted but was not limited to the following:
Midline:
-Maintenance, Flush Each Lumen - Non-Valved every 12 hours with normal saline (NS) 10 milliliters (mL's), 3 mL 10 units/mL heparin [blood thinner that prevents harmful clots from forming in blood vessels], valved 10 mL NS every week
-Transparent Dressing Change - Insertion, then weekly and as needed. Measure upper arm circumference and exterior catheter length with each dressing change and as needed
-Needleless Connector Changes - On admission, every week, and as needed
Administration Set Changes - primary, every 24 hours
PICC:
-Maintenance, Flush Each Lumen - Non-valved every 12 hours with NS 10 mL, 5 mL 10 units/mL heparin, valved 10 mL NS every week, Intermittent Non-Valved - 10 mL NS, 5 mL 10 units/mL heparin
-Transparent Dressing Change - Insertion, then weekly and as needed, measure upper arm circumference and exterior catheter length with each dressing change and as needed
-Needleless Connector Device - On admission, then weekly and as needed
-Administration Set Changes - primary, every 24 hours
Resident #20 was admitted to the facility in September 2022 with diagnoses including Behcet's disease (rare disorder causing inflammation of blood vessels), chronic peripheral venous insufficiency, morbid obesity, type II diabetes mellitus, chronic diastolic heart failure (CHF), peripheral vascular disease (PVD), chronic embolism and thrombosis of deep veins of left lower extremity, and recurrent urinary tract infections (UTI).
Review of the Minimum Data Set (MDS) assessment, dated 8/2/23, indicated Resident #20 was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) score of 14 out of 15, required extensive assistance with bed mobility, and was receiving an anticoagulant (blood thinner) and antibiotic.
Review of the medical record failed to indicate a comprehensive care plan was developed and implemented for care and treatment of the PICCs/Midline devices inserted or for the Resident's history of chronic embolism and thrombosis.
a. Midline Placement #1 (10/10/22)
Review of the Bard PowerMidline Instructions for Use (IFU), revised November 2016, indicated but was not limited to the following:
The PowerMidline Catheters are indicated for short term access to the peripheral venous system for selected intravenous therapies, blood samples, and power injection of contrast media.
Warnings:
-Do not use the catheter if there is any evidence of mechanical damage or leaking.
The potential exists for serious complications including the following:
-Air embolism, catheter emboli, catheter occlusion, catheter related sepsis, exterior site infection, exterior site necrosis, hematoma, phlebitis, perforation of vessels, thromboembolism, venous thrombosis
Suggested Catheter Maintenance:
Dressing Changes:
-Assess the dressing the first 24 hours for accumulation of blood, fluid, or moisture beneath the dressing. -During dressing changes, assess the external length of the catheter to determine if migration of the catheter has occurred. Periodically confirm catheter placement, tip location, patency, and security of dressing
Flushing:
-Flush each lumen of the catheter with 10 mL of sterile saline every 12 hours or after each use. In addition, lock each lumen of the catheter with sterile saline. Upon confirmation of patency, administration of medication should be given in a syringe appropriately sized for the dose. Do not infuse against resistance.
Occluded or Partially Occluded Catheter:
-Catheters that present resistance to flushing and aspiration may be partially or completely occluded. Do not flush against resistance. If it has been determined that a catheter is occluded with blood, a de-clotting procedure per institution protocol may be appropriate.
Review of a Nurse Practitioner's (NP) Note, dated 10/7/22 (4:55 P.M.), indicated but was not limited to the following:
-Resident has a past medical history significant for DVT on Eliquis (apixaban- blood thinner), frequent hospitalizations, and recurrent urinary tract infections.
-Urinalysis positive, awaiting culture results for antibiotic treatment.
Review of Physician's Orders indicated the following:
-May insert peripheral IV, schedule midline placement if unable, may place PICC line for IV antibiotic therapy every shift for 1 day, 10/9/22
-Cefepime HCL solution, 2 gm/100 mL, use 100 mL intravenously every 12 hours related to pseudomonas aeruginosa, for 10 days, give 2 gm/100 ml IV every 12 hours for 10 days, 10/9/22
Review of the Midline Insertion Record, dated 10/10/22, indicated a single lumen PowerMidline catheter was placed into the cephalic vein of the Resident's left arm at 11:05 A.M. for non-vesicant (does not irritate tissues) therapy greater than 14 days.
Review of a Nurse Progress Note, dated 10/14/22 (3:08 P.M.), indicated but was not limited to the following:
-Resident's left upper extremity Midline leaking. Nurse #11 indicated the dressing was wet and when flushed fluid could be seen at the entrance to the site. The MD was notified, and an order was obtained to have a new one (midline) inserted.
-No further assessment of the site was documented by Nurse #11.
Nurse #11 was unavailable for interview and was unable to be reached by phone by the surveyor.
Review of the October 2022 Medication Administration Record (MAR) indicated Nurse #9 administered the first dose of the IV cefepime on 10/10/22 as per her initials after the Midline catheter placement. Eight total doses of the antibiotic were administered from 10/10/22 to 10/14/22.
Review of the medical record failed to indicate orders had been entered and implemented for the care and treatment of the Resident's midline device including adequate monitoring for signs and symptoms of IV related complications, catheter lumen flushing, dressing orders, needleless connector change frequency, tubing change frequency, and any reports of pain or discomfort per professional standards of practice and facility policy.
b. Midline Placement #2 (10/14/22)
Review of Physician's Orders indicated the following:
-May replace Midline to left upper extremity related to leakage, may miss dose until IV replaced, 10/14/22
-Cefepime HCL solution 2 gm/100 mL, use 100 mL intravenously every 8 hours related to pseudomonas aeruginosa for 7 days, give 2 gm/100 mL IV every 8 hours for 7 days (start once line placed), 10/14/22
Review of a Nurse Practitioner's Note, dated 10/14/22 (5:29 PM.), indicated but was not limited to the following:
-Resident on a seven day course of Cefepime, his/her midline leaking and awaiting a midline change.
-Cefepime frequency increased to every 8 hours for another 7 days for a total of 10 days.
Review of the Midline Insertion Record, dated 10/14/22, indicated a single lumen Midline catheter was placed in the cephalic vein of the Resident's right arm at 9:00 P.M. for non-vesicant therapy less than six days.
Review of the October 2022 MAR indicated the cefepime was administered six times from 10/15/22 through 10/16/22 (three times a day for each day).
Review of the medical record failed to indicate orders had been entered and implemented for the care and treatment of the Resident's midline device including adequate monitoring for signs and symptoms of IV related complications, catheter lumen flushing, dressing orders, needleless connector change frequency, tubing change frequency, and any reports of pain or discomfort per professional standards of practice and facility policy.
c. Power Injectable PICC Placement #1 (10/18/22)
Review of Bard PowerPICC Instructions for Use (IFU), revised November 2010, indicated but was not limited to the following:
The PowerPICC SV is indicated for short- or long-term peripheral access to the central venous system for intravenous therapy, blood sampling, power injection of contrast media, and allows for central venous pressure monitoring.
Contraindications:
-Previous episodes of venous thrombosis
-Do not use the catheter if there is any evidence of mechanical damage or leaking. Damage to the catheter may lead to rupture, fragmentation, possible embolism, and surgical removal.
Possible Complications:
-Air embolism, bleeding, cardiac arrhythmia, cardiac tamponade, catheter embolism, catheter occlusion, catheter related sepsis, endocarditis, exit site infection, exit site necrosis, hematoma, phlebitis, thromboembolism, venous thrombosis
Dressing Changes:
-Assess the dressing in the first 24 hours for accumulation of blood, fluid, or moisture beneath the dressing. During all dressing changes, assess the external length of the catheter to determine if migration of the catheter has occurred. Periodically confirm catheter placement, tip location, patency, and security of dressing.
Flushing:
-Flush each lumen of the catheter with 10 mL of saline every 12 hours or after each use. In addition, lock each lumen of the catheter with heparinized saline.
Occluded or partially Occluded Catheter:
-Catheters that present resistance to flushing and aspiration may be partially or completely occluded. Do not flush against resistance. If the lumen will neither flush nor aspirate and it has been determined that the catheter is occluded with blood, a de-clotting procedure per institution may be appropriate.
Review of Lippincott Nursing Procedures, eighth edition, dated 2019, indicated but was not limited to the following:
Peripherally Inserted Central Catheter (PICC) Use:
Flushing a PICC:
-Review the patient's medical records to confirm the type and size of the catheter and the location of the catheter tip, because the flush protocol depends on the type and size of the catheter.
-Inspect the entire infusion system for clarity of the solution, integrity of the system (such as absence of leakage), accurate flow rate, expiration dates of the solution and administration set.
Performing a PICC Dressing Change:
-Inspect the catheter-skin junction and surrounding area and palpate through intact dressing for redness, tenderness, swelling, and drainage. Pay attention to the patient's reports of pain.
-Use a sterile tape measure to measure the external length of the catheter from hub to skin entry to make sure the catheter hasn't migrated.
Special Considerations:
-Assess the catheter insertion site daily by inspection and palpation through the transparent semi-permeable dressing to discern tenderness. Look at the catheter and cannula pathway, and check for bleeding, redness, drainage and swelling. Ask the patient about pain associated with therapy.
-For catheters that aren't being used routinely, flush non-valved catheters at least every 24 hours and valved catheters at least weekly. Flush the catheter with preservative free normal saline solution; lock with heparin (10 units/mL) if applicable.
-Encourage the patient to report changes in the catheter site or any new discomfort
Complications:
-PICCs are associated with higher rates of DVT than other central venous access devices owing to insertion into the veins with a smaller diameter and greater movement of the upper extremity.
-PICC insertion sites at the antecubital fossa have higher rates of DVT than mid-upper arm insertion sites. Infection and catheter breakage on removal are other possible complications.
Documentation:
-For flushing, document the site's appearance as well as the date, time, and type and amount of flush solution used. Document patency, absence of signs and symptoms of complications, lack of resistance when flushing, and presence of blood return upon aspiration. Document whether the patient experienced pain or discomfort during flushing. Note patient teaching performed.
Review of Physician's Orders indicated the following:
-Replace 10 cm midline in the right arm due to leak one time only for leak, 10/17/22
-Take the Midline out, not functioning replaced with PICC line, 10/18/22
-Insert a PICC line for administration of cefepime for UTI, 10/18/22
Review of the PICC Insertion Record, dated 10/18/22, indicated a single lumen, non-valved (neutral pressure, valve remains closed, reducing risk of air embolism, blood reflux and clotting) Power Injectable PICC was inserted into the basilic vein in the Resident's left arm at 12:40 P.M.
Review of the medical record failed to indicate orders had been entered and implemented for the care and treatment of the Resident's Power Injectable PICC device including adequate monitoring for signs and symptoms of IV related complications, proper catheter lumen flushing per facility protocol and manufacturer's IFUs, dressing orders, needleless connector change frequency, tubing change frequency, and any reports of pain or discomfort per facility policy and professional standards of practice.
Review of the October 2022 MAR indicated the cefepime was restarted and administered by Nurse #9 per her initials after the PICC was inserted on 10/18/22 at approximately 2:00 P.M.
Review of a Nurse Progress note, dated 10/18/23 (4:40 P.M.), indicated but was not limited to the following:
-He/she had a PICC line inserted today and midline removed due to leaking, continues with his/her cefepime IV.
The surveyor was unable to locate documentation in the medical record to indicate details of the previously placed midline leaking.
Review of the Nurse Practitioner's note, dated 10/19/22 (9:49 P.M.), indicated but was not limited to the following:
-Midline had been changed to a PICC line due to a second midline malfunction.
Review of Physician's Orders indicated the following:
-Flush each lumen with 10 mL of normal saline every 8 hours whenever lumen is locked with no infusion, currently running every 8 hours, start 10/22/22, (4 days after the PICC was placed)
Further review of the physician's order failed to indicate the proper flushing protocol for the non-valved PICC line per facility protocol and manufacturer's IFUs which indicated to flush each lumen of the catheter with 10 mL of saline every 12 hours or after each use. In addition, to lock each lumen of the catheter with heparinized saline (keeps the catheter open and free of clots).
Review of Physician's Orders indicated the following:
-May remove PICC line from RUE, no longer in use, one time only for completed antibiotics for 1 day, 10/26/22
Review of a Nurse Progress Note, dated 10/30/22 (10:29 P.M.), indicated but was not limited to the following:
-Resident to have a midline catheter placed in the morning by the contracted vascular access nurse for a slight right upper lobe infiltrate (when a substance denser than air, e.g., pus, edema, blood, lingers within the lung).
During an interview on 9/12/23 at 12:59 P.M., Nurse #9 said all IVs need orders to include flushing, changing the tubing, changing the dressing, and checking for signs and symptoms of infection. She said managers usually enter the orders, but nursing staff are responsible as well. Nurse #9 said documentation also includes progress notes and if the resident tolerated the medication well and if there are any signs and symptoms of infection. She said she had administered the antibiotic via the Resident's Midline catheter and/or PICC at least seven times last October but didn't notice there were no orders for the care and treatment of them, so she didn't enter them (the orders). She said the purpose of monitoring and assessing is because you want to keep the resident safe, it's the health of the patient, to assess for signs and symptoms of infection and DVT. Nurse #9 said the danger of a DVT is that it can block their arteries or lead to a stroke or go to the heart. She said proper care and treatment could help prevent any complications.
d. Power Injectable PICC Placement #2 (11/1/22)
Review of Physician's Orders indicated the following:
-Ceftriaxone Sodium solution reconstituted, 1 gm IM stat for pneumonia, 10/30/22
-Ceftriaxone Sodium solution reconstitution 1 gm, use 1 gm intravenously one time a day for pneumonia until 11/3/22, start 10/30/22
-May insert midline to administer Ceftriaxone every shift for pneumonia for 1 day, 10/30/22
Review of a Procedure Note for Vascular Access Device Insertion, dated 10/31/22, indicated but was not limited to the following:
-Resident was somnolent on assessment, not baseline per care team. Patient unable to consent for midline, discussed to establish peripheral IV in interim as patient may be sent to hospital.
-Peripheral IV inserted. Patient with bilateral upper extremity edema.
Review of a Nurse Progress Note, dated 10/31/22 (12:05 P.M.), indicated but was not limited to the following:
-He/she is very swollen, he/she has been for a few days (note did not indicate where). Lasix (diuretic) was increased.
-Right now he/she is completely out of it. Has a UTI and pneumonia and did not even flinch when they put the IV in his/her right hand.
-NP was made aware, and the Resident was sent out to the hospital.
Review of a Nurse Practitioner's Note, dated 11/1/22 (6:39 P.M.), indicated but was not limited to the following:
-Resident was transferred back from the Emergency Department (ED) on 10/31/22 and was negative for any acute findings but was treated in the ED for a possible UTI.
-Was started on PO cefpodoxime and returned to the facility with instructions to transition to IV cefepime if needed. -Patient currently complaining of dysuria (pain or burning sensation while passing urine), states he/she was told by the ED he/she had a bad UTI while in the ED, patient requesting cefpodoxime to be changed to IV cefepime.
Review of the PICC Insertion Record, dated 11/1/22, indicated a single lumen, non-valved, Power Injectable PICC was inserted at 6:57 P.M. into the basilic vein in the Resident's left arm.
Review of the medical record failed to indicate orders had been entered and implemented for the care and treatment of the Resident's Power Injectable PICC device including adequate monitoring for signs and symptoms of IV related complications, proper catheter lumen flushing per facility protocol and manufacturer's IFU, dressing orders, needleless connector change frequency, tubing change frequency, and any reports of pain or discomfort per facility policy and professional standards of practice.
Review of a Nurse Progress Note, dated 11/3/22 (6:38 P.M.), indicated but was not limited to the following:
-Resident was sent to the hospital due to possible left arm infiltration.
Review of the hospital's History and Physical Nurse Practitioner's Note, dated 11/3/22, indicated but was not limited to the following:
-Patient has a history of congestive heart failure (CHF), chronic obstructive pulmonary disease (COPD), morbid obesity, DVT, suprapubic catheter, chronic pain, and recurrent UTIs and returned to the hospital for evaluation of pain and swelling in the left arm, most significantly at the site of the PICC.
-Patient had a right sided PICC line two months ago and had superficial thrombus in the right arm at that time, suspect both DVTs are related to the PICC lines. Interestingly, the patient tells me that he/she feels that the swelling in his/her left upper extremity (LUE) began over a week ago, prior to PICC placement, though he/she admits this worsened after the PICC was inserted.
-On arrival at the ED, a bilateral upper extremity (BUE) duplex showed an acute occlusive left DVT involving one of the paired brachial veins and left axillary vein surrounding the PICC line. Central extension of nonocclusive thrombus into the left subclavian vein surrounding the PICC was also seen. A new acute occlusive right sided DVT of the right subclavian vein was also noted, along with acute occlusive superficial thrombosis involving the left basilic and cephalic veins.
-The PICC line was removed immediately and a Heparin (blood thinner) drip was started. While it does make sense that the PICC line would be the causative factor in this DVT formation, it does not explain the bilateral nature of these findings. A vascular surgery consult was conducted.
Review of a Hospital Care Management note, dated 11/8/22, indicated but was not limited to the following:
-Resident had been assessed for discharge needs. The patient was on antibiotics for a UTI and was at the hospital for BUE DVTs and now has a tunneled subclavian central line for IV antibiotics. Unable to use BUE due to DVTs. Palliative NP met with the patient who is agreeable to hospice.
Review of the Hospital Discharge summary, dated [DATE], indicated but was not limited to the following:
-The admission extended from 11/3/22 through 11/8/22.
-The patient recently, on 10/31/22, had a PICC line placed at the SNF to begin treatment with IV cefepime for a pseudomonas UTI. He/she returned to the hospital on [DATE] from SNF with swelling and pain to his/her left arm, most significantly at the site of the PICC. On arrival at the ED, a BUE duplex (diagnoses DVTs and venous insufficiency) showed extensive bilateral DVTs. The patient has been seen by palliative care regarding poor quality of life and frequent hospitalizations. The discharge diagnosis was acute bilateral upper extremity DVTs and a follow up recommendation with hospice. The patient was discharged back to the SNF on Apixaban.
During an interview on 9/11/23 at 12:27 P.M., Resident #20 said he/she remembered last October and when he/she was sent to the hospital. The Resident said the IVs were big and didn't feel right the whole time and were painful to him/her in the left arm. The Resident said he/she had to stay in the hospital and that's what he/she was trying to avoid. Resident #20 said it was an aide who discovered the swelling and told the nurse but didn't remember much more.
During an interview on 9/11/23 at 11:38 A.M., Nurse #4 said potential problems of a PICC/Midline could include occlusion, clotting, and infection. She said orders would need to be in place for monitoring on the MAR or TAR but said the October 2022 MAR and TAR did not reflect that other than an order to flush on 10/22/22 when it was locked. Unit Manager (UM) #1 entered the nurses' station and said there should have been orders placed for the care and treatment of the PICC/Midline devices last October and November but weren't. She said staff need to know what kind of line it is to know what orders to enter, and it should have been care planned but wasn't.
During an interview on 9/11/23 at 12:33 P.M., the Director of Nurses (DON) said she was relatively new to the facility and UM #2 would know better but the orders should have been entered with the IV insertion order and the Resident monitored for signs and symptoms of adverse events. She said the type of IV access would determine the treatment orders. She said if the documentation was not in the electronic record, then it was not done. UM #2 entered the DON's office and said she reviewed the Resident's record, and the orders were not there, there was nothing. She said the point of monitoring is to prevent any adverse events from occurring. The DON said there should have been a care plan in place but wasn't.
During an interview on 9/12/23 at 3:00 P.M., the Medical Director (MD) said he was assigned to Resident #20 who had a history of a suprapubic catheter for chronic urinary retention, a long history of multidrug resistance use for UTIs, a hypercoagulable condition, chronic pain, heart failure, tobacco dependency, morbid obesity, was relatively immobile, monthly hospitalizations for the past year, and had a history of clots in both arms. He said at one point he/she had a clot in his/her leg as well and required IV access for multidrug-resistant organisms (MDRO) UTIs. He said the Resident was on Eliquis prior and would need, per the hematologist, lifelong anticoagulation after DVTs. He said he/she was at risk for clots and was on Eliquis. He said he wasn't sure who was responsible for entering the bundled orders (group of orders pertaining to the care and treatment of a midline/PICC). He said the orders should be entered to monitor the insertion site for no infection, nothing abnormal around the site, infiltrate, or clotting. The MD said whenever a patient requires a PICC line or Midline there would be a lot of active monitoring from his nurse practitioners to make sure the patient is doing well, that there's a response to treatment. Nursing staff would document monitoring and assessment of the site daily as well as in conjunction with the NPs. He said Resident #20 got a clot in his/her arm at the site of the PICC and, looking back now, there was a delay in diagnosing the clot when the patient had pain and swelling. He said one of his colleagues put another line in then sent him/her back to the hospital where a bilateral upper extremity duplex was done and showed extensive DVTs, and now we know why there's pain and swelling. He said he did not know there weren't any orders for monitoring, and it was obviously suboptimal. The MD said there should be adequate monitoring to avoid any complications or adverse events.
During an interview on 9/12/23 at 4:20 P.M., the DON said there was nothing in the old records regarding paper documentation for the central lines, someone did look, and they didn't find it. She said she had no documentation to provide to the surveyor that the facility had identified the issue and conducted a plan of correction or educational piece. She said the expectation would be for whoever the nurse was that took the PICC/Midline insertion order, to enter the orders for the care and treatment of a central line to include things such as monitoring for swelling, redness, signs and symptoms of infection, flushing, dressing changes, changing the tubing, and monitoring for migration. She said nursing staff are expected to properly assess and monitor the site to avoid any potential adverse outcomes.
No further documentation was provided to the surveyor prior to exiting the facility.
See F694
2. Review of the facility's policy titled Infusion Intravenous (IV) Access Line Maintenance Protocol, dated 12/1/18, indicated but was not limited to the following:
-Needleless Connector Changes: On admission, every week and as needed.
-Administration Set Changes: Every 24 hours
-Transparent Dressing Changes: Insertion, then weekly and as needed. Measure upper arm circumference and exterior catheter length with each dressing change and as needed.
-Dressing Changes: Gauze should only be used if patients are sensitive to clear transparent dressings and must be changed every 2 days.
Review of the facility's competency for: Changing the Needleless Connector on an IV Catheter (dated 2/2014) indicated but was not limited to the following:
-Primes needleless connector with prescribed flushing agent while maintaining sterility, leaves syringe attached.
Review of the [NAME] NURSING PROCEDURES - 9th Ed. (2023)- Flushing a PICC indicated but was not limited to the following:
- While maintaining the sterility of the syringe tip, attach a prefilled 10-mL syringe containing preservative-free normal saline solution to the needleless connector.
-Unclamp the catheter and slowly aspirate for a blood return that's the color and consistency of whole blood.
-If you don't obtain a blood return, take steps to locate an external cause of obstruction.
-If you obtain a blood return, slowly inject preservative-free normal saline solution into the catheter.
-Don't forcibly flush the device.
-Further evaluate the device if you meet resistance.
Resident #39 was admitted to the facility in May 2016 with diagnoses including diabetes, chronic non-pressure ulcer of the right calf, and cellulitis.
Record review indicated that on 9/3/23, Resident #39 was sent to the hospital and admitted with diagnoses including septic shock with organ failure, acute kidney injury. and bacteremia presumed secondary to left foot blister lesion. The Resident returned to the facility on 9/12/23 with a PICC in place for the continued administration of Intravenous (IV) antibiotics.
Review of the Hospital Discharge summary, dated [DATE], indicated that the Resident was to receive four doses of intravenous (IV) antibiotics (9/13/23 through 9/16/23), and then the PICC was to be removed (on 9/16/23) after the last dose of the antibiotic had been administered.
Review of the September 2023 Physician's Orders for the PICC line indicated the following:
-Flush each lumen with 10 milliliters (mls) of normal saline every 8 hours, when lumen is locked with no infusion currently running. Discontinue once the line has been pulled.
-Occlusive dressing supplies at bedside in the event the line is dislodged. Discontinue once line has been pulled.
-Change PICC line catheter transparent dressing upon admission and every 7 days.
-Flush catheter lumen pre- and post- medication administration with 10 mls of Normal saline every evening shift until 9/16/23. Line to be pulled after last dose given on 9/16/23.
-Maintain emergency clamp at bedside at all times.
-Monitor PICC line catheter every shift for signs/symptoms of IV related complications. Discontinue once line has been pulled.
Further review of the Physician's orders failed to indicate the following:
-Measure upper arm circumference and exterior catheter length with each dressing change and as needed
-Needleless Connector Device - On admission, th[TRUNCATED]
CRITICAL
(J)
Immediate Jeopardy (IJ) - the most serious Medicare violation
Deficiency F0694
(Tag F0694)
Someone could have died · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, policy review, and interview, the facility failed to ensure the proper care and treatment o...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, policy review, and interview, the facility failed to ensure the proper care and treatment of a peripherally inserted central catheter (PICC) and/or midline catheter device in accordance with the facility policy/protocols. Specifically, the facility failed:
1. For one Resident (#20), who had a history of chronic embolism and thrombosis (formation of a blood clot within blood vessels or arteries limiting the natural flow of blood), out of a total sample of three residents with peripheral lines in place, to ensure physician's orders were in place and implemented for the care and treatment of two out of two midline catheters and two out of two PICCs to include monitoring for signs and symptoms of intravenous (IV) related complications, catheter lumen flushing, dressing orders, needleless connector change frequency, tubing change frequency, and any reports of pain or discomfort by the Resident per professional standards of practice and facility policy during the timeframe of 10/10/22 through 11/3/22. This resulted in the Resident experiencing pain and swelling in his/her left arm resulting in an extended hospital stay from 11/3/22 through 11/8/22 with a diagnosis of acute extensive bilateral upper extremity deep vein thromboses (DVT) (blood clot in a deep vein) with extension into the subclavian vein and an occlusive left arm DVT involving one of the brachial veins and left axillary vein surrounding the PICC; and
2. For one Resident (#39), out of a total sample of two residents currently residing in the facility with a PICC or midline device in place, to provide care and treatment of the PICC. Specifically, the facility failed to ensure the PICC dressing change was performed correctly, three of three lumens of the PICC were flushed correctly, the needleless connector of one of three lumens was primed before being changed according to facility policies and PICC protocol/standards of practice. The facility also failed to have complete orders in place for care of the Resident's PICC.
It was determined the Immediate Jeopardy began on 10/10/22 and was identified on 9/13/23. The Department of Public Health sent a Notice of Determination of Immediate Jeopardy (IJ) and the IJ templates to the Facility Administrator on 9/13/23.
Findings include:
1. Review of the facility's policy titled Central Line Policy, revised June 2022, indicated but was not limited to the following:
-The purpose of this procedure is to outline the protocol when caring for residents that have a midline (thin, soft tube that is placed into a vein at the level of the armpit) used for IV treatments or peripherally inserted central catheters (PICC- long, thin tube inserted through a vein in your arm and passed through to the larger veins near your heart).
-Enter standing orders including but not limited to:
a. monitoring the site for signs and symptoms of IV related complications
b. catheter lumen flushing
c. dressing orders
d. tubing change frequency
Review of the facility's document titled, Pharmscript Infusion Intravenous (IV) Access Line Maintenance Protocol, dated December 2018, indicated but was not limited to the following:
Midline:
-Maintenance, Flush Each Lumen - Non-Valved every 12 hours with normal saline (NS) 10 milliliters (mL), 3 mL 10 units/mL heparin [blood thinner that prevents harmful clots from forming in the blood vessels], valved 10 mL NS every week
-Transparent Dressing Change - Insertion, then weekly and as needed. Measure upper arm circumference and exterior catheter length with each dressing change and as needed
-Needleless Connector Changes - On admission, every week, and as needed
Administration Set Changes - primary, every 24 hours
PICC:
-Maintenance, Flush Each Lumen - Non-valved every 12 hours with NS 10 mL, 5 mL 10 units/mL heparin, valved 10 mL NS every week, Intermittent Non-Valved - 10 mL NS, 5 mL 10 units/mL heparin
-Transparent Dressing Change - Insertion, then weekly and as needed, measure upper arm circumference and exterior catheter length with each dressing change and as needed
-Needleless Connector Device - On admission, then weekly and as needed
-Administration Set Changes - primary, every 24 hours
Resident #20 was admitted to the facility in September 2022 with diagnoses including Behcet's disease (rare disorder causing inflammation of blood vessels), chronic peripheral venous insufficiency, morbid obesity, type II diabetes mellitus, chronic diastolic heart failure (CHF), peripheral vascular disease (PVD), chronic embolism and thrombosis of deep veins of left lower extremity, and recurrent urinary tract infections (UTIs).
Review of the Minimum Data Set (MDS) assessment, dated 8/2/23, indicated Resident #20 was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) score of 14 out of 15, required extensive assistance with bed mobility, and was receiving an anticoagulant (blood thinner) and antibiotic.
Review of the medical record failed to indicate a comprehensive care plan was developed and implemented for care and treatment of the PICCs/midline catheter devices inserted from 10/10/22 through 11/3/22 or for the Resident's history of chronic embolism and thrombosis.
a. Midline Placement #1 (10/10/22)
Review of the Bard PowerMidline Instructions for Use (IFUs), revised November 2016, indicated but was not limited to the following:
The PowerMidline Catheters are indicated for short term access to the peripheral venous system for selected intravenous therapies, blood samples, and power injection of contrast media.
Warnings:
-Do not use the catheter if there is any evidence of mechanical damage or leaking.
The potential exists for serious complications including the following:
-Air embolism, catheter emboli, catheter occlusion, catheter related sepsis, exterior site infection, exterior site necrosis, hematoma, phlebitis, perforation of vessels, thromboembolism, venous thrombosis
Suggested Catheter Maintenance:
Dressing Changes:
-Assess the dressing the first 24 hours for accumulation of blood, fluid, or moisture beneath the dressing. -During dressing changes, assess the external length of the catheter to determine if migration of the catheter has occurred. Periodically confirm catheter placement, tip location, patency, and security of dressing
Flushing:
-Flush each lumen of the catheter with 10 mL of sterile saline every 12 hours or after each use. In addition, lock each lumen of the catheter with sterile saline. Upon confirmation of patency, administration of medication should be given in a syringe appropriately sized for the dose. Do not infuse against resistance.
Occluded or Partially Occluded Catheter:
-Catheters that present resistance to flushing and aspiration may be partially or completely occluded. Do not flush against resistance. If it has been determined that a catheter is occluded with blood, a de-clotting procedure per institution protocol may be appropriate.
Review of a Nurse Practitioner's (NP) Note, dated 10/7/22 (4:55 P.M.), indicated but was not limited to the following:
-Resident has a past medical history significant for DVT on Eliquis (apixaban- blood thinner), frequent hospitalizations, and recurrent urinary tract infections.
-Urinalysis positive, awaiting culture results for antibiotic treatment.
Review of a Nurse Progress Note, dated 10/9/22 (11:32 P.M.), indicated but was not limited to the following:
-Message sent to the attending physician that the patient refused PO (by mouth) antibiotics while awaiting the culture and requested IV antibiotics because the hospital said he/she would die of sepsis if not treated with IV antibiotics instead of PO ones.
Review of Physician's Orders indicated the following:
-May insert peripheral IV, schedule midline placement if unable, may place PICC line for IV antibiotic therapy every shift for 1 day, 10/9/22
-Cefepime HCL solution, 2 gm/100 mL, use 100 mL intravenously every 12 hours related to pseudomonas aeruginosa, for 10 days, give 2 gm/100 ml IV every 12 hours for 10 days, 10/9/22
Review of the Midline Insertion Record, dated 10/10/22, indicated a single lumen PowerMidline catheter was placed into the cephalic vein of the Resident's left arm at 11:05 A.M. for non-vesicant (does not irritate tissues) therapy greater than 14 days.
Review of a Nurse Progress Note, dated 10/14/22 (3:08 P.M.), indicated but was not limited to the following:
-Resident's left upper extremity Midline leaking. Nurse #11 indicated the dressing was wet and when flushed, fluid could be seen at the entrance to the site. The MD was notified, and an order was obtained to have a new one (midline) inserted.
No further assessment of the site was documented by Nurse #11.
Nurse #11 was unavailable for interview and was unable to be reached by phone by the surveyor.
Review of the October 2022 Medication Administration Record (MAR) indicated Nurse #9 administered the first dose of the IV cefepime on 10/10/22 as per her initials after the Midline catheter placement. Eight total doses of the antibiotic were administered from 10/10/22 to 10/14/22.
Review of the medical record failed to indicate orders had been entered and implemented for the care and treatment of the Resident's midline device including adequate monitoring for signs and symptoms of IV related complications, catheter lumen flushing, dressing orders, needleless connector change frequency, tubing change frequency, and any reports of pain or discomfort per professional standards of practice and facility policy.
b. Midline Placement #2 (10/14/22)
Review of Physician's Orders indicated the following:
-May replace Midline to left upper extremity related to leakage, may miss dose until IV replaced, 10/14/22
-Cefepime HCL solution 2 gm/100 mL, use 100 mL intravenously every 8 hours related to pseudomonas aeruginosa for 7 days, give 2 gm/100 mL IV every 8 hours for 7 days (start once line placed), 10/14/22
Review of a Nurse Practitioner's Note, dated 10/14/22 (5:29 PM.), indicated but was not limited to the following:
-Resident on a seven day course of Cefepime, his/her midline leaking and awaiting a Midline change.
-Cefepime frequency increased to every 8 hours for another 7 days for a total of 10 days.
Review of the Midline Insertion Record, dated 10/14/22, indicated a single lumen midline catheter was placed into the cephalic vein of the Resident's right arm at 9:00 P.M. for non-vesicant therapy less than six days.
Review of the October 2022 MAR indicated the cefepime was administered six times from 10/15/22 through 10/16/22 (three times a day each day).
Review of the medical record failed to indicate orders had been entered and implemented for the care and treatment of the Resident's midline device including adequate monitoring for signs and symptoms of IV related complications, catheter lumen flushing, dressing orders, needleless connector change frequency, tubing change frequency, and any reports of pain or discomfort per professional standards of practice and facility policy.
c. Power Injectable PICC Placement #1 (10/18/22)
Review of Bard PowerPICC Instructions for Use (IFUs), revised November 2010, indicated but was not limited to the following:
The PowerPICC SV is indicated for short- or long-term peripheral access to the central venous system for intravenous therapy, blood sampling, power injection of contrast media, and allows for central venous pressure monitoring.
Contraindications:
-Previous episodes of venous thrombosis
-Do not use the catheter if there is any evidence of mechanical damage or leaking. Damage to the catheter may lead to rupture, fragmentation, possible embolism, and surgical removal.
Possible Complications:
-Air embolism, bleeding, cardiac arrhythmia, cardiac tamponade, catheter embolism, catheter occlusion, catheter related sepsis, endocarditis, exit site infection, exit site necrosis, hematoma, phlebitis, thromboembolism, venous thrombosis
Dressing Changes:
-Assess the dressing in the first 24 hours for accumulation of blood, fluid, or moisture beneath the dressing. During all dressing changes, assess the external length of the catheter to determine if migration of the catheter has occurred. Periodically confirm catheter placement, tip location, patency, and security of dressing.
Flushing:
-Flush each lumen of the catheter with 10 mL of saline every 12 hours or after each use. In addition, lock each lumen of the catheter with heparinized saline.
Occluded or partially Occluded Catheter:
-Catheters that present resistance to flushing and aspiration may be partially or completely occluded. Do not flush against resistance. If the lumen will neither flush nor aspirate and it has been determined that the catheter is occluded with blood, a de-clotting procedure per institution may be appropriate.
Review of a Nurse Progress note, dated 10/16/22 (2:58 P.M.), indicated but was not limited to the following:
-Midline to RUE [right upper extremity] intact/flushes well.
Review of Physician's Orders indicated the following:
-Replace 10 cm midline in the right arm due to leak one time only for leak, 10/17/22
-Take the Midline out, not functioning replaced with PICC line, 10/18/22
-Insert a PICC line for administration of cefepime for UTI, 10/18/22
Review of the PICC Insertion Record, dated 10/18/22, indicated a single lumen, non-valved (neutral pressure, valve remains closed, reducing risk of air embolism, blood reflux and clotting) Power Injectable PICC was inserted into the basilic vein in the Resident's left arm at 12:40 P.M.
Review of the medical record failed to indicate orders had been entered and implemented for the care and treatment of the Resident's Power Injectable PICC device including adequate monitoring for signs and symptoms of IV related complications, proper catheter lumen flushing per facility protocol and manufacturer's IFUs, dressing orders, needleless connector change frequency, tubing change frequency, and any reports of pain or discomfort per facility policy and professional standards of practice.
Review of the October 2022 MAR indicated the cefepime was restarted and administered by Nurse #9 per her initials after the PICC was inserted on 10/18/22 at approximately 2:00 P.M.
Review of a Nurse Progress note, dated 10/18/22 (4:40 P.M.) indicated but was not limited to the following:
-He/she had a PICC line inserted today and midline removed due to leaking, continues with his/her cefepime IV.
The surveyor was unable to locate documentation in the medical record to indicate details of the previously placed midline leaking.
Review of a Nurse Practitioner's Note, dated 10/19/22, indicated but was not limited to the following:
-Midline had been changed to a PICC line due to a second midline malfunction.
Review of Physician's Orders indicated the following:
-Flush each lumen with 10 mL of normal saline every 8 hours whenever lumen is locked (when IV is not connected to a running line) with no infusion currently running, start 10/22/22, (4 days after the PICC was placed)
Further review of the physician's order failed to indicate the proper flushing protocol for the non-valved PICC line per facility protocol and manufacturer's IFUs which indicated to flush each lumen of the catheter with 10 mL of saline every 12 hours or after each use. In addition, to lock each lumen of the catheter with heparinized saline (keeps the catheter open and free of clots).
Review of Physician's Orders indicated the following:
-May remove PICC line from RUE, no longer in use, one time only for completed IV antibiotics for 1 day, 10/26/22
Review of a Nurse Progress Note, dated 10/30/22 (10:29 P.M.), indicated but was not limited to the following:
-Resident to have a Midline catheter placed in the morning by the contracted vascular access nurse for a slight right upper lobe infiltrate (when a substance denser than air, e.g., pus, edema, blood, lingers within the lung).
During an interview on 9/12/23 at 12:59 P.M., Nurse #9 said all IVs need orders to include flushing, changing the tubing, changing the dressing, and checking for signs and symptoms of infection. She said managers usually enter the orders, but nursing staff are responsible as well. Nurse #9 said documentation also includes progress notes and if the resident tolerated the medication well and if there are any signs and symptoms of infection. She said she had administered the antibiotic via the Resident's Midline catheter and/or PICC at least seven times last October but didn't notice there were no orders for the care and treatment of them so she didn't enter them (the orders). She said the purpose of monitoring and assessing is because you want to keep the resident safe, it's the health of the patient, to assess for signs and symptoms of infection and DVT. Nurse #9 said the danger of a DVT is that it can block their arteries or lead to a stroke or go to the heart. She said proper care and treatment could help prevent any complications.
d. Power Injectable PICC Placement #2 (11/1/22)
Review of Physician's Orders indicated the following:
-Ceftriaxone Sodium solution reconstituted, 1 gm IM stat for pneumonia, 10/30/22
-Ceftriaxone Sodium solution reconstitution 1 gm, use 1 gm intravenously one time a day for pneumonia until 11/3/22, start 10/30/22
-May insert midline catheter to administer Ceftriaxone every shift for pneumonia for 1 day, 10/30/22
Review of a Procedure Note for Vascular Access Device Insertion, dated 10/31/22, indicated but was not limited to the following:
-Resident was somnolent on assessment, not baseline per care team. Patient unable to consent for midline, discussed to establish peripheral IV in interim as patient may be sent to hospital. Peripheral IV with bilateral upper extremity edema.
Review of a Nurse Progress Note, dated 10/31/22 (12:05 P.M.), indicated but was not limited to the following:
-He/she is very swollen, he/she has been for a few days (note did not indicate where). Lasix (diuretic) was increased.
-Right now he/she is completely out of it. Has a UTI and pneumonia and did not even flinch when they put the IV in his/her hand.
-NP was made aware, and the Resident was sent out to the hospital.
Review of a Nurse Practitioner's Note, dated 11/1/22 (6:39 P.M.), indicated but was not limited to the following:
-Resident transferred back from the Emergency Department (ED) on 10/31/22 and was negative for any acute findings but was treated in the ED for a possible UTI.
-Was started on PO cefpodoxime and returned to the facility with instructions to transition to IV cefepime if needed.
-Patient currently complaining of dysuria (pain or burning sensation while passing urine), states he/she was told by the ED he/she had a bad UTI while in the ED, patient requesting cefpodoxime to be changed to IV cefepime.
Review of the PICC Insertion Record, dated 11/1/22, indicated a single lumen, non-valved, Power Injectable PICC was inserted into the basilic vein in the Resident's left arm at approximately 6:57 P.M.
Review of the medical record failed to indicate orders had been entered and implemented for the care and treatment of the Resident's Power Injectable PICC device including adequate monitoring for signs and symptoms of IV related complications, proper catheter lumen flushing per facility protocol and manufacturer's IFUs, dressing orders, needleless connector change frequency, tubing change frequency, and any reports of pain or discomfort per facility policy and professional standards of practice.
Review of a Nurse Progress Note, dated 11/3/22 (6:38 P.M.), indicated but was not limited to the following:
-Resident was sent to the hospital due to possible left arm infiltration.
Review of the hospital's History and Physical Nurse Practitioner Note, dated 11/3/22, indicated but was not limited to the following:
-Patient has a history of congestive heart failure (CHF), chronic obstructive pulmonary disease (COPD), morbid obesity, DVT, suprapubic catheter, chronic pain, and recurrent UTIs and returned to the hospital for evaluation of pain and swelling in the left arm, most significantly at the site of the PICC.
-Patient had a right sided PICC line two months ago and had superficial thrombus in the right arm at that time, suspect both DVTs are related to the PICC lines. Interestingly, the patient tells me that he/she feels that the swelling in his/her left upper extremity (LUE) began over a week ago, prior to PICC placement, though he/she admits this worsened after the PICC was inserted.
-On arrival at the ED, a bilateral upper extremity (BUE) duplex (diagnoses DVTs and venous insufficiency) showed an acute occlusive left DVT involving one of the paired brachial veins and left axillary vein surrounding the PICC line. Central extension of nonocclusive thrombus into the left subclavian vein surrounding the PICC was also seen. A new acute occlusive right sided DVT of the right subclavian vein was also noted, along with acute occlusive superficial thrombosis involving the left basilic and cephalic veins.
-The PICC line was removed immediately and a Heparin (blood thinner) drip was started. While it does make sense that the PICC line would be the causative factor in this DVT formation, it does not explain the bilateral nature of these findings. A vascular surgery consult was conducted.
Review of a Hospital Care Management note, dated 11/8/22, indicated but was not limited to the following:
-Resident had been assessed for discharge needs. The patient was on antibiotics for a UTI and was at the hospital for bilateral upper extremity (BUE) DVTs and now has a tunneled subclavian central line for IV antibiotics. Unable to use BUE due to DVTs. Palliative NP met with the patient who is agreeable to hospice.
Review of the Hospital Discharge summary, dated [DATE], indicated but was not limited to the following:
-The admission extended from 11/3/22 through 11/8/22.
-The patient recently, on 10/31/22, had a PICC line placed at the SNF to begin treatment with IV cefepime for a pseudomonas UTI. He/she returned to the hospital on [DATE] from SNF with swelling and pain to his/her left arm, most significantly at the site of the PICC. On arrival at the ED, a BUE duplex showed extensive bilateral DVTs. The patient has been seen by palliative care regarding poor quality of life and frequent hospitalizations. The discharge diagnosis was acute bilateral upper extremity DVTs and a follow up recommendation with hospice. The patient was discharged back to the SNF on Apixaban.
During an interview on 9/11/23 at 12:27 P.M., Resident #20 said he/she remembered last October and when he/she was sent to the hospital. The Resident said the IVs were big and didn't feel right the whole time and were painful to him/her in the left arm. The Resident said he/she had to stay in the hospital and that's what he/she was trying to avoid. Resident #20 said it was an aide who discovered the swelling and told the nurse but didn't remember much more.
During an interview on 9/11/23 at 11:38 A.M., Nurse #4 said potential problems of a PICC/Midline could include occlusion, clotting, and infection. She said orders would need to be in place for monitoring on the MAR or TAR but said the October 2022 MAR and TAR did not reflect that other than an order to flush on 10/22/22 when it was locked. Unit Manager (UM) #1 entered the nurses' station and said there should have been orders placed for the care and treatment of the PICC/Midline devices last October and November but weren't. She said staff need to know what kind of line it is to know what orders to enter, and it should have been care planned but wasn't.
During an interview on 9/11/23 at 12:33 P.M., the Director of Nurses (DON) said she was relatively new to the facility and UM #2 would know better but the orders should have been entered with the IV insertion order and the Resident monitored for signs and symptoms of adverse events. She said the type of IV access would determine the treatment orders. She said if the documentation was not in the electronic record, then it was not done. UM #2 entered the DON's office and said she reviewed the Resident's record and the orders were not there, there was nothing. She said the point of monitoring is to prevent any adverse events from occurring. The DON said there should have been a care plan in place but wasn't.
During an interview on 9/12/23 at 3:00 P.M., the Medical Director (MD) said he was assigned to Resident #20 who had a history of a suprapubic catheter for chronic urinary retention, a long history of multidrug resistance use for UTIs, a hypercoagulable condition, chronic pain, heart failure, tobacco dependency, morbid obesity, was relatively immobile, monthly hospitalizations for the past year, and had a history of clots in both arms. He said at one point the Resident had a clot in his/her leg as well and required IV access for multidrug-resistant organisms (MDRO) UTIs. He said the Resident was on Eliquis prior and would now need, per the hematologist, lifelong anticoagulation after DVTs. He said he/she was at risk for clots and was on Eliquis. He said he wasn't sure who was responsible for entering the bundled orders (group of orders pertaining to the care and treatment of a midline/PICC). He said the orders should be entered to monitor the insertion site for no infection, nothing abnormal around the site, infiltrate, or clotting. The MD said whenever a patient requires a PICC line or Midline there would be a lot of active monitoring from his nurse practitioners to make sure the patient is doing well, that there's a response to treatment. Nursing staff would document monitoring and assessment of the site daily as well as in conjunction with the NPs. He said Resident #20 got a clot in his/her arm at the site of the PICC and, looking back now, there was a delay in diagnosing the clot when the patient had pain and swelling. He said one of his colleagues put another line in then sent him/her back to the hospital where a bilateral upper extremity duplex was done and showed extensive DVTs, and now we know why there's pain and swelling. He said he did not know there weren't any orders for monitoring, and it was obviously suboptimal. The MD said there should be adequate monitoring to avoid any complications or adverse events.
During an interview on 9/12/23 at 4:20 P.M., the DON said there was nothing in the old records regarding paper documentation for the central lines, someone did look, and they didn't find it. She said she had no documentation to provide to the surveyor that the facility had identified the issue and conducted a plan of correction or educational piece. She said the expectation would be for whoever the nurse was that took the PICC/Midline insertion order, to enter the orders for the care and treatment of a central line to include things such as monitoring for swelling, redness, signs and symptoms of infection, flushing, dressing changes, changing the tubing, and monitoring for migration. She said nursing staff are expected to properly assess and monitor the site to avoid any potential adverse outcomes.
No further documentation was provided to the surveyor prior to exiting the facility.
2. Review of the facility's policy titled Infusion Intravenous (IV) Access Line Maintenance Protocol, dated 12/1/18, indicated but was not limited to the following:
-Needleless Connector Changes: On admission, every week and as needed.
-Administration Set Changes: Every 24 hours
-Transparent Dressing Changes: Insertion, then weekly and as needed. Measure upper arm circumference and exterior catheter length with each dressing change and as needed.
-Dressing Changes: Gauze should only be used if patients are sensitive to clear transparent dressings and must be changed every 2 days.
Review of the facility's competency for: Changing the Needleless Connector on an IV Catheter (dated 2/2014) indicated but was not limited to the following:
-Primes needleless connector with prescribed flushing agent while maintaining sterility, leaves syringe attached.
Review of the [NAME] NURSING PROCEDURES - 9th Ed. (2023)- Flushing a PICC indicated but was not limited to the following:
- While maintaining the sterility of the syringe tip, attach a prefilled 10-mL syringe containing preservative-free normal saline solution to the needleless connector.
-Unclamp the catheter and slowly aspirate for a blood return that's the color and consistency of whole blood.
-If you don't obtain a blood return, take steps to locate an external cause of obstruction.
-If you obtain a blood return, slowly inject preservative-free normal saline solution into the catheter.
-Don't forcibly flush the device.
-Further evaluate the device if you meet resistance.
Resident #39 was admitted to the facility in May 2016 with diagnoses including diabetes, chronic non-pressure ulcer of the right calf, and cellulitis.
Record review indicated that on 9/3/23, Resident #39 was sent to the hospital and admitted with diagnoses including septic shock with organ failure, acute kidney injury. and bacteremia presumed secondary to left foot blister lesion. The Resident returned to the facility on 9/12/23 with a PICC in place for the continued administration of Intravenous (IV) antibiotics.
Review of the Hospital Discharge summary, dated [DATE], indicated that the Resident was to receive four doses of intravenous (IV) antibiotics (9/13/23 through 9/16/23), and then the PICC was to be removed (on 9/16/23) after the last dose of the antibiotic had been administered.
Review of the September 2023 Physician's Orders for the PICC line indicated the following:
-Flush each lumen with 10 milliliters (mls) of normal saline every 8 hours, when lumen is locked with no infusion currently running. Discontinue once the line has been pulled.
-Occlusive dressing supplies at bedside in the event the line is dislodged. Discontinue once line has been pulled.
-Change PICC line catheter transparent dressing upon admission and every 7 days.
-Flush catheter lumen pre- and post- medication administration with 10 mls of Normal saline every evening shift until 9/16/23. Line to be pulled after last dose given on 9/16/23.
-Maintain emergency clamp at bedside at all times.
-Monitor PICC line catheter every shift for signs/symptoms of IV related complications. Discontinue once line has been pulled.
Further review of the Physician's orders failed to indicate the following:
-Measure upper arm circumference and exterior catheter length with each dressing change and as needed
-Needleless Connector Device - On admission, then weekly and as needed
-Administration Set Changes - primary, every 24 hours
On 9/13/23 at 1:00 P.M., the surveyor observed Resident #39's PICC. The dressing had been changed on 9/6/23 (while the Resident had been in the hospital). The transparent dressing was intact and the antimicrobial disc (used in hospitals) and securement device was visible beneath the transparent dressing. The dressing was due to be changed by the facility 9/13/23 (today).
During an observation and interview on 9/13/23 at 3:15 P.M., Nurse #3 and Nurse # 5 said that they had just completed the PICC dressing change. Nurse #3 said that she was going to change the needleless connectors and flush the three lumens. The surveyor made the following observations:
-Nurse #3 changed the first needleless connector, attached the prefilled syringe of saline and flushed the first lumen. Nurse #3 was unable to remove the other two needleless connectors despite multiple attempts. Although she was unable to change the connectors, she was able to flush the lumens. Nurse #3 did not prime the first needleless connector prior to flushing the lumen and did not check for a blood return with the flushes for three of three lumens as required.
-Under the transparent dressing, the insertion cite was covered
SERIOUS
(G)
Actual Harm - a resident was hurt due to facility failures
Accident Prevention
(Tag F0689)
A resident was harmed · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Review of the facility's policy titled Smoking policy and procedure, dated as revised October 2022, indicated but was not lim...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Review of the facility's policy titled Smoking policy and procedure, dated as revised October 2022, indicated but was not limited to the following:
-Independent Smoker: those assessed by the interdisciplinary team (IDT) to be able to safely smoke in the designated smoking area without staff supervision. Residents must keep all smoking materials at designated secure areas.
-Supervised Smoker: those assessed by the IDT to require a staff member accompany them during smoking for safety at designated times. All smoking materials will be stored and handed out by staff.
- No resident is allowed to keep lighters, matches or other lighting materials on their person or in their rooms.
- A specific care plan will be designed to meet the individual needs of the residents. All safety interventions will be included in this care plan, such as a smoking apron, adaptive devices, etc.
- Each unit is responsible for escorting supervised residents to the designated smoking area until they are escorted back into the facility safely.
Review of the List of Residents Who Smoke indicated but was not limited to the following:
- Supervised smokers: Residents #34, #22, and #51
- Independent smokers: Residents #28 and #2
Review of the current smoking care plan for Resident #34 indicated but was not limited to the following:
- Resident requires supervision with smoking (3/13/23)
- Resident utilizes a smoking apron (3/13/23)
Review of the current smoking care plan for Resident #22 indicated but was not limited to the following:
- Resident requires supervision while smoking (8/22/20)
- Resident requires a smoking apron while smoking (8/22/20)
- Observe clothing and skin for signs of cigarette burns (8/22/20)
Review of the current smoking care plan for Resident #51 indicated but was not limited to the following:
- Supervised smoking (4/10/23)
- Utilize smoking apron (10/21/20)
Review of the current smoking care plan for Resident #28 indicated but was not limited to the following:
- Resident often hides smoking materials on own person and attempts to smoke in non-smoking areas of the facility (3/13/23)
Review of the current smoking care plan for Resident #2 indicated but was not limited to the following:
- Educate resident on the facility smoking policy (10/21/20)
During an interview on 9/7/23 at 9:25 A.M., Resident #34 said he/she is an active smoker, has recently been educated on the facility smoking policy and has supervised smoke breaks four times a day. He/She said the activity assistants take them to smoke and are responsible for storing their cigarettes and lighters, and he/she uses an apron during smoking to prevent potential burns.
During an observation with interview on 9/7/23 at 1:18 P.M., Activity Assistant (AA) #1 said Resident #34 wears a smoking apron. The surveyor observed AA #1 place an apron over the Resident's legs only, and not secure the apron up around the neck of the Resident to cover their body. She said supervised smoking is four times a day and managed by the activity department. She said independent smokers keep their own cigarettes and has seen independent smokers with their own lighters but she doesn't know the process since she is only responsible for maintaining supervised smokers' smoking materials.
During an observation with interview on 9/8/23 at 11:44 A.M., the surveyor observed Resident #28 enter the smoking area and pull both a pack of cigarettes and a lighter from his/her right shorts pocket. He/she said they are an independent smoker and can smoke whenever they chose to do so in the enclosed courtyard. He/she said the facility does not provide a lighter to him/her and he/she maintains their own smoking materials.
On 9/8/23 at 1:28 P.M., the surveyor observed Resident #2 enter the Resident smoking area and remove both a cigarette and a lighter from a black zipper pouch. The Resident declined to discuss the storage of his/her cigarettes and lighter but did state that they were an independent smoker.
On 9/8/23 at 1:56 P.M., the surveyor entered the Residents' smoking area and observed Resident #34, Resident #22, and Resident #2 smoking, there were no staff members present in the smoking area at this time. Resident #34 had a smoking safety apron draped over his/her lap. Resident #22 was not observed to have a smoking safety apron in place.
During an observation with interview on 9/8/23 at 1:59 P.M., AA #2 returned to the Resident smoking area and said he stepped away to transport Resident #51 back to their room following their cigarette. He said supervised smokers have their cigarettes and lighters stored in the atrium under lock and key and managed by activity staff. He said the independent smokers are responsible for managing their own cigarettes and lighters. He said there is no list to go by on which Residents require a smoking apron and which ones do not and he just goes by memory. He said Resident #34 requires one but did not identify Resident #22 as requiring a smoking apron. The surveyor observed Resident #22 with 3 burn marks in the shape of a cigarette burn on the right leg of his/her black pants during this smoking observation, however Resident #22 did not have a smoking apron on as indicated in his/her plan of care.
On 9/12/23 at 10:39 A.M., the surveyor observed Resident #51 smoking in the designated area with a smoking apron draped over his/her legs. The smoking apron was not secured up around the Resident's leg to protect the upper portion of the body. The surveyor observed Resident #51 to have cigarette ashes on his/her shirt.
During an interview on 9/12/23 at 11:04 A.M., Nurse #4 said both independent and supervised smokers reside on her unit. She said she has never had an independent smoker request a lighter or smoking materials from her while she has been on duty. She said there was no cigarettes or lighters available to supply to the smokers in the nurses' station or locked in the medication room and she believes that even though they are not supposed to keep their own smoking materials that they do.
During an interview on 9/12/23 at 11:12 A.M., Nurse #7 said she had independent smokers on her assignment. She said she has not had an independent smoker request any smoking materials from her.
During an interview on 9/12/23 at 11:57 A.M., the Director of Nurses was made aware of the surveyor's observations of resident smoking. She said residents who wear smoking aprons should have them secured up around their necks and covering both the upper portion of their body and their legs. She said staff should be following the individualized care plans for smoking and using safety aprons for those who are designated as requiring them. She said supervised smokers should not be left alone unsupervised at any time while smoking, as they were on 9/8/23. She said independent smokers are not supposed to have their lighters on their person and they should be getting lighters from the nurses; lighters are in a locked box at the nurses' station. She said the facility struggles with the independent smokers and they are aware that the independent smokers procure their own lighters and the smoking process is a work in progress. She said the facility smoking policy is not being followed as it should be.
Based on observations, interviews, and record review, the facility failed to maintain an environment free of accident hazards for two Residents (#71 and #64), out of a total sample of 24 residents, and for 5 out of 9 identified facility smokers, Residents (#34, #22, #2, #28, and #51). Specifically, the facility failed to ensure:
1. For Resident #71, had effective interventions implemented to prevent three unwitnessed falls, one of which resulted in a five-day hospitalization for a subdural hematoma (a pool of blood between the brain and its outermost covering) and comminuted mildly displaced nasal bone fracture (a fracture in which the bone is broken in several fragments. This type of fracture is typically caused by severe trauma/injury);
2. For Resident #64, hazardous items were not left at the bedside; and
3. For Residents #34, #22, #2, #28, and #51, smoking was conducted in a safe manner per the facility policy.
Findings include:
1. Review of the facility's policy titled Managing Falls and Fall Risk Policy Statement, undated, included but was not limited to:
-Based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling;
Resident-Centered Approaches to Managing Falls and Fall Risk:
-The staff, with input of the attending physician, will implement a resident-centered fall prevention plan to reduce the specific risk factor(s) of falls for each resident at risk or with a history of falls;
-If falling recurs despite initial interventions, staff will implement additional or different interventions, or indicate why the current approach remains relevant;
-If underlying causes cannot be readily identified or corrected, staff will try various interventions, based on assessment of the nature or category of falling, until falling is reduced or stopped, or until the reason for the continuation of the falling is identified as unavoidable;
-Position-change alarms may be used to assist the staff in identifying patterns and routines of the resident. The use of alarms will be monitored for efficacy and staff will respond to alarms in a timely manner;
-The staff will monitor and document each resident's response to interventions intended to reduce falling or the risks of falling;
-If the resident continues to fall, staff will re-evaluate the situation and whether it is appropriate to continue or change current interventions; and
-The staff and/or physician will document the basis for conclusions that specific irreversible risk factors exist that continue to present a risk for falling or injury due to falls.
Resident #71 was admitted to the facility in August 2023 with diagnoses including repeated falls, traumatic subdural hemorrhage with loss of consciousness, fracture of thoracic spine: T11-T12 vertebra, multiple fractures of ribs, left side, contusion of front wall of thorax, contusion of left hip, and dementia.
Review of the Minimum Data Set (MDS) assessment, dated 8/8/23, indicated Resident #71 was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) score of 14 out of 15, required extensive assistance of two staff for bed mobility and transfers, had wandering behavior, was unsteady while walking, experienced falls within the past six months prior to admission, and had one fall with injury since admission to the facility.
Review of the medical record indicated an 8/1/23 admission Fall Risk Evaluation/Note. The instructions indicated if the total score is 10 or greater, the resident should be considered at HIGH RISK for potential falls. Prevention protocol should be initiated immediately and documented on the care plan. The Fall Risk Evaluation Note indicated a fall risk score of 21 (high risk).
Review of comprehensive care plans included but was not limited to:
-Focus: Risk for falls (8/2/23)
-Approaches: Determine Resident's ability to transfer (8/2/23); Evaluate fall risk on admission and as needed (8/2/23); If fall occurs, alert provider (8/2/23); If fall occurs, initiate frequent neuro and bleeding evaluation per facility protocol (8/2/23); If Resident is a fall risk, initiate fall risk precautions (8/2/23)
-Goal: Resident will be free of falls (8/2/23)
The comprehensive care plan for risk of falls failed to indicate any interventions had been developed to prevent falls.
Review of the medical record and fall incident reports and investigations indicated Resident #71 had three unwitnessed falls as follows:
-On 8/4/23 at 5:40 A.M., staff heard a loud bang and the Resident was found on the floor in his/her bedroom. The Resident sustained a skin tear to left elbow. The Resident stated he/she was trying to go to the bathroom. The medical record failed to identify any interventions in place at the time of the fall.
Review of comprehensive care plans failed to indicate any new interventions were developed to prevent Resident #71 from having future falls.
On 8/9/23 at 11:00 P.M., staff heard the Resident scream and was found on the floor lying on his/her back. A head strike was confirmed, and the Resident complained of headache. A hematoma was found on the back of the Resident's head. Review of staff statements indicated the Resident said he/she was trying to go to the bathroom. The physician was notified and the Resident was sent to the hospital.
Medical record review failed to identify any interventions in place at the time of the fall.
Review of the Emergency Department Provider Notes and the Discharge Planning Assessment Note, dated 8/10/23, indicated but was not limited to the following:
-A computerized tomography scan (CT scan- a series of X-ray images) was performed and revealed no fractures, and the prior subdural hematomas (identified in July 2023, prior to admission to the facility) had slightly increased.
The Resident was discharged back to the facility on 8/10/23.
Review of a Fall Risk Evaluation Note, dated 8/10/23, indicated Resident #71 remained a high fall risk with a score of 19.
Review of comprehensive care plans identified a new intervention to assist the Resident with ambulation and transfers, utilizing therapy recommendations (8/10/23).
Medical record review indicated no therapy recommendations had been identified.
On 9/6/23 at 2:30 A.M., staff heard a loud thud coming from Resident #71's room. The Resident was found by staff on the floor face down in a large pool of blood. The Resident told staff, I was going to the bathroom. A laceration was noted to the bridge of the Resident's nose, and frank red bleeding noted from both nostrils. The Resident's physician was notified, 911 was called, and the Resident was transported to the hospital for evaluation and treatment.
Medical record review failed to identify any interventions in place at the time of the fall.
Review of the Hospital Discharge summary, dated [DATE], indicated Resident #71 presented to the hospital after a recurrent unwitnessed fall, and was found to have forehead lacerations, nasal fracture, and small acute-subacute right-sided subdural hematoma. The summary indicated Emergency Medical Service documentation noted the Resident was walking to the bathroom when he/she lost his/her footing and fell to the ground landing face first.
A facial CT showed comminuted mildly displaced nasal bone fracture, and multiple facial lacerations. The trauma surgeon/trauma team reviewed the comminuted nasal bone fracture and indicated no immediate intervention, but the Resident should follow up with plastic surgery 2 weeks after the event for assessment.
Resident #71 returned to the facility on 9/11/23 after a five-day hospitalization (9/6/23 to 9/11/23).
Review of comprehensive care plans failed to indicate any new interventions had been developed to prevent Resident #71 from future falls.
During an interview on 9/7/23 at 8:41 A.M., Nurse #3 said Resident #71 was sent out to the hospital on 9/6/23 after having a fall with a possible nasal fracture and facial lacerations. She said the Resident thinks he/she can walk safely on his/her own but can't.
During an interview on 9/13/23 at 1:00 P.M., Unit Manager #2 reviewed Resident #71's medical record. She said a care plan with interventions should have been developed with interventions to prevent falls upon admission to the facility, especially considering the Resident's history of recurrent falls with major injury. She said each time the Resident had a fall, interventions should have been developed, added to the care plan, and implemented but were not. Unit Manager #2 said she was concerned about the lack of interventions and documentation regarding the Resident's risks and falls.
During a subsequent interview on 9/14/23 at 10:14 A.M., Unit Manager #2 said she has reviewed Resident #71's medical record and incident reports and said the Resident's falls are clearly related to the Resident's need to use the bathroom. She said the Resident should have been placed on a toileting program after the first fall in an effort to prevent him/her from getting up on his/her own and falling.
During an interview on 9/14/23 at 10:50 A.M., Resident #71's son said Resident #71 has only been at the facility a few weeks and has had multiple falls. He said he cannot understand why the facility can't do something to prevent the falls.
2. Resident #64 was admitted to the facility in May 2023 with diagnoses including unspecified dementia, unspecified severity, with other behavioral disturbance and mild cognitive impairment.
Review of the most recent MDS assessment, dated 8/30/23, indicated that Resident #64 had severe cognitive impairment as evidenced by a BIMS score of 4 out of 15 and required extensive assist for personal hygiene.
The Resident resides on a secure unit with wandering residents.
On 9/7/23 at 9:15 A.M., the surveyor observed a bottle of mouthwash on Resident #64's nightstand unsecured and accessible to all residents.
On 9/7/23 at 9:40 A.M., the surveyor observed residents wandering in the hallway.
On 9/8/23 at 9:41 A.M., the surveyor observed residents wandering in the hallway.
On 9/8/23 at 9:50 A.M., the surveyor observed a bottle of mouthwash on the Resident's nightstand unsecured and accessible to all residents. Residents were wandering in the hallway.
On 9/11/23 at 7:36 A.M., the surveyor observed a bottle of mouthwash on the Resident's nightstand unsecured and accessible to all residents.
On 9/11/23 at 9:22 A.M., the surveyor observed a bottle of mouthwash on the Resident's nightstand unsecured and accessible to all residents.
On 9/11/23 at 12:56 P.M., the surveyor observed residents wandering in the hallway.
On 9/12/23 at 10:27 A.M., the surveyor observed a bottle of mouthwash on the Resident's nightstand unsecured and accessible to all residents. Additionally, at this time the surveyor observed other residents wandering in the hallway.
According to manufacturer's specifications, mouthwash should be stored in a safe place. If more mouthwash is swallowed than the recommended amount used for rinsing, get medical help or contact Poison Control Center right away.
During an interview on 9/12/23 at 10:33 A.M., Nurse #3 said the mouthwash should not be on top of the Resident's nightstand; it should be stored secured in the Resident's top drawer of their nightstand or dresser in a wash basin.
SERIOUS
(H)
Actual Harm - a resident was hurt due to facility failures
Deficiency F0726
(Tag F0726)
A resident was harmed · 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 ensure licensed nursing staff had the appropriate com...
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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 licensed nursing staff had the appropriate competencies and skill set for providing the necessary care and treatment for residents with a peripherally inserted central catheter (PICC- long, thin tube inserted through a vein in your arm and passed through to the larger veins near your heart that delivers fluids and/or medications) and/or midline catheter (thin, soft tube that is placed into a vein at the level of the armpit that delivers fluids and/or medications directly into the vein) device per facility policy and acceptable standards of practice and to ensure nursing practice by nursing students and their supervising nurse were adhered to for the administration of medications. Specifically, the facility failed:
1. For Resident #20, who had a history of chronic embolism and thrombosis (formation of a blood clot within blood vessels or arteries limiting the natural flow of blood), to ensure physician's orders were in place and implemented for the care and treatment of 2 out of 2 midline catheters and 2 out of 2 PICC lines to include monitoring for signs and symptoms of IV related complications, catheter lumen flushing, dressing orders, needleless connector change frequency, tubing change frequency, and any reports of pain or discomfort by the Resident during the timeframe of 10/10/22 through 11/3/22. This resulted in the Resident experiencing pain and swelling in his/her left arm resulting in an extended hospital stay from 11/3/22 through 11/8/22 with a diagnosis of acute extensive bilateral upper extremity deep vein thromboses (DVT) (blood clot in a deep vein) with extension into the subclavian vein and an occlusive left arm DVT involving one of the brachial veins and left axillary vein surrounding the PICC;
2. For Resident #39, to conduct, upon hire and annually, competencies and training for all licensed nursing staff to provide the appropriate care and treatment for residents with a PICC and/or midline catheter device; and
3. For Resident #16,
a. to ensure nursing practice by nursing students, and supervision of nursing students adhered to the parameters issued by the Massachusetts Board of Registration in Nursing (BORN), and
b. to ensure orientation to the patient care environment that aligns with the individual student academic preparation and competencies was provided to one unlicensed Nurse (Graduate Nurse #1), as required.
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 acceptable standards of practice.
Competency is a measurable pattern of knowledge, skills, abilities, and other characteristics that an individual needs to perform work roles or occupational functions successfully.
1. Review of the Facility Assessment (a document with a competency-based approach provided by the facility assessing the capability of the facility and its population), last updated in August 2023 and reviewed by Quality Assurance and Performance Improvement (QAPI) Committee on 4/19/23, indicated the following:
Part 1- Our Resident Profile:
Special Treatments and Conditions - IV medications
Part 3.3:
Staff Training and Competencies - Only Nurses
-IV competencies, IV Pump Program, Central Line Dressing, Medication Administration
Review of the Licensed Orientation Checklist for New Hires, undated, indicated the following:
Treatments:
-IVs - Peripheral vs. PICC line, care of, measurement of, admission documentation, weekly dressing change
Review of the Competency Record - To be Completed on Hire and Annually, undated, indicated the following:
IV Competencies:
-IV pump programming and troubleshooting, central line dressing, documentation
Review of the facility's policy titled Legal Aspects of Infusion Therapy for Nurses, revised 2019, indicated but was not limited to the following:
-Purpose: To identify licensed personnel who are designated by the facility to perform infusion therapy.
-Policy: Nurses administering infusion therapies will practice within the scope of practice for their licensure as established in the State Nurse Practice Act, and within their clinical level of competency as established by the facility training and competency evaluation programs.
-Scope of Practice for Specific Infusion Therapy for Nursing Functions: Caring for and maintaining infusion equipment and catheters (peripheral and central venous access catheters). This includes flushing, dressing changes, site assessment, change IV tubing and needleless connection devices, observing and reporting on catheter patency, insertion site, complications, and resident reaction to treatment.
-Facility /Administration Responsibilities for IV Therapy: Providing education or verifying qualifications of the staff that will be providing infusion therapy. This may include IV fundamental classes, precepting and/or clinical competency evaluations.
Resident #20 was admitted to the facility in September 2022 with diagnoses including Behcet's disease (rare disorder causing inflammation of blood vessels), chronic peripheral venous insufficiency, morbid obesity, type II diabetes mellitus, chronic diastolic heart failure (CHF), peripheral vascular disease (PVD), chronic embolism and thrombosis of deep veins of left lower extremity, and recurrent urinary tract infections (UTIs).
Review of the medical record indicated Resident #20 had two midline catheters placed on 10/10/22 and 10/14/22 and two PICC lines placed on 10/18/22 and 11/1/22 for antibiotic therapy. The midline/PICCs were not appropriately monitored by nursing staff for signs and symptoms of IV related complications, catheter lumen flushing, dressing orders, needleless connector change frequency, tubing change frequency, and for any reports of pain or discomfort by the Resident per facility policy and professional standards of practice.
Resident #20 was admitted to the hospital from [DATE] through 11/8/22 after complaints of pain and swelling in the left arm, most significantly at the site of the PICC. Upon arrival to the emergency department (ED), a bilateral upper extremity (BUE) duplex (test used to evaluate blood clots and venous insufficiency) showed an acute occlusive left deep vein thrombosis (DVT) involving one of the paired brachial veins and left axillary vein surrounding the PICC line. Central extension of nonocclusive thrombus into the left subclavian vein surrounding the PICC was also seen. A new acute occlusive right sided DVT of the right subclavian vein was also noted, along with acute occlusive superficial thrombosis involving the left basilic and cephalic veins. The PICC line was removed immediately, and a Heparin (blood thinner) drip was started.
During an interview on 9/12/23 at 10:05 A.M., the surveyor reviewed the IV Education Binder with the Director of Nursing (DON). The binder contained 25 nursing staff certificates of IV training by six outside educational institutions, however, the surveyor was unable to determine the content of the training and if it included the care and treatment for a resident with a PICC and/or midline catheter device for 22 out of 25 certificates reviewed. No IV competencies were included in the education binder. The DON said the staff development coordinator (SDC) was no longer at the facility and a new SDC was still learning and transitioning. The DON said she was not able to verify the training content for the outside educational institutions and said it would still be the facility's responsibility to verify the competencies anyway. The DON said, thus far, she could not locate any central line IV competencies for nursing staff.
On 9/12/23 at 10:35 A.M., the DON provided the surveyor with a list of current licensed nursing staff at the facility. There were 37 listed.
Review of the IV Competency binder provided to the surveyor by the DON, for three out of three Nurses (#9, #10, #11) reviewed that had cared for Resident #20 in October of 2022 during the time he/she had a PICC and/or midline catheter device, failed to indicate documentation that any of them were included. Furthermore, review of Nurse #9, Nurse #10, and Nurse #11's personnel files also did not indicate documentation of the required IV competencies.
During an interview on 9/12/23 at 10:38 A.M., the surveyor reviewed the IV Competency binder with the DON. Review of the binder indicated 13 of 37 current staff were included and did not contain a complete record of all the required IV competencies to be validated by the facility. The DON said she was unable to locate any other documentation of the IV competencies that were required and said all licensed nursing staff should have been checked off that they were competent.
During an interview on 9/12/23 at 12:59 P.M., Nurse #9 said she needed education and competencies to care for a resident with a central line. She said it's not often that she cares for a resident that has one.
Nurse #10 and Nurse #11 were unavailable for interview and were not reachable by phone.
During an interview on 9/12/23 at 4:20 P.M., the DON said nursing staff were expected to properly assess and monitor the site to avoid any potential adverse outcomes.
During an interview on 9/12/23 at 5:19 P.M., the Administrator said the orientation checklist is the same for new or experienced nurses and the facility was not able to provide to the surveyor a complete record of nursing PICC/midline competencies and proper training.
No further documentation was provided to the surveyor prior to exiting the facility.
3. Review of the facility's policy titled Graduate Nursing Policy, revised 6/9/23, included but was not limited to:
-Section 25 of Chapter 20 of the Acts of 2020 continues the authorization of nursing practice by graduates and students in their last semester of nursing education programs in accordance with guidance from the Massachusetts Board of Registration in Nursing (BORN). It is expected the order will expire March 31, 2024.
Individuals who are graduates of a registered nursing or practical nursing program approved by BORN and individuals who are nursing students attending the last semester of BORN approved registered nursing or practical nursing program are authorized to practice nursing and are exempt from the prohibitions against the unlicensed practice of nursing specified in G.L. c. §§ 80, 80A and 80B provided that:
1. The individuals are employed by or providing health care services at the direction of a licensed health care facility, are directly supervised by a licensed nurse while providing health care services, and the health care services are provided in response to the impact of staffing due to the COVID State of Emergency; and
2. The employing licensed health care facility has verified that the individual is a graduate of a BORN approved registered nursing or practical nursing program or that the individual is a nursing student in his or her last semester at a BORN approved registered nursing or practical nursing program.
Pursuant to the legislation, nursing practice by nursing students, and supervision of nursing students must adhere to the following parameters issued by the Board:
1. Nursing students in their last semester and graduate nursing students must practice under the direction and supervision of a licensed nurse, performing tasks within the scope of practice of the supervising nurse of equal or higher educational preparation;
2. Direct supervision includes but is not limited to the supervising licensed nurse being physically present in the health care practice setting and readily available where nursing students and graduate nursing students are practicing;
3. Nursing students and graduate nursing students must be assigned tasks by the supervising nurse and seek assistance immediately when he or she encounters patient care situations that are beyond his or her competency and level of academic preparation;
4. The employing licensed health care facility provides nursing students with an orientation to the patient care environment that aligns with the individual student academic preparation and competencies;
5. The employing licensed health care facility or licensed health care provider provides nursing students with policies that support their practice in the clinical setting where they are assigned; and
6. The employing licensed health care facility or health care provider ensures that patients are informed that such individuals are nursing students.
Resident #16 was admitted to the facility in July 2023 with diagnoses including chronic kidney disease-stage and hypertension.
a. Review of the medical record indicated a 9/6/23 Progress Note written by Nurse #6 indicated Resident #16 received additional medication at approximately 9:25 A.M. No further information related to the additional medication was documented in the note.
During an interview on 9/11/23 at 7:21 A.M., Nurse #6 said she was doing a morning medication pass with Graduate Nurse #1 on 9/6/23 at 9:30 A.M. on the North Unit. Nurse #6 said she checked Resident #175's Physician's orders in the computer with the Graduate Nurse, popped 13 pills into a plastic cup, signed off the medications on the Medication Administration Record, wrote Resident #175's name, room and bed number on the medication cup, and told Graduate Nurse #1 to give the medications to the Resident in the A bed. She said the Graduate Nurse took the medication cup into the room and came out and said she gave the medication to the wrong Resident. Nurse #6 said she remained at the medication cart during the entire time the Graduate Nurse was in the Residents' room, and did not directly supervise or observe her give the medication to the wrong Resident or hear her verify the identity of the Resident prior to giving the medications to Resident #16 instead of Resident #175. Nurse #6 said she thought Graduate Nurse #1 was a newly hired Registered Nurse, and not a graduate nurse that required direct supervision.
During an interview on 9/12/23 at 10:57 A.M., Graduate Nurse #1 said she graduated from nursing school in May 2023, but has not passed the board exam and is not a Registered Nurse yet. She said she worked on the North unit on 9/6/23 with Nurse #6 and administered medications to a few Residents, including Resident #16. She said when Nurse #6 gave her the plastic cup with medications in it, she thought she said to bring them to the resident in the window bed. She said she did not ask the resident his/her name or verify the resident's identify prior to administering the medication. Graduate Nurse #1 said after the resident swallowed the medications, she saw Resident #16's name on a water bottle on the over bed table and immediately realized she gave the medication to the wrong resident.
During interviews on 9/8/23 at 2:00 P.M. and 9/14/23 at 3:00 P.M., the Director of Nursing (DON) said on 9/6/23 at 9:30 A.M., Graduate Nursing Student #1 administered 13 doses of medication to Resident #16 in error. She said the medications were meant for Resident #16's roommate (Resident #175). The DON said Graduate Nurse #1 had not had a competency assessment for medication administration. She provided the surveyor a copy of the Medication Error Form, investigation (including a blank Medication Administration Competency Evaluation), and Resident #175's Medication Administration Record. The documents indicated medications administered to Resident #16 by the Graduate Nursing Student in error on 9/6/23 were:
-Citalopram Hydrobromide (antidepressant) 20 milligrams (mg)
-Hydrochlorothiazide (antihypertensive) 12.5 mg
-Amlodipine Besylate (antihypertensive) 10 mg
-Aspirin (anticoagulant) 81 mg
-Colace (laxative) 100 mg
-Depakote Sprinkles (anticonvulsant) 125 mg, give 4 capsules to equal 500 mg
-Folic Acid (vitamin used to treat anemia) 1 mg
-Labetalol HCI (beta blocker) 200 mg
-Losartan Potassium (antihypertensive) 100 mg
-Metformin HCI ER (antidiabetic) 750 mg
b. Review of Graduate Nurse #1's employment and education file failed to indicate any competency assessments for medication administration had been conducted.
2. Review of the facility's policy titled Infusion Intravenous (IV) Access Line Maintenance Protocol, dated 12/1/18, indicated but was not limited to the following:
-Needleless Connector Changes: On admission, every week and as needed.
-Administration Set Changes: Every 24 hours
-Transparent Dressing Changes: Insertion, then weekly and as needed. Measure upper arm circumference and exterior catheter length with each dressing change and as needed.
-Dressing Changes: Gauze should only be used if patients are sensitive to clear transparent dressings and must be changed every 2 days.
Review of the facility's competency for: Changing the Needleless Connector on an IV Catheter (dated 2/2014) indicated but was not limited to the following:
-Primes needleless connector with prescribed flushing agent while maintaining sterility, leaves syringe attached.
Resident #39 was admitted to the facility in May 2016 with diagnoses including diabetes, chronic non-pressure ulcer of the right calf, and cellulitis.
Record review indicated that on 9/3/23, Resident #39 was sent to the hospital and admitted with diagnoses including septic shock with organ failure, acute kidney injury. and bacteremia presumed secondary to left foot blister lesion. The Resident returned to the facility on 9/12/23 with a PICC in place for the continued administration of Intravenous (IV) antibiotics.
During an observation and interview on 9/13/23 at 3:15 P.M., Nurse #3 and Nurse # 5 were in Resident #39's room and told the surveyor they had just completed the PICC dressing change. Nurse #3 said that she was going to change the needleless connectors and flush the three lumens. The surveyor made the following observations:
Nurse #3 completed the procedure; however she was unable to change all three needleless connectors (1 of 3 was changed) and she did not prime the first needleless connector that was changed prior to flushing the lumen and did not check for a blood return prior to flushing the catheter for 3 of 3 lumens as per the facility policy/protocols.
At this time, the surveyor observed that under the transparent dressing, the insertion cite was covered with a piece of gauze. The surveyor brought her observation to the attention of Nurse #3 and Nurse #5 and asked the rationale for applying the gauze. Nurse #5 said it was provided in the dressing change kit (piece of gauze that contained a slit-resembles a drain sponge) so we applied it.
During an interview on 9/14/23 at 8:25 A.M., the surveyor informed the Staff Development Coordinator (SDC) of her observations of the PICC flushing by Nurse #3 and Nurse #5 and the gauze present under the transparent dressing. The SDC said that the gauze should not be applied because the insertion site is no longer visible for assessment. She further said that when a PICC is flushed the procedure is that the nurse assess for a blood return and that the needleless connectors should be primed before it is changed.
Review of Nurse #3's education file indicated that she completed a Comprehensive Intravenous (IV) Therapy course 10/9/19.
Further review of her education file failed to indicate that she had annual competencies, as required per the facility policy/protocols, addressing the proper care and treatment of the PICC.
During an interview on 9/14/23 at 1:27 P.M., Nurse #5 said that she had helped Nurse #3 with the Resident's PICC dressing change on 9/13/23. She further stated that they performed the dressing change together and that she did perform some of the steps in the procedure (hands on). The surveyor asked about any certifications/competencies in IV therapy, specifically proper care and treatment of a PICC. Nurse #5 said that she is not IV certified/had no competencies completed.
During an interview on 9/14/23 at 3:35 P.M., the SDC said that a nurse who has not had any training in IV therapy/proper and treatment of a PICC, should not participate (hands on) with any part of the dressing change. She said that she explained this to Nurse #3 and Nurse #5 yesterday. The SDC again said that Nurse #5 should have not performed any part of the PICC dressing change.
During an interview on 9/14/23 at 4:00 P.M., the Regional Nurse and the President of Operations said that there was no annual competency for proper care and treatment of a PICC for Nurse #5.
The facility failed to complete annual competencies for proper care and treatment of a PICC and failed to ensure nurses were evaluated for competency to provide proper care and treatment of a PICC.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0578
(Tag F0578)
Could have caused harm · This affected 1 resident
Based on record review and interview, the facility failed to ensure Advance Directives were formulated and signed by the health care proxy (HCP), for one Resident (#38), out of a total sample of 24 re...
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Based on record review and interview, the facility failed to ensure Advance Directives were formulated and signed by the health care proxy (HCP), for one Resident (#38), out of a total sample of 24 residents.
Findings include:
Review of the Massachusetts Medical Orders for Life-Sustaining Treatment (MOLST) form, dated August 10, 2013, indicated but was not limited to the following:
Instructions:
-This form should be signed based on goals of care discussions between the patient (or patient's representative signing below) and the signing clinician.
-Sections A through C are valid orders only if sections D and E are complete.
If any section is not completed, there is no limitation on the treatment indicated in that section.
Section D: Patient or patient's representative signature is required.
Section E: Clinician signature required.
Resident #38 was admitted to the facility in December 2015 with a diagnosis of dementia in other diseases classified elsewhere, moderate, with other behavioral disturbance.
Review of the Minimum Data Set (MDS) assessment, dated 8/31/23, indicated Resident #38 scored 13 out of 15 on the Brief Interview for Mental Status (BIMS) exam which indicated the Resident was cognitively intact.
Review of the Physician's Orders indicated Resident #38's HCP was invoked.
Review of Resident #38's MOLST indicated in Section D: Patient or patient's representative signature required, the following handwritten information, spoke to HCP via phone, the HCP's name, the nurse's name, and date 5/28/20. Resident #38's HCP did not sign the form.
During an interview on 9/13/23 at 2:37 P.M., the Director of Social Service said the Resident's MOLST is not valid because it was not signed by the HCP.
During an interview on 9/14/23 at 12:16 P.M., Nurse #3 said the MOLST is not valid because it has to have a HCP signature and not verbal consent.
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 interview, document review, and policy review, the facility failed to complete their grievance process when verbal complaints were made by two Residents (#58 and #34), out of a total sample o...
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Based on interview, document review, and policy review, the facility failed to complete their grievance process when verbal complaints were made by two Residents (#58 and #34), out of a total sample of 24 residents, resulting in a delay of resolution to the grievances.
Findings Include:
Review of the facility's policy titled Complaint/Grievance policy and procedure, dated as reviewed October 2022, indicated but was not limited to the following:
- Voiced grievances are not limited to a formal, written process and may include a resident's verbalized complaint to facility staff
- the grievance official will complete the grievance within 72 business hours and submit to the Social Service Department and Administrator
- the grievance official will complete the grievance form to include: date received, summary of statement, steps taken, summary of findings, confirmation of grievance and corrective action to be taken and document the date of the resolution
- the grievance official will review findings with the resident and provide written resolution if requested
1. Resident #58 was admitted to the facility in July 2020 and has a Brief Interview for Mental Status (BIMS) score of 15 out of 15, indicating he/she is cognitively intact.
During an interview on 9/7/23 at 2:36 P.M., the Ombudsman said Resident #58 had voiced a concern multiple times regarding a neighboring resident who was loud in the evening preventing them from sleeping and has not yet received any resolution to the concern.
During an interview on 9/12/23 at 4:41 P.M., Resident #58 said he/she has been complaining about another resident on the unit who is loud at night and preventing him/her from sleeping for about the last six weeks. The Resident said about two weeks ago he/she informed the Director of Nurses (DON) personally about the issue and has not yet had any resolution or been aware of any attempts the facility has made to address the complaint in any way.
Review of the facility provided grievance log failed to indicate a grievance was completed for this complaint by Resident #58.
During an interview on 9/12/23 at 5:00 P.M., the DON said she received this complaint verbally from Resident #58 approximately two weeks ago. She said she told the Resident she would look into the concern and get back to him/her with a response but has not yet done so. She said she did not complete a grievance form but believes the Administrator did when she informed the Administrator of the complaint.
During an interview on 9/12/23 at 5:05 P.M., the Administrator said she was made aware of this complaint by the Resident a few weeks ago by the Ombudsman and discussed it with the DON as well. She said she had attempted to address the issue with the offending resident, but it is unresolved and she never provided a plan of resolution to the complaining Resident. She reviewed the grievance book and facility grievance log and said a grievance was not completed for Resident #58's concern and should have been. She said the facility policy for resolving grievances was not followed as it should have been.
2. Resident #34 was admitted to the facility in November 2021 and has a BIMS score of 13 out of 15, indicating he/she is cognitively intact.
During an interview on 9/13/23 at 11:47 A.M., Resident #34 said he/she had complained about their roommate being intrusive and noisy during the nighttime and requested a room change. He/She said they lodged the complaint about 4-5 weeks ago and are still waiting for their request to be granted or an alternative resolution to their concern.
Review of the facility provided grievance log failed to indicate a grievance was completed for this complaint by Resident #34.
During an interview on 9/13/23 at 12:12 P.M., the Social Worker (SW) and DON said they were aware of Resident #34's complaints about his/her roommate. The DON said the request for a room change was denied because the facility did not have any empty beds. She said although the facility is running below capacity, she did not consider moving the Resident to a short-term room temporarily to alleviate the concern because the Resident is here for long term care and they try to only have short term rehab residents on the short-term unit. She said no other options or interventions were offered to Resident #34 to alleviate his/her situation. The SW said he documented a note offering Resident #34 support and denoting his/her willingness to change rooms in the beginning of August when he was first aware of the concern, but again offered no other options or resolution to the Resident. The SW and DON said a grievance should have been completed and the process should have been followed according to the facility policy but it was not.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Abuse Prevention Policies
(Tag F0607)
Could have caused harm · This affected 1 resident
Based on interviews, record review, and policy review, the facility failed to ensure their abuse prevention policies were implemented for one Resident (#59), out of a sample of 24 residents. Specifica...
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Based on interviews, record review, and policy review, the facility failed to ensure their abuse prevention policies were implemented for one Resident (#59), out of a sample of 24 residents. Specifically, the facility failed to follow their policy of reporting an allegation of abuse.
Findings include:
Review of the facility's policy titled Abuse Policy (not dated) indicated but was not limited to:
-It is the policy of this facility to take appropriate steps to prevent the occurrence of abuse, neglect, injuries of unknown source and misappropriation of resident's property and to ensure that all alleged violations of Federal or State laws which involve mistreatment, neglect, abuse, injuries of unknown source and misappropriation of resident property (alleged violations), are reported immediately to the Executive Director of the facility. Such violations will also be reported to State agencies in accordance with existing State law. The facility will investigate each alleged violation thoroughly and report the results of all investigations to the Executive Director or his or her designee, as well as State agencies as required by State and Federal Law.
-An employee who suspects an alleged violation shall immediately notify the E.D. or his/her designee. The E.D. shall notify the appropriate State agency in accordance with State law.
-The results of all investigations must be reported to the E.D or his/her designee and to the appropriate State agency, as required by law with initial report submitted within 2 hours and follow-up within five (5) working days of the violation.
-Send initial report to the Department of Public Health via Virtual Gateway immediately but no more than 2 hours.
Resident #59 was admitted to the facility in June 2023 with diagnoses including Parkinson's disease, depression, mild cognitive impairment, and insomnia.
Review of the Minimum Data Set (MDS) assessment, dated 7/7/23, indicated Resident #59 was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) score of 15 out of 15.
Review of the medical record indicated a 7/11/23 Complete Evaluation/Biopsychosocial Assessment conducted by the facility's mental health provider. The assessment indicated the Resident's chief complaint and reason for the visit was surrounding a very negative event/complaint regarding a nurse he/she encountered. The Resident said that he/she had rung the call bell for help but it was not answered. The Resident said he/she went to the Nursing station and a male nurse immediately stated loudly, You need to go to your room. You need to go back to bed, then put his two hands on his/her neck area and said the Nurse's fingers dug right into me. The Resident said the Nurse pushed him/her backwards towards the room until he/she was finally in and pushed him/her down on the bed into a sitting position. The Resident said he/she was very upset and scared and knew that it was not proper care.
Review of a 7/11/23 incident report indicated the E.D. was notified by a Nurse on 7/11/23 at 8:15 A.M. that Resident #44 had alleged that an agency nurse was rough with him/her on 7/8/23.
Review of the Health Care Facility Reporting System (HCFRS) on 9/12/23 at 12:30 P.M., indicated the allegation of abuse occurred on 7/8/23, but was reported on 7/11/23.
During an interview on 9/12/23 at 1:07 P.M., the Director of Nursing said the allegation should have been reported right away. She said the nurse that was told about the allegation on 7/8/23 did not notify us of the allegation of abuse until 7/11/23.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Report Alleged Abuse
(Tag F0609)
Could have caused harm · This affected 1 resident
Based on policy review, record review, and interview, the facility failed to ensure an allegation of abuse by one Resident (#59), out of a total sample of 24 residents, was reported to the Department ...
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Based on policy review, record review, and interview, the facility failed to ensure an allegation of abuse by one Resident (#59), out of a total sample of 24 residents, was reported to the Department of Public Health's (DPH) Health Care Facility Reporting System (HCFRS) within the required two-hour timeframe.
Findings include:
Review of the facility's policy titled Abuse Policy (not dated) indicated but was not limited to:
-It is the policy of this facility to take appropriate steps to prevent the occurrence of abuse, neglect, injuries of unknown source and misappropriation of resident's property and to ensure that all alleged violations of Federal or State laws which involve mistreatment, neglect, abuse, injuries of unknown source and misappropriation of resident property (alleged violations), are reported immediately to the Executive Director of the facility. Such violations will also be reported to State agencies in accordance with existing State law. The facility will investigate each alleged violation thoroughly and report the results of all investigations to the Executive Director or his or her designee, as well as State agencies as required by State and Federal Law.
-An employee who suspects an alleged violation shall immediately notify the E.D. or his/her designee. The E.D. shall notify the appropriate State agency in accordance with State law.
-The results of all investigations must be reported to the E.D or his/her designee and to the appropriate State agency, as required by law with initial report submitted within 2 hours and follow-up within five (5) working days of the violation.
-Send initial report to the Department of Public Health via Virtual Gateway immediately but no more than 2 hours.
Resident #59 was admitted to the facility June 2023 with diagnoses including Parkinson's disease, depression, mild cognitive impairment, and insomnia.
Review of the Minimum Data Set (MDS) assessment, dated 7/7/23, indicated Resident #15 was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) score of 15 out of 15.
Review of the medical record indicated a 7/11/23 Complete Evaluation/Biopsychosocial Assessment conducted by the facility's mental health provider. The assessment indicated the Resident's chief complaint and reason for the visit was surrounding a very negative event/complaint regarding a nurse he/she encountered. The Resident said that he/she had rung the call bell for help but it was not answered. The Resident said he/she went to the Nursing station and a male nurse immediately stated loudly, You need to go to your room. You need to go back to bed, then put his two hands on his/her neck area and said the Nurse's fingers dug right into me. The Resident said the Nurse pushed him/her backwards towards the room until he/she was finally in and pushed him/her down on the bed into a sitting position. The Resident said he/she was very upset and scared and knew that it was not proper care.
Review of a 7/11/23 incident report indicated the E.D. was notified by a Nurse on 7/11/23 at 8:15 A.M. that Resident #44 had alleged that an agency nurse was rough with him/her on 7/8/23.
Review of the Health Care Facility Reporting System (HCFRS) on 9/12/23 at 12:30 P.M., indicated the allegation of abuse occurred on 7/8/23 but was not reported until 7/11/23.
During an interview on 9/12/23 at 1:07 P.M., the Director of Nursing said the allegation should have been reported to the E.D. right away, and the Department of Public Health within 2 hours as required.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Investigate Abuse
(Tag F0610)
Could have caused harm · This affected 1 resident
Based on policy review, record review, and interview, the facility failed to ensure staff implemented the facility's abuse policy for one Resident (#16), of a total sample of 18 residents. Specificall...
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Based on policy review, record review, and interview, the facility failed to ensure staff implemented the facility's abuse policy for one Resident (#16), of a total sample of 18 residents. Specifically, the facility failed to ensure an allegation of neglect by a Nurse was thoroughly investigated according to facility policy.
Findings include:
Review of the facility's Abuse Policy, dated May 2023, indicated, but was not limited to:
-What Constitutes Abuse/Mistreatment/Neglect: Neglect-failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness. This includes failing to provide liquids to keep a resident hydrated.
-Policy and Procedure: Investigation of Suspected Resident Abuse/Mistreatment/Misappropriation/Neglect/Injury of Unknown Origin
-If a family member, resident or staff reports an incident of abuse/mistreatment/neglect, it is to be reported to the Director of Nursing Services (DNS) or manager immediately and an Incident/Accident Report is to be completed.
-The supervisor is to initiate the following steps:
a. Immediate investigation into the alleged incident/
b. Interview staff member implicated. Get a written statement.
c. Interview other staff members. Employee should document incident in a written narrative.
d. Interview with resident or resident witnesses. Supervisor to document written statement from resident(s).
e. All statements should include date and time of alleged incident, and date and time statement is written.
-Employee involved is to be sent home pending investigation.
-Immediate notification to the Director of Nurses and Executive Director.
-Sent initial report to the Department of Public Health via Virtual Gateway Immediately but no more than 2 hours.
-Notify the Social Worker who will interview the resident. Document in a Social Services Progress Note.
-Internal written reports are to be initiated during the shift the incident occurred, and completed within 24-48 hours.
-Final report to be submitted to the Department of Public Health via Virtual Gateway within five (5) days of the initial report.
Resident #16 was admitted to the facility in July 2023 with diagnoses including deep vein thrombosis and hypertension.
Review of the 7/25/23 Minimum Data Set assessment indicated Resident #16 had moderate cognitive impairment as evidenced by a Brief Interview for Mental Status (BIMS) score of 11 out of 15.
Review of the medical record indicated a 10/7/23 Health Status Note written by Nurse #1: Resident drank 128 ounces of water in 90 minutes. Family teaching: Centers for Disease Control and Prevention recommends not to drink more than 48 ounces (6 cups) per hour related to hyponatremia (sodium level in the blood is below normal) without effect, continue to monitor for symptoms.
Review of a 10/10/23 Social Services Note indicated that the Social Worker and Unit Manager #1 met with Resident #16's Health Care Proxy (HCP) and was told that over the past weekend, the Resident was not given water when he/she asked.
Review of the Grievance Log indicated a 10/10/23 Grievance filed by Resident #16's HCP:
-Nurse denied water when Resident #16 asked.
-Steps taken to investigate: Nurse Unit Manager and Social Worker met with the HCP and reported the Resident is not on a fluid restriction.
-Statements collected: the box for not applicable was checked.
-Corrective action taken or to be taken: Nurse Unit Manager will educate nursing staff that Resident #16 is not on a fluid restriction.
-The Grievance was signed by the Social Worker and Administrator
The grievance documentation failed to indicate the facility identified the grievance as an allegation of neglect, failed to identify the accused Nurse, and failed to thoroughly investigate the allegation according to facility policy.
During an interview on 10/19/23 at 11:05 A.M., Unit Manager #1 said she learned on 10/10/23 that Nurse #1 refused to give Resident #16 water when he/she asked on 10/7/23. She said she called the Nurse on 10/10/23 and she said she did not give him/her water because she felt the Resident drank too much. She said she did not document her interview with Nurse #1 and did not interview any other staff.
During an interview on 10/19/23 at 11:20 A.M. and 12:00 P.M., the surveyor and Administrator reviewed the 10/10/23 grievance for Resident #16. She said there was no additional information or any interviews related to the incident, and it was not a thorough investigation.
During an interview on 10/19/23 at 2:57 P.M., the Director of Social Services (DSS) said he completed and signed the 10/10/23 grievance form. However, he did not conduct any interviews or otherwise participate in an investigation of the incident.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0655
(Tag F0655)
Could have caused harm · This affected 1 resident
Based on record review, policy review, and interview, the facility failed to ensure that staff developed and implemented a baseline care plan within 48 hours of the resident's admission, that included...
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Based on record review, policy review, and interview, the facility failed to ensure that staff developed and implemented a baseline care plan within 48 hours of the resident's admission, that included the instructions needed to provide effective and person-centered care to the resident that meet professional standards of quality care for two Residents (#71 and #125), in a total sample of 24 residents. Specifically, the facility failed to ensure:
1. For Resident #71, a baseline care plan was developed for the Resident's high fall risk; and
2. For Resident #125, a baseline care plan was developed for the Resident's code status.
Findings include:
Review of the facility's policy titled Care Plans-Baseline, undated, included but was not limited to:
-A baseline plan of care to meet the resident's immediate needs shall be developed for each resident within 48 hours of admission.
-The baseline care plan will be used until the staff can conduct the comprehensive assessment and develop an interdisciplinary person-centered care plan.
1. Resident #71 was admitted to the facility in August 2023 with diagnoses including repeated falls, traumatic subdural hemorrhage with loss of consciousness, fracture of thoracic spine: T11-T12 vertebra, multiple fractures of ribs, left side, contusion of front wall of thorax, contusion of left hip, and dementia.
Review of the medical record indicated a nine page Baseline Care Plan v1.1 document dated 8/1/23. All nine pages of the document were blank.
Review of comprehensive care plans included but was not limited to:
-Focus: Risk for falls (8/2/23)
-Approaches: Determine Resident's ability to transfer (8/2/23); Evaluate fall risk on admission and as needed (8/2/23); If fall occurs, alert provider (8/2/23); If fall occurs, initiate frequent neuro and bleeding evaluation per facility protocol (8/2/23); If Resident is a fall risk, initiate fall risk precautions (8/2/23)
-Goal: Resident will be free of falls (8/2/23)
The baseline/comprehensive care plan failed to include any person-centered care instructions or interventions to address the Resident's high fall risk and to prevent falls.
During an interview on 9/13/23 at 1:00 P.M., Unit Manager #1 reviewed Resident #71's medical record. She said a baseline care plan or comprehensive care plan should have been developed with individualized, identified, person-centered interventions to address the Resident's high fall risk and to prevent falls within 48 hours of the Resident's admission.
2. Resident #125 was admitted to the facility in August 2023 with diagnoses including transient ischemic attack, chronic diastolic heart failure, and atherosclerotic heart disease.
Review of the Minimum Data Set (MDS) assessment (work in progress) indicated Resident #125 was cognitively intact as evidence by Brief Interview for Mental Status (BIMS) of 15 out of 15.
Review of the Massachusetts Health Care Proxy dated 8/21/23 indicated the Resident has an appointed Health Care Agent. The HCP has not yet been activated.
Review of the Massachusetts Medical Orders for Life sustaining Treatment dated 8/29/23 indicated the Resident's Cardiopulmonary Resuscitation as follows: Do not use non-invasive ventilation (e.g., CPAP), and transfer to hospital.
Review of the Baseline Interdisciplinary Care Plan Meeting, dated 9/2/23, failed to include a baseline care plan to address the Resident's DNR/DNI code status.
Review of the Physician's Orders, dated 9/13/23, included Do not Resuscitate and Do not intubate order dated 8/29/23.
During an interview on 9/13/23 at 8:45 A.M., the Resident said he/she did not receive a copy of the baseline care plan summary.
The facility failed to develop a baseline/comprehensive care plan within 48 hours of admission including any person-centered care instructions or interventions to address the Resident's code status and prevent unnecessary Cardiopulmonary Resuscitation.
During an interview with the Administrator and the Director of Nurses (DON) on 9/14/23 at 11:28 A.M., the Administrator said within 48 hours of admission the baseline care plan must be completed. She said a copy must be provided to the Resident and/or Responsible Party. The DON said a copy of the completed baseline care plan must be maintained in the Resident's medical record.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Comprehensive Care Plan
(Tag F0656)
Could have caused harm · This affected 1 resident
2. Resident #20 was admitted to the facility in September 2022 with diagnoses including Behcet's disease (rare disorder causing inflammation of blood vessels), morbid obesity, type II diabetes mellitu...
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2. Resident #20 was admitted to the facility in September 2022 with diagnoses including Behcet's disease (rare disorder causing inflammation of blood vessels), morbid obesity, type II diabetes mellitus, chronic embolism and thrombosis of deep veins of left lower extremity, and recurrent urinary tract infections (UTIs).
Review of the Minimum Data Set (MDS) assessment, dated 8/2/23, indicated Resident #20 was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) score of 14 out of 15, required extensive assistance with bed mobility, and was receiving an antibiotic.
Review of Physician's Orders indicated the following:
-May insert peripheral IV, schedule midline (thin, soft tube that is placed into a vein at the level of the armpit that delivers fluids and/or medications directly into the vein) placement if unable, may place PICC line (long, thin tube inserted through a vein in your arm and passed through to the larger veins near your heart that delivers fluids and/or medications) for IV antibiotic therapy every shift for 1 day, 10/9/22
Review of the Midline Insertion Record, dated 10/10/22, indicated a single lumen PowerMidline catheter was placed into the cephalic vein of the Resident's left arm at 11:05 A.M. for non-vesicant (does not irritate tissues) therapy greater than 14 days.
Review of Physician's Orders indicated the following:
-May replace midline to left upper extremity related to leakage, may miss dose until IV replaced, 10/14/22
-Cefepime HCL (antibiotic) solution 2 gm/100 mL, use 100 mL intravenously every 8 hours related to pseudomonas aeruginosa for 7 days, give 2 gm/100 mL IV every 8 hours for 7 days (start once line placed), 10/14/22
Review of the Midline Insertion Record, dated 10/14/22, indicated a single lumen midline catheter was placed into the cephalic vein of the Resident's right arm at 9:00 P.M. for non-vesicant therapy less than six days.
Review of Physician's Orders indicated the following:
-Insert a PICC line for administration of cefepime for UTI, 10/18/22
Review of the PICC Insertion Record, dated 10/18/22, indicated a single lumen, non-valved (neutral pressure, valve remains closed, reducing risk of air embolism, blood reflux and clotting) Power Injectable PICC was inserted into the basilic vein in the Resident's left arm at 12:40 P.M. for cefepime 3 times daily until 10/22.
Review of Physician's Orders indicated the following:
-Ceftriaxone Sodium (antibiotic) solution reconstitution 1 gram (gm), use 1 gm intravenously one time a day for pneumonia until 11/3/22, start 10/30/22
-May insert midline catheter to administer ceftriaxone every shift for pneumonia for 1 day, 10/30/22
Review of the PICC Insertion Record, dated 11/1/22, indicated a single lumen, non-valved, Power Injectable PICC was inserted into the basilic vein in the Resident left arm at approximately 6:57 P.M.
Further review of the medical record failed to indicate a comprehensive care plan was developed and implemented for the care and treatment of the PICCs/midline catheter devices inserted from 10/10/22 through 11/3/22.
During an interview on 9/11/23 at 12:33 P.M., the surveyor reviewed Resident #20's medical record with the Director of Nursing who, with the assistance of Unit Manager (UM) #2, said there wasn't a care plan developed for the PICC/midline catheter devices that were inserted last October and November but there should have been. She said the purpose of a care plan is so everyone can be informed of what the plan is for the Resident. The DON said interventions would have been listed so everyone would know what to do and how to take care of the Resident. She said, I'm not seeing it. Based on observation, record review, policy review, and interview, the facility failed to ensure that individualized, comprehensive care plans were developed and consistently implemented for two Residents (#22 and #20), out of 24 sampled residents. Specifically, the facility failed to ensure:
1. For Resident #22, care plan interventions for safe smoking were implemented; and
2. For Resident #20, care plans were developed for the use of Peripherally Inserted Central Catheter(PICC)/midline catheter devices that were inserted in October 2022 and November 2022.
Findings include:
Review of the facility's policy titled Comprehensive Person-Centered Care Plan, undated, included but not limited to:
-The care plan interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment.
-The comprehensive, person-centered care plan will include an assessment of the resident's strengths and needs.
-Incorporate risk factors associated with identified problems.
1. Resident #22 was admitted to the facility in October 2018 with diagnoses including nicotine dependence.
Review of comprehensive care plans included but was not limited to:
-Focus: I am a smoker (8/22/20)
-Approaches: Observe clothing and skin for signs of cigarette burns (8/22/20); The resident requires a smoking apron while smoking (8/22/20); The Resident requires supervision while smoking (8/22/20); The resident's smoking supplies are stored with activity staff (8/22/20)
-Goal: I will not smoke without supervision through the review date (8/22/20)
On 9/8/23 at 1:56 P.M., the surveyor observed Resident #22 outside in the courtyard smoking a cigarette with two other residents. The Resident did not have a smoking apron on, burn holes were noted on his/her pants, and there were no staff supervising the residents while they smoked.
During an interview on 9/11/23 at 9:20 A.M., Resident #22 said he/she does not wear a smoking apron while outside smoking.
On 9/11/23 at 4:05 P.M., the surveyor observed Resident #22 outside in the front of the facility smoking a cigarette. The Resident did not have a smoking apron on, and there was no staff in the vicinity to supervise the Resident smoking.
During an interview on 9/12/23 at 10:25 A.M., the Activity Director said activity staff are responsible for implementing the smoking program, including providing smoking aprons and supervision. The surveyor shared observations of Resident #22 smoking without a smoking apron and supervision, and she said the Resident should have been supervised by staff and had a smoking apron on according to the comprehensive care plan.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Incontinence Care
(Tag F0690)
Could have caused harm · This affected 1 resident
Based on observations, interviews, record review, and policy review, the facility failed to implement the facility policy for the care of urinary catheters for one Resident (#125), with an indwelling ...
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Based on observations, interviews, record review, and policy review, the facility failed to implement the facility policy for the care of urinary catheters for one Resident (#125), with an indwelling catheter, out of total of 23 sampled residents. Specifically, the facility failed to maintain unobstructed urine flow and follow infection control practice to prevent the potential for infection for in use continuous drainage (CD) bags.
Findings include:
Review of the facility's policy titled Catheter Care, urinary, undated, included but was not limited to:
Policy:
-The purpose of this procedure is to prevent catheter-associated urinary tract infections
Maintaining Unobstructed Urine Flow
The urinary drainage bag must be always held or positioned lower than the bladder to prevent the urine in the tubing and drainage bag from flowing back into the urinary bladder.
Infection Control:
-Be sure the catheter tubing and drainage bag are kept off the floor.
Resident #125 was admitted in August 2021 with diagnoses which included urinary retention and urinary tract infection.
Review of the medical record indicated the Resident had an indwelling urinary catheter due to urine retention.
The surveyor made the following observations of the Resident's catheter bag:
On 09/07/23 at 11:03 A.M., CD bag resting the floor while in bed.
On 09/07/23 at 05:03 P.M., CD bag resting on the floor while in bed.
On 09/12/23 08:59 A.M., CD bag resting on the floor while in bed.
On 09/13/23 08:40 A.M., The Resident was eating breakfast in his/her room. The CD bag was hanging on the Resident's walker by his/her left side positioned higher than the bladder.
During an interview on 09/13/23 at 09:25 A.M., Certified Nursing Assistant (CNA) #5 observed the Resident's CD bag on the Resident's walker hanging higher than his/her bladder. CNA #5 said there was nothing wrong with the CD bag, she said it looks good.
During an interview on 09/13/23 at 08:46 A.M., Nurse # 9 said the CD bag was positioned higher than the Resident's bladder which could cause the urine in the tubing and drainage bag from flowing back into the urinary bladder.
During an interview on 9/14/23 at 11:36 A.M., the Director of Nurses said the policy is to ensure that the CD bags are kept off the floor and positioned lower than the Resident's bladder.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Respiratory Care
(Tag F0695)
Could have caused harm · This affected 1 resident
Based on observation, interview, and policy review, the facility failed for three Residents (#3, #34, and #24) to ensure respiratory equipment and tubing was managed and stored in a sanitary way to pr...
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Based on observation, interview, and policy review, the facility failed for three Residents (#3, #34, and #24) to ensure respiratory equipment and tubing was managed and stored in a sanitary way to prevent the potential of contamination from environmental debris and germs. Specifically, the facility failed:
1. For Resident #3, to ensure respiratory nebulizer tubing and mouthpiece were stored in a sanitary manner;
2. For Resident #34, to provide the Resident with nebulizer tubing and set up that was free from exposure to environmental debris and germs when not in use and document the date equipment was changed or cleaned; and
3. For Resident #24, to ensure the proper care and storage of the Resident's respiratory equipment, including the cleaning of the oxygen concentrator and filter and storage of nebulizer equipment.
Findings include:
Review of the facility's policy titled Respiratory therapy - prevention of infection, undated, indicated but was not limited to the following:
- the purpose of this procedure is to guide prevention of infections associated with respiratory therapy tasks and equipment
- when respiratory equipment not in use, store in a plastic bag
- discard nebulizer tubing set-up every seven days and as needed, date equipment
- document the date that respiratory equipment was changed or cleaned
- wash filters from oxygen concentrators every seven days with soap and water, rinse and squeeze dry
1. Resident #3 was admitted to the facility in September 2022 with diagnoses including dementia and anxiety.
Review of the current Physician's Orders for Resident #3 indicated but was not limited to the following:
- Albuterol sulfate nebulizing solution 0.63%, 3 milliliters (ml) inhaled orally by nebulizer for shortness of breath (SOB) or wheeze (7/10/23)
- Nebulizers: change tubing weekly, date and initial tubing and storage bag one time a week on Wednesdays (8/30/23)
During an interview with observation on 9/7/23 at 8:56 A.M., the surveyor observed a nebulizer machine with tubing and set-up, including mouthpiece, sitting on the Resident's windowsill, not in a plastic respiratory storage equipment bag and not in use by the Resident, exposed to environmental debris and germs. The Resident said that is where the equipment is kept when he/she is not using it. He/She said they do not recall ever seeing the equipment stored in a plastic bag and none was observed in the room by the surveyor.
On 9/7/23 at 1:00 P.M., the surveyor observed the Resident's nebulizer machine with tubing, set-up, and mouthpiece on the Resident's windowsill exposed to environmental debris, not in a respiratory equipment storage bag and not in use by the Resident.
During an interview on 9/8/23 at 8:25 A.M., Unit Manager #1 said respiratory equipment tubing, including nebulizer set-up and mouthpiece, should be stored in a plastic respiratory equipment bag when not in use by the Resident. She was made aware of the surveyor's observations and said the equipment was not stored as it should have been and the tubing and set-up was considered dirty having been left out to be exposed to environmental debris and germs.
2. Resident #34 was admitted to the facility in November 2021 and has diagnoses including chronic obstructive pulmonary disease (COPD- group of lung diseases that block airflow and make it difficult to breathe) and chronic respiratory failure with hypoxia (the absence of enough oxygen in the system to sustain organ function).
Review of the current Physician's Orders for Resident #34 indicated, but were not limited to the following:
- Ipratropium-Albuterol solution 3mg/ml nebulizer solution inhale orally every four hours as needed COPD SOB (8/30/23)
The orders failed to indicate the nebulizer tubing required changing or storage in a respiratory storage bag to be labeled weekly as per the facility policy.
During an observation with interview on 9/7/23 at 9:25 A.M., the surveyor observed Resident #34's nebulizer machine with tubing and set-up attached on his/her room chair with linens and pillows touching the tubing and mouthpiece, not protected in a plastic respiratory equipment bag. The Resident said the staff leave the equipment on the chair when it is not in use and he/she does not remember it ever being stored in a plastic bag.
On 9/7/23 at 1:15 P.M., the surveyor observed the Resident's nebulizer machine with tubing, set-up, and mouthpiece on the Resident's bedside chair exposed to environmental debris and partially covered with throw pillows and linens, not in use by the Resident or stored in a respiratory equipment storage bag.
During an interview on 9/8/23 at 8:25 A.M., Unit Manager #1 said respiratory equipment tubing, including nebulizer set-up and mouthpiece, should be stored in a plastic respiratory equipment bag when not in use by the Resident. She was made aware of the surveyor's observations and said the equipment was not stored as it should have been.
During an interview on 9/12/23 at 12:50 P.M., the Director of Nurses was made aware of the surveyor's observations of the nebulizer tubing and set-up for both Resident #3 and Resident #34 and said the expectation and facility policy dictates that all respiratory tubing and equipment should be stored in a dated respiratory storage bag when not in use by the Resident to protect the tubing from exposure to germs and environmental debris. She said the process for storing respiratory tubing was not completed as it should have been per the facility policy.
3. Resident #24 was admitted to the facility in August 2021 with diagnoses including chronic obstructive pulmonary disease (COPD), pneumonia, and chronic respiratory failure with hypoxia.
Review of the Minimum Data Set (MDS) assessment, dated 6/28/23, indicated Resident #24 was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) score of 13 out of 15, and was receiving Oxygen (O2) therapy.
Review of current Physician's Orders indicated the following:
-Nebulizers: Change and date tubing and bag weekly, date and initial tubing/bag, designate day and shift every night every Wednesday, 8/30/23
-O2 at 4 Liters/minute nasal cannula continuous to maintain O2 sats greater than 90% every shift for oxygen therapy
-O2 concentrators: Change tubing and bag and clean filter weekly every night shift, every Wednesday
During an observation with interview on 9/7/23 at 10:53 A.M., the surveyor observed Resident #24 lying in bed with a nasal cannula (lightweight tube which one end splits into two prongs which are placed in the nostrils from which a mixture of oxygen and air flows) in place attached to an oxygen concentrator delivering O2. The O2 concentrator and its filter were observed laden with dust and debris. Resident #24 said he/she was on Oxygen for his/her COPD. A nebulizer machine was observed on top of the Resident's side table with the mask/tubing resting on top of the table. The mask/tubing was not properly stored in a plastic bag and was potentially exposed to environmental contaminants. Resident #24 said he/she was using the nebulizer for a cough.
During an observation with interview on 9/7/23 at 11:36 A.M., Unit Manager (UM) #1 entered the room with the surveyor. The O2 concentrator and its filter were observed laden with dust and debris. UM #1 said the filter was hard to clean and probably needed a new one and the concentrator had not been wiped down. She said this should be done once a week.
On 9/11/23 at 8:16 A.M., the surveyor observed the Resident sitting up in bed with a nasal cannula in place attached to an O2 concentrator delivering O2. The O2 concentrator and its filter were laden with dust and debris. The nebulizer machine was observed on top of the Resident's side table. No mask or tubing was attached. The nebulizer machine had visible brown stains on and around the device.
During an interview on 9/12/23 at 4:46 P.M., the Director of Nursing said the nebulizer tubing should be rinsed and air dried after use and placed in a plastic bag to prevent contamination. She said staff should be wiping down the nebulizer machine as they change the tubing and said the O2 concentrator filter should have been cleaned weekly and the concentrator wiped down weekly during the nasal cannula tubing changes.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0712
(Tag F0712)
Could have caused harm · This affected 1 resident
Based on record review and interview, the facility failed to ensure residents are seen by the physician at least every 30 days for the first 90 days after admission and at least 60 days thereafter, wi...
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Based on record review and interview, the facility failed to ensure residents are seen by the physician at least every 30 days for the first 90 days after admission and at least 60 days thereafter, with alternate visits by a nurse practitioner for one Resident (#22), of 24 sampled residents.
Findings include:
Resident #22 was admitted to the facility in October 2018 with diagnoses including bradycardia (slower than normal heart rate) and chronic embolism (blockage of the pulmonary arteries).
Review of the medical record indicated the following Physician (MD)/ Nurse Practitioner/Psychiatric (NP) documentation:
2/16/23-MD
No March notes
4/18/23-NP
No May notes
6/6/23-NP
7/21/23-MD
During an interview on 9/14/23 at 10:14 A.M., Unit Manager #1 reviewed Resident #22's MD/NPs notes and said Physician visits should occur every 60 days and can alternate between the NP and the MD. She said she searched the medical record and could not find any evidence that the MD saw Resident #22 in June 2023 as required.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0583
(Tag F0583)
Could have caused harm · This affected multiple residents
Based on observation and interview, the facility failed to ensure protected health information was secured, and not printed on Missing Resident Profile Forms in an Elopement book that was kept in the ...
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Based on observation and interview, the facility failed to ensure protected health information was secured, and not printed on Missing Resident Profile Forms in an Elopement book that was kept in the facility's entrance area and accessible to anyone entering the building.
Findings include:
On 9/8/23 at 1:55 P.M., the surveyor observed a bright yellow colored 3-ring binder labeled, Elopement Binder on a table next to a visitor sign-in book. Inside the binder were seven pages labeled Missing Resident Profile Form. Each page included, but was not limited to the following information about each resident:
-photograph
-date of birth
-address
-height
-weight
-hair color
-eye color
-distinguishing characteristics
-additional information
-medical conditions
-Physician's name
-emergency contact person
During an interview on 9/8/23 at 2:00 P.M., the Director of Nursing said there was no reception desk at the facility entrance, and the elopement book is kept on the table in the lobby. The surveyor and Director of Nursing reviewed the contents of the book, and the DON said the book should be kept in an office, and not in the lobby area because it contained private health information.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Drug Regimen Review
(Tag F0756)
Could have caused harm · This affected multiple residents
5. Resident #34 was admitted to the facility in November 2021 and had diagnoses including: major depressive disorder, anxiety disorder, and insomnia. The most recent brief interview for mental status ...
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5. Resident #34 was admitted to the facility in November 2021 and had diagnoses including: major depressive disorder, anxiety disorder, and insomnia. The most recent brief interview for mental status (BIMS) assessment completed in August of 2023, indicated the Resident was cognitively intact with a score of 13 out of 15.
Review of the current September 2023 Physician's Orders for Resident #34 indicated but were not limited to the following:
- Buspar (an anti-anxiety medication) 5 milligrams (mg) tablet, give 5mg by mouth two times a day for anxiety
Review of the September 2023 Medication Administration Record (MAR) for Resident #34 indicated but was not limited to the following under the administration of Buspar:
- Behavior, Other - Yes/No, to be documented twice a day with medication administration
Review of the Pharmacist's progress notes for Resident #34 indicated but were not limited to the following:
- 2/25/23: MRR complete, recommend target behaviors
- 6/24/23: MRR complete, see pharmacy report
- 7/29/23: MRR complete, recommend evaluate unused as needed (PRN) orders
Review of the current care plans for Resident #34 indicated but were not limited to the following:
The Resident uses anti-anxiety medication Buspar related to anxiety disorder (revised: 4/19/22)
- Monitor/record occurrence of target behavior symptoms (2/28/22)
- Administer anti-anxiety medications as ordered and monitor for effectiveness every shift (11/17/21)
The Resident has behavior problem related to Other Behaviors (11/19/22)
- Administer medications as ordered, monitor for effectiveness (11/19/22)
- Anticipate and meet the resident's needs (11/19/22)
- Assist the resident to develop more appropriate methods of coping and interacting; encourage resident to express feelings (11/29/22)
The care plans failed to indicate individualized targeted behaviors for the Resident's use of Buspar as recommended on the 2/25/23 MRR.
During an interview on 9/13/23 at 10:04 A.M., Nurse #4 said she knows Resident #34 well and the Resident does not have any behaviors that she is aware of and has never exhibited any behaviors to her knowledge. She reviewed the Resident's care plans and said she does not know what targeted behaviors should be monitored and does not know what the care plan indicating: behaviors related to other behaviors means. She said on the MAR the nurses document whether any behaviors are present but they are not Resident specific.
During an interview on 9/13/23 at 10:38 A.M., Nurse #1 said she cares for Resident #34 frequently and is not aware of any behaviors that Resident #34 has and she has not exhibited any behaviors that she is aware of.
There were no documented responses to the recommendations made on 2/25/23, 6/24/23, or 7/29/23 in the Resident's medical record.
During an interview on 9/13/23 at 10:51 A.M., the Director of Nurses (DON) reviewed the medical record of Resident #34 and said she could only locate the MRR recommendations from January 2023 and no other recommendations appear to have been addressed or were in the medical record. She reviewed the care plans for Resident #34 and said they do not contain target behaviors for the use of the psychotropic medication and it appears the MRR recommendation is incomplete as no other documentation could be located at this time addressing the recommendations made. She said she would look further for documents that may not be filed, but her expectation is that MRR recommendations are addressed with a documented response in about two weeks but not longer than 30 days.
During a follow up interview on 9/13/23 at 12:47 P.M., the DON said she could not locate any documents for the June 2023 MRR and the July 2023 MRR were still in her email and had not been dispersed to the staff for completion and were therefore incomplete. She said the February recommendation for target behaviors was not completed as it should have been and she could not find evidence that the June or July recommendations were, but the staff development coordinator (SDC) is responsible for the follow up on MRRs and may have more information.
During an interview on 9/13/23 at 1:48 P.M., the SDC said the February recommendation for target behaviors was not completed and no documented target behaviors could be found for the Resident. She said the June and July MRR recommendations for the Resident were not completed at this time and not in the medical record. She said she just recently received the MRRs for follow up and had not yet had a chance to have them addressed and the process had not been followed as it should have been.
Further review of the medical record failed to indicate any documentation from the Pharmacist consultant to identify if the recommendations were addressed.
During an interview on 9/13/23 at 3:00 P.M., the Pharmacy consultant said she reviewed the medical record and her notes for Resident #34. She said she should have documented whether or not the prior recommendation was accepted or declined in her notes to track the progress of the MRR recommendations and did not do so for this Resident. She said the February, June and July recs for this Resident don't appear to have been completed and she did not document the follow up on them as she should have and the Resident fell through the cracks. She said the MRR process was not followed for this Resident as it should have been and the documentation is not in place on review as it should be.
Based on record review, policy review, and interviews, the facility failed to ensure that pharmacy recommendations were reviewed and addressed for five Residents (#11, #44, #16, #70 and #34), out of a total sample of 24 residents. Specifically, the facility failed:
1. For Resident #11, to ensure the consultant pharmacist's recommendations were addressed for a Gradual Dose Reduction (GDR) of the antidepressant medication Trazodone;
2. For Resident #44, to ensure the consultant pharmacist's recommendations were addressed for safety and efficacy for the use of uric acid reducing medication;
3. For Resident #16, to ensure repeated pharmacy recommendations related to the use of an antihypertensive medication was addressed by the Physician;
4. For Resident #70, to ensure repeated pharmacy recommendations related to the use of an antipsychotic medication was addressed by the Physician; and
5. For Resident #34, to ensure the Medication Regimen Review process was completed and follow up documentation was in place regarding the recommendations left by the pharmacy consultant.
Findings include:
Review of the facility's policy titled Pharmscript-Medication Regimen Review, dated 8/2020, included but was not limited to:
Policy:
-The consultant pharmacist performs a comprehensive review of each resident's medication regimen and clinical record at least monthly. The medication regimen review (MRR) includes evaluation of the resident's response to medication therapy to determine that the resident maintains the highest practicable level of functioning and preventing or minimizing adverse consequences related to medication therapy.
Procedures:
-In performing medication regimen reviews, the consultant pharmacist incorporates federally mandated standards of care in addition to other applicable professional standards, such as the American Society of Consultant Pharmacist (ASCP) Practice Standards, and clinical standards such as the Agency for Healthcare Research and Quality (AHRQ) Clinical Practice Guidelines and American Medical Directors Association (AMDA) Clinical Practice Guidelines.
-The consultant pharmacist identifies irregularities through a variety of sources including the resident's clinical record, pharmacy records, and other applicable documents.
-Resident-specific irregularities and/or clinically significant risks resulting from or associated with medication are documented in the resident's active record and reported to the Director of Nursing (DON), Medical Director, and/or prescriber as appropriate.
-Recommendations are acted upon and documented by the facility staff and/or prescriber. The prescriber accepts and acts upon recommendations or rejects and provides an explanation for disagreeing.
1. Resident #11 was admitted to the facility in April 2019 with diagnoses including major depressive disorder.
Review of September 2023 Physician's Orders included but was not limited to:
- Trazodone HCl Tablet 100MG; Give 100mg by mouth at bedtime for Insomnia (Order Date 1/13/2020)
- Trazodone HCl Tablet 50 MG; Give 0.5 tablet by mouth in the morning for ANTIDEPRESSANTS (25mg) (Order date 7/25/22)
Review of the medical record indicated the consultant pharmacist conducted a medication regimen review and recommendations were made on 7/30/23 and 8/31/23.
Review of the Consultant Pharmacist's recommendations for Resident #11 indicated recommendations to the prescriber as follows:
-7/30/23: This resident receives the psychopharmacological medication Trazodone. For as long as a resident remains on a sedative/hypnotic that is used routinely and beyond the manufacturer's recommendations for the duration of use, the facility should attempt to taper the medication at least quarterly unless clinically contraindicated.
-8/31/23: This resident receives the psychopharmacological medication Trazodone. For as long as a resident remains on a sedative/hypnotic that is used routinely and beyond the manufacturer's recommendations for the duration of use, the facility should attempt to taper the medication at least quarterly unless clinically contraindicated.
Further review of the medical record failed to indicate the physician/physician extender addressed the consultant pharmacist's recommendations.
2. Resident #44 was admitted to the facility June 2019 with diagnoses of chronic kidney disease, stage 3, type 2 diabetes mellitus with diabetic neuropathy, and acute kidney failure.
Review of September 2023 Physician's Orders included but was not limited to:
- Allopurinol Tablet (uric acid reducer) 100MG; Give 100mg by mouth in the morning for elevated uric acid level (Order Date 3/20/20)
Review of the medical record indicated the consultant pharmacist conducted a medication regimen review and recommendations were made in 7/30/23 and 8/31/23.
Review of the Consultant Pharmacist's recommendations for Resident #44 indicated recommendations to the prescriber as follows:
-7/30/23: This resident is currently receiving allopurinol 100mg daily and has compromised kidney function with an eGFR=33 (a measure of how well your kidneys are working). The maximum daily dosing recommended for eGFR between 30-60, is 50mg daily. Please consider evaluating this order to ensure safety and efficacy.
-8/31/23: This resident is currently receiving allopurinol 100mg daily and has compromised kidney function with an eGFR=33. The maximum daily dosing recommended for eGFR between 30-60, is 50mg daily. Please consider evaluating this order to ensure safety and efficacy.
Further review of the medical record failed to indicate the physician/physician extender addressed the consultant pharmacist's recommendations.
During an interview on 9/12/23 at 1:52 P.M., the Director of Nursing (DON) said that her expectation is that once the pharmacist sends her the MRR she will then hand out the pharmacy recommendations to the nurses who would ensure that they are completed in a week if not sooner but was not done.
3. Resident #16 was admitted to the facility in July 2023 with diagnoses including hypertension.
Review of the medical record indicated the following Physician's Order:
-Doxazosin Mesylate (antihypertensive) 8 mg one time a day for hypertension (7/20/23)
Review of the medical record indicated 7/30/23 and 8/31/23 Pharmacist Consultant Notes indicating the Resident's medication regime was reviewed with a recommendation to evaluate the risk/benefit of Doxazosin.
Review of 7/30/23 and 8/31/23 Note to Attending Physician/Prescriber indicated:
-This Resident is currently receiving Doxazosin, which is considered potentially inappropriate according to the Beers criteria due to the risk of orthostatic hypotension (low blood pressure). Please consider using a safer alternative. If continuing, please document a risk/benefit analysis in the context of clinical condition, existing medication regimen and related factors to keep this facility in compliance with current regulations.
Review of the American Geriatrics Society 2023 updated American Geriatric Society (AGS) Beers Criteria® for potentially inappropriate medication use in older adults (https://pubmed.ncbi.nlm.nih.gov), indicated the AGS Beers Criteria® is an explicit list of Potentially Inappropriate Medication (PIM) that are typically best avoided by older adults in most circumstances or under specific situations, such as in certain diseases or conditions.
Further review of the 7/30/23 and 8/31/23 Note to Attending Physician/Prescriber documents indicated they were unsigned by the Physician/Prescriber.
Review of the medical record failed to indicate the pharmacy recommendations were reviewed and acted upon by the Physician/Prescriber as required.
During an interview on 9/8/23 at 12:00 P.M., Unit Manager #1 could not explain why the Pharmacy consultant's recommendations for Resident #16 were not addressed by the Physician or Nurse Practitioner.
During an interview on 9/13/23 at 2:27 P.M., the Pharmacy consultant said she made the repeated recommendations regarding Resident #16's medications because she noted the Physician did not address her initial recommendations in July 2023.
4. Resident #70 was admitted to the facility in June 2021 with diagnoses including Alzheimer's disease with anxiety.
Review of the medical record indicated the following Physician's Order:
-Olanzapine 5 mg two times a day for agitation (6/21/23)
Review of the medical record indicated 7/30/23 and 8/31/23 Pharmacist Consultant Notes indicating the Resident's medication regime was reviewed with a recommendation to identify an allowable diagnosis to support the use of antipsychotic medication.
Review of 7/30/23 and 8/31/23 Note to Attending Physician/Prescriber indicated:
-This resident is receiving the antipsychotic agent Olanzapine-but lacks an allowable diagnosis to support its use.
The following DSM-IV TR are considered appropriate diagnoses/conditions:
-Schizophrenia
-Schizoaffective disorder
-Delusional disorder
-Mania, bipolar disorder, depression with psychotic features, treatment of refractory major depression
-Schizophreniform disorder
-Atypical psychosis
-Brief psychotic disorder
-Dementing illnesses with associated behavioral symptoms
-Medical illnesses/delirium with manic/psychotic symptoms/treatment related psychosis/mania
Please verify the diagnosis for this antipsychotic.
Further review of the 7/30/23 and 8/31/23 Note to Attending Physician/Prescriber documents indicated they were unsigned by the Physician/Prescriber.
Review of the medical record failed to indicate the pharmacy recommendations were reviewed and acted upon by the Physician/Prescriber as required.
During an interview on 9/8/23 at 12:00 P.M., Unit Manager #1 could not explain why the Pharmacy consultant's recommendations for Resident #70 were not addressed by the Physician or Nurse Practitioner.
During an interview on 9/13/23 at 2:27 P.M., the Pharmacy consultant said she made repeated recommendations regarding Resident #70's medications because she noted the Physician did not address her initial recommendations in July 2023.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0760
(Tag F0760)
Could have caused harm · This affected multiple residents
Based on record review, policy review, and interview, the facility failed to ensure one Resident (#16) was free from a significant medication error, out of a total sample of 24 residents. Specifically...
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Based on record review, policy review, and interview, the facility failed to ensure one Resident (#16) was free from a significant medication error, out of a total sample of 24 residents. Specifically, Resident #16 was administered his/her roommate's (Resident #175) medications by an unlicensed Nurse.
Findings include:
Review of the facility's policies titled Adverse Consequences and Medication Errors, undated, and Administering Oral Medications, undated, included but was not limited to:
-A medication error is defined as the preparation or administration of drugs or biological which is not in accordance with physician's orders, manufacturer's specifications, or accepted professional standards and principals of the professional(s) providing the services
-Examples of medication errors include an unauthorized drug- a drug that is administered without a physician's order
-Steps in the procedure for medication administration include: confirm the identity of the resident
Review of Nursing Rights of Medication Administration, (https://www.ncbi.nlm.nih.gov), indicated it is standard during nursing education to receive instruction on a guide to clinical medication administration and upholding patient safety known as the 'five rights' or 'five R's' of medication administration.
The five traditional rights in the traditional sequence include:
-'Right patient' - ascertaining that a patient being treated is, in fact, the correct recipient for whom medication was prescribed.
-'Right drug' - ensuring that the medication to be administered is identical to the drug name that was prescribed.
-'Right Route' - Medications can be given to patients in many different ways, all of which vary in the time it takes to absorb the chemical, time it takes for the drug to act, and potential side-effects based on the mode of administration.
-'Right time' - administering medications at a time that was intended by the prescriber. Often, certain drugs have specific intervals or window periods during which another dose should be given to maintain a therapeutic effect or level.
-'Right dose'-- Incorrect dosage, conversion of units, and incorrect substance concentration are prevalent modalities of medication administration error.
Review of the facility's policy titled Graduate Nursing Policy, dated 6/9/23, included but was not limited to:
-Section 25 of Chapter 20 of the Acts of 2020 continues the authorization of nursing practice by graduates and students in their last semester of nursing education programs in accordance with guidance from the Massachusetts Board of Registration in Nursing (BORN). It is expected the order will expire March 31, 2024.
Resident #16 was admitted to the facility in July 2023 with diagnoses including chronic kidney disease-stage 4 and dementia.
Review of the 7/25/23 Minimum Data Set assessment indicated Resident #16 had moderate cognitive impairment as evidenced by a Brief Interview for Mental Status (BIMS) score of 11 out of 15.
Review of the medical record indicated a 9/6/23 Progress Note written by Nurse #6 indicated Resident #16 received additional medication at approximately 9:25 A.M. No further information related to the additional medication was documented in the note.
During interviews on 9/8/23 at 2:00 P.M. and 9/14/23 at 3:00 P.M., the Director of Nursing (DON) said on 9/6/23 at 9:30 A.M., Graduate Nursing Student #1 administered 13 doses of medication to Resident #16 in error. She said the medications were meant for Resident #16's roommate (Resident #175). The DON said Graduate Nurse #1 had not had a competency assessment for medication administration. She provided the surveyor a copy of the Medication Error Form, investigation (including a blank Medication Administration Competency Evaluation), and Resident #175's Medication Administration Record. The documents indicated medications administered to Resident #16 by the Graduate Nursing Student in error on 9/6/23 were:
-Citalopram Hydrobromide (antidepressant) 20 milligrams (mg)
-Hydrochlorothiazide (antihypertensive) 12.5 mg
-Amlodipine Besylate (antihypertensive) 10 mg
-Aspirin (anticoagulant) 81 mg
-Colace (laxative) 100 mg
-Depakote Sprinkles (anticonvulsant) 125 mg, give 4 capsules to equal 500 mg
-Folic Acid (vitamin used to treat anemia) 1 mg
-Labetalol HCI (beta blocker) 200 mg
-Losartan Potassium (antihypertensive) 100 mg
-Metformin HCI ER (antidiabetic) 750 mg
During an interview on 9/11/23 at 7:21 A.M., Nurse #6 said she was doing a morning medication pass with Graduate Nurse #1 on 9/6/23 when the Graduate Nurse gave the wrong resident the medication. She said she checked Resident #175's Physician's orders in the computer with the Graduate Nurse, popped 13 pills into a plastic cup, signed off the medications on the Medication Administration Record, wrote Resident #175's name, room and bed number on the medication cup, and told Graduate Nurse #1 to give the medications to the Resident in the A bed. She said the Graduate Nurse took the medication cup into the room and came out and said she gave the medication to the wrong Resident. Nurse #6 said she remained at the medication cart during the entire time the Graduate Nurse was in the Residents' room, and did not observe her give the medication to the wrong Resident or hear her verify the identity of the Resident prior to giving the medications. Nurse #6 said she had already administered Resident #16's medications at 7:00 A.M.
During an interview on 9/11/23 at 12:45 P.M., Resident#16's spouse said Nurse #6 called him/her last week to let him/her know that Resident #16 was given his/her roommate's medications by a trainee by mistake and was concerned.
During an interview on 9/12/23 at 10:57 A.M., Graduate Nurse #1 said she graduated from nursing school in May 2023, but has not passed the board and is not a Registered Nurse yet. She said she worked on North unit on 9/6/23 with Nurse #6 and administered medications to a few Residents, including Resident #16. She said when Nurse #6 gave her the plastic cup with medications in it, she thought she said to bring them to the resident in the window bed. She said she did not ask the resident his/her name or verify the resident's identify prior to administering the medication. Graduate Nurse #1 said after the resident swallowed the medications, she saw the resident's name on a water bottle on the overbed table and immediately realized she gave the medication to the wrong resident.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0838
(Tag F0838)
Could have caused harm · This affected multiple residents
Based on review of the Facility Assessment and interview, the facility failed to implement staff educational resources (in-servicing) and competencies needed to care for residents receiving intravenou...
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Based on review of the Facility Assessment and interview, the facility failed to implement staff educational resources (in-servicing) and competencies needed to care for residents receiving intravenous (IV) central line medications. Specifically, the facility failed to conduct the education and competency training required of all nursing staff to provide the appropriate care and treatment for residents with peripherally inserted central catheters (PICC- long, thin tube inserted through a vein in your arm and passed through to the larger veins near your heart) and midline catheter (thin, soft tube that is placed into a vein at the level of the armpit) devices used for intravenous (IV) antibiotic treatments per the Facility Assessment.
Findings include:
Review of the Facility Assessment (a document with a competency-based approach provided by the facility assessing the capability of the facility and its population), last updated in August 2023 and reviewed by Quality Assurance and Performance Improvement (QAPI) Committee on 4/19/23, indicated the following:
Part 1- Our Resident Profile:
Special Treatments and Conditions - IV medications
Part 3.3:
Staff Training and Competencies - Only Nurses
-IV competencies, IV Pump Program, Central Line Dressing, Medication Administration
Review of the Licensed Orientation Checklist for New Hires, undated, indicated the following:
Treatments:
-IVs - Peripheral vs. PICC line, care of, measurement of, admission documentation, weekly dressing change
Review of the Competency Record - To be Completed on Hire and Annually, undated, indicated the following:
IV Competencies:
-IV pump programming and troubleshooting, central line dressing, documentation
During the survey period, from 9/7/23 to 9/8/23 and from 9/11/23 through 9/14/23, two residents resided in the facility with a PICC or midline device.
During an interview on 9/12/23 at 10:05 A.M., the surveyor reviewed the IV Education Binder with the Director of Nursing (DON). The binder contained 25 nursing staff certificates of IV training by six outside educational institutions, however, the surveyor was unable to determine the content of the training and if it included the care and treatment for a resident with a PICC/midline catheter device for 22 out of 25 certificates reviewed. No IV competencies were included in the education binder. The DON said the staff development coordinator (SDC) was no longer at the facility and a new SDC was still learning and transitioning. The DON said she was not able to verify the training content for the outside educational institutions and said it would still be the facility's responsibility to verify the competencies anyway. The DON said, thus far, she could not locate any IV competencies for nursing staff.
On 9/12/23 at 10:35 A.M., the DON provided the surveyor with a list of current licensed nursing staff at the facility. There were 37 listed.
During an interview on 9/12/23 at 10:38 A.M., the surveyor reviewed an IV Competency binder provided by the DON with the DON. Review of the binder indicated only 13 of 37 current staff were included and none of the staff had all the required IV competencies documented as being validated by the facility per the Facility Assessment. The DON said she was unable to locate any other documentation of complete IV competencies that were required for central lines and said all licensed nursing staff should have been checked off that they were competent.
During an interview on 9/12/23 at 5:19 P.M., the Administrator said the Facility Assessment said that resident support/care needs included administration of medications via the intravenous route (peripheral and central lines) but did not include information regarding the actual care and treatment. She said the competencies listed included IV competencies, IV pump program, and central line dressings specific to nurses only and all nursing staff should be educated and have competencies validated during onboarding. The Administrator said the orientation checklist is the same for new or experienced nurses. She said she oversees the Facility Assessment, but the Medical Director is also responsible. She said the facility was not able to provide a complete record of nursing PICC/midline competencies and proper training per the Facility Assessment and said, if it's on there, then we should be able to provide it.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0849
(Tag F0849)
Could have caused harm · This affected multiple residents
Based on record review, hospice contract review, and staff interview, the facility failed to ensure for one Resident (#49), out of a total sample of 24 residents, that hospice services were provided i...
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Based on record review, hospice contract review, and staff interview, the facility failed to ensure for one Resident (#49), out of a total sample of 24 residents, that hospice services were provided in accordance with the agreement between the hospice and the facility. Specifically, the facility failed to provide ongoing documentation and maintain a complete medical record of services to ensure prompt and effective communication and continuity of care for the Resident, in accordance with the hospice agreement.
Findings include:
Review of the facility agreement with hospice, dated March 2022, indicated but was not limited to the following:
- the facility will identify space in the medical record of the hospice patient for ongoing documentation and communication by hospice personnel
- the hospice will retain responsibility for continuity of care for hospice patients including coordination of facility services
- the facility will prepare and maintain medical records for each hospice patient receiving services
Resident #49 was admitted to the facility in July 2022 with diagnoses including Alzheimer's disease and dementia.
Review of the medical record indicated the Resident started hospice services in June 2023. Further review of the medical record and facility hospice record failed to indicate evidence of visit notes by any discipline since 6/22/23.
During an interview on 9/12/23 at 11:36 A.M., Nurse #1 reviewed both the hospice record and the full medical record of Resident #49 and said there were no notes in either area indicating hospice staff from any discipline had visited the Resident since June 2023. She said in general the hospice staff report to the nurse on duty verbally when they are in the facility and visit the Resident, and the Hospice nurse was currently in the facility.
During an interview on 9/12/23 at 11:37 A.M., Hospice Nurse #1 said she visits the Resident about two times a week and the Resident is also seen by a hospice aide three times a week and has a social worker and spiritual involvement as well. She said the hospice staff document in their electronic medical record system and the process is for the case manager to print the notes and place them in the facility hospice record. She reviewed the hospice record and medical record for Resident #49 and said there were no visit notes in the record from any discipline from hospice since the initial hospice evaluations in June of 2023. She said the visit information should be available for the facility in the medical record and it is not.
During an interview on 9/12/23 at 11:53 A.M., the Director of Nurses said the expectation is that all hospice disciplines provide a copy of their visit notes to the facility following their visit to the Resident. She said the lack of hospice visit notes available to the facility at this time indicate the process for maintaining a complete record with coordination and continuity of the hospice care is not occurring as it should be.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Antibiotic Stewardship
(Tag F0881)
Could have caused harm · This affected multiple residents
Based on policy review, document review, and interview, the facility failed to implement an antibiotic stewardship program which included antibiotic use protocols and monitoring antibiotic use in line...
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Based on policy review, document review, and interview, the facility failed to implement an antibiotic stewardship program which included antibiotic use protocols and monitoring antibiotic use in line with the facility antibiotic stewardship program.
Findings include:
Review of the Centers for Disease Control and Prevention (CDC) guidance titled The Core Elements of Antibiotic Stewardship for Nursing Homes, undated, indicated but was not limited to the following:
- The purpose of an antibiotic stewardship program is to improve the use of antibiotics in healthcare to protect patients and reduce the threat of antibiotic resistance.
- Antibiotic stewardship refers to a set of commitments and actions designed to optimize the treatment of infections while reducing the adverse events associated with antibiotic use.
- The CDC recommends that all nursing homes take steps to improve antibiotic prescribing practices and reduce inappropriate use.
- Any action taken to improve antibiotic use is expected to reduce adverse events, prevent emergence of resistance, and lead to better outcomes for residents in this setting.
Review of the facility's policy titled Antibiotic Stewardship, undated, indicated but was not limited to the following:
- when antibiotics are prescribed over the phone (verbally) the care practitioner (Medical Doctor [MD] or Nurse Practitioner [NP]) will assess the resident within 72 hours of the telephone order.
Review and surveillance of antibiotic use and outcomes:
- as part of the antibiotic stewardship program all clinical infections treated with antibiotics will undergo review by the Infection Preventionist (IP), or designee
- the IP or designee will review antibiotic utilization and identify specific situations that are not consistent with appropriate antibiotic use
- at the conclusion of the review the provider will be notified of the reviewer's findings
- all resident antibiotic regimens will be documented on the facility approved antibiotic surveillance tracking forms and include: resident name and medical record number, unit and room number, date symptoms appeared, name of antibiotic, start date and stop date of antibiotic with total days of therapy, pathogen identified, site of infection, culture date, outcomes and adverse events.
During an interview on 9/7/23 at 9:45 A.M., the Administrator said the Director of Nurses (DON) was IP trained and overseeing the infection control program within the facility and is working as the facility IP.
During an interview on 9/8/23 at 1:07 P.M., the DON said the facility does not have an antibiotic tracking list or any antibiotic stewardship documentation except for what is available on the laboratory surveillance line listings form that the facility uses and McGeer criteria sheets. She said she would expect that if the MD/NP were to review a resident's antibiotic usage and assess them after ordering an antibiotic verbally or over the telephone they should be documenting that in a progress note within the policy timeframe of 72 hours. She said the facility uses McGeer criteria to determine if an infection exists and an antibiotic is an appropriate intervention. She said she is unaware of any additional documents for the antibiotic stewardship that would track, monitor, analyze, or demonstrate communication to the MD/NP regarding antibiotic evaluations but would speak with the staff development coordinator (SDC) who had been assisting her in completing both the line listings and implementing the infection control program as a whole.
Review of the facility provided laboratory surveillance line listings and McGeer criteria sheets, indicated but were not limited to the following:
May 2023
- Resident #49 documented as having a skin infection with McGeer criteria not being met but was treated with Augmentin (an antibiotic)
- Resident #48 documented as having a skin infection with McGeer criteria not being met but was treated with Doxycycline (an antibiotic)
Review of the medical records for Resident #49 and Resident #48 indicated the antibiotics were ordered verbally by telephone but failed to indicate the MD/NP had assessed the Residents within 72 hours of the antibiotic treatments being ordered or that a review of the antibiotic use had been completed by the IP (or designee) and communicated to the physician.
July 2023
- Resident #69 documented as having a skin infection with McGeer criteria not being met but was treated with Keflex (an antibiotic)
- Resident #3 documented as having an upper respiratory (URI) with McGeer criteria not being met but was treated with Azithromycin (an antibiotic)
- Resident #20 documented as having a URI with McGeer criteria not being met but was treated with Azithromycin
Review of the medical records for Residents #69, #3, and #20 indicated the antibiotics were ordered verbally by telephone but failed to indicate the MD/NP had assessed the Residents within 72 hours of the antibiotic treatments being ordered or that a review of the antibiotic use had been completed by the IP (or designee) and communicated to the physician.
During an interview on 9/12/23 at 12:06 P.M., both the DON and SDC reviewed the identified issues with Residents #49, #48, #69, #3, and #20 and said they could not locate any additional information or documentation that would indicate the Residents were evaluated by their MD/NP within 72 hours of starting the antibiotics prescribed verbally/by telephone or that any antibiotic review had occurred by the IP/designee and was communicated to the MD. They said they had not completed any antibiotic reviews and were unaware of that part of the facility antibiotic stewardship program. They said the facility was not meeting all the aspects of their antibiotic stewardship program as they should be per their policies.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0883
(Tag F0883)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, policy review, and interview, the facility failed to provide education, assess for eligibility, and offe...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, policy review, and interview, the facility failed to provide education, assess for eligibility, and offer Pneumococcal Vaccinations per the Centers for Disease Control and Prevention (CDC) recommendations and facility policy for three Residents (#3, #22, and #20), out of a total sample of five residents. Specifically, the facility failed to ensure that staff offered, assessed, and provided education on the recommended 20-Valent Pneumococcal Conjugate Vaccine (PCV20) (an active immunizing agent used to prevent infection caused by certain types of pneumococcal bacteria).
Findings include:
Review of the facility's policy titled Resident Pneumococcal Immunization, undated, indicated but was not limited to the following:
- Residents will be offered immunizations to protect them from pneumococcal disease as recommended by the Centers for Disease Control and Prevention (CDC).
Review of the CDC website Pneumococcal Vaccine Timing for Adults greater than or equal to 65 years (cdc.gov), dated 3/15/23 indicated but was not limited to the following:
- For adults 65 and over who have not had any prior pneumococcal vaccines, then the patient and provider may choose Pneumococcal conjugate vaccine (PCV) 20 or PCV15 followed by Pneumococcal polysaccharide vaccine (PPSV) 23 one year later.
-For adults 65 and over who has had Pneumococcal Conjugate Vaccine 13 (PCV13) and Pneumococcal Polysaccharide Vaccine 23 (PPSV23) and it has been 5 years or greater since the last Pneumococcal Vaccination, then the patient and the vaccine provider may choose to administer the 20-Valent Pneumococcal Conjugate Vaccine (PCV20).
Resident #3 was admitted to the facility in September 2022 and is currently [AGE] years old.
Review of the immunization record for Resident #3 indicated the Resident had received the following pneumococcal vaccinations:
- Prevnar (PCV 13) in 9/2015
- Pneumovax (PPSV23) in 9/2016
Review of the consent for immunization for Resident #3, dated 7/2/23, indicated the Resident had received the PCV 13 and PPSV23 vaccination on the first page, the second page of the consent was left blank.
The record failed to indicate the Resident or his/her responsible party were offered or educated on the availability of PCV20, or the Resident was assessed for eligibility of the vaccination, even though it had been more than five years since the prior pneumococcal vaccine.
Resident #22 was admitted to the facility in October of 2018 and is currently [AGE] years old.
Review of the immunization record for Resident #22 indicated the Resident had received the following pneumococcal vaccinations
- Pneumovax (PPSV23) in 11/2013
- Prevnar (PCV 13) in 9/2018
Review of the consent for immunization for Resident #22, dated 10/15/18, indicated the Resident had consented to PPSV23 but no other available pneumococcal vaccinations were addressed on the one page form.
The record failed to indicate the Resident or his/her responsible party were offered or educated on the availability of PCV20, or the Resident was assessed for eligibility of the vaccination, even though it had been five years since the prior pneumococcal vaccine.
Resident #20 was admitted to the facility in September 2022 and is currently [AGE] years old.
Review of the immunization record for Resident #20 failed to indicate the Resident had received or declined any pneumococcal vaccinations.
Review of the consent for immunization for Resident #20, dated 9/20/22, indicated the Resident had consented to receive both the PCV 13 and PPSV23 vaccinations on the first page, the second page of the consent was left blank. The consent did not address the option of receiving the PCV20 pneumococcal vaccination.
The record failed to indicate the Resident had been vaccinated against pneumococcal by any available vaccinations, or a rational for the lack of vaccination.
During an interview on 9/12/23 at 12:06 P.M., the Director of Nurses said the staff development coordinator (SDC) has been responsible for the resident immunization program.
During an interview on 9/12/23 at 12:42 P.M., the SDC said she is still in the process of determining which residents in the facility need any of the pneumococcal vaccinations and has to complete an audit. She said her focus was on other vaccinations and did not yet start the pneumococcal vaccination program for the residents. She said the program is a work in progress and has not been implemented or updated at this time and the Residents are not up to date with their pneumococcal vaccinations as they should be.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0925
(Tag F0925)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and documentation review, the facility failed to implement an effective pest control program, a...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and documentation review, the facility failed to implement an effective pest control program, as evidenced by mice sightings and mice droppings on 2 of 3 units and the dry storage room in the kitchen.
Findings include:
During an interview on 9/7/23 at 1:06 P.M., Resident #14 said that there is a mouse problem. The Resident stated that four mice came into his/her room and into the closet. The Resident stated that he/she has seen them on and off for the last six to eight months.
During the Resident Group meeting on 9/8/23 at 1:00 P.M., 10 residents were in attendance. The residents represented/resided on the North and South Units (there were no residents representing the East Unit) and complained that there are mice (multiple mice seen) and bugs (ants), with the most recent sightings being last night. The residents said they come out of the closet, go into the bathroom, under the furniture, come from holes in the walls and ceiling, and along the floor. All of the residents said it has been a problem for a long, long time and pest control service needs to come in again.
During an observation and interview on 09/13/23 at 8:20 A.M., the surveyor and Kitchen Consultant #1 inspected the dry food storage area and observed debris (paper scraps, plastic utensils, and food remnants) on the floors underneath the metal storage racks along with numerous mouse droppings present around the bait stations. Kitchen Consultant #1 confirmed that the floors needed to be cleaned and that he would make the Maintenance Director aware of the mice droppings. Kitchen Consultant #1 entered the observation into the Pest Sighting log.
Review of the Pest Sighting log indicated but was not limited to the following:
Details where Insect/Rodent (sic):
7/27/23- room [ROOM NUMBER] spotted mice
7/27/23- Executive Director (ED) office in ceiling
8/15/23- North Unit, room [ROOM NUMBER]- mice running through room at night
8/16/23- North Unit, Rooms 16, 3, 2- multiple sightings
8/20/23- Basement office
8/31/23- North Unit kitchen
The pest control company indicated that traps were set on 9/11/23 for the above concerns.
9/12/23- Assistant Director of Nursing (ADON) office- heard in ceiling/ seen on floor
9/13/23- Dry storage droppings
9/14/23- Atrium across baseboards (sic)
Review of the Service Inspection Reports indicated that the Pest Control Service came into the building on 6/7/23, 6/21/23, 8/10/23, and 9/11/23.
There was no visit in July 2023- (there had been two sightings in the Pest Sighting log in 7/2023).
There had been six entries of mice sightings recorded by the Maintenance Director between the 8/10/23 pest control visit and the 9/11/23 pest control visit, with no additional visits requested by the facility when the mice sightings continued.
Review of the Service Inspection Report, dated 9/11/23, indicated but was not limited to the following:
Pest Logbook Entries:
-room [ROOM NUMBER],4,14,16 all reported mice
-basement offices reported mice
-kitchen reported mice
Today's Pest Findings:
-mouse activity in rooms 3,4,14,16
-mouse activity found in basement offices and kitchen
Exterior Service Performed:
-inspected all exterior stations (bait) finding heavy bait consumption
Sanitation Observations:
-mouse droppings found in closet in rooms 3,4,14,16 in North
-gaps under most exterior doors
During an interview on 9/13/23 at 10:00 A.M., the Maintenance Director said that the new pest control company has been here since March 2023. He said that the company had been in the building monthly but as of 9/11/23, due to the concerns identified last week (residents' complaints of mice sightings, etc.), he said he is now increasing the frequency of the pest control visits from monthly to twice a month.
On 9/13/23 at 1:47 P.M., the surveyor observed a mouse across from the atrium activity/dining area. The mouse was alongside the wall, and then started running under the baseboard heater in the hallway. The surveyor notified the Administrator of the mouse sighting.
During an interview on 9/13/23 at 4:59 P.M., the Maintenance Director said that the Administrator had alerted him to the sighting of the mouse in the atrium today, and he said that he has contacted the pest control service.
The facility failed to maintain a pest control program that proactively addressed the continued concern with mice in the facility.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0940
(Tag F0940)
Could have caused harm · This affected multiple residents
Based on observation, document review, and interview, the facility failed to ensure necessary trainings were completed, as indicated in their facility assessment.
Findings include:
Review of the Fac...
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Based on observation, document review, and interview, the facility failed to ensure necessary trainings were completed, as indicated in their facility assessment.
Findings include:
Review of the Facility Assessment, dated as updated in August 2023, indicated but was not limited to the following:
Staff training/education and competencies (not an all-inclusive list)
The positions of RN, LPN and certified nurse assistant (CNA) training would occur upon orientation and annually to include:
- Communication - effective communications for direct care staff
- Caring for residents with mental and psychosocial disorders, as well as residents with trauma and post-traumatic stress disorder and implementing non-pharmacological interventions
For Nurses only:
- Intravenous (IV) competencies, IV pump program and central line dressings
Review of the facility's in-service competency and education records failed to indicate the facility provided annual IV competency training to licensed nurses. Further, in-servicing on communication and caring for residents with mental and psychological disorders could not be located.
During an interview on 9/14/23 at 11:43 A.M., the Staff Development Coordinator (SDC) said she was not able to locate any documentation of the requested trainings and had not completed any herself.
During an interview on 9/14/23 at 1:51 P.M., the Administrator reviewed the facility assessment regarding the indicated necessary trainings and said the facility has provided the survey team the only trainings they had record of and no other documents were available to indicate further trainings were completed as indicated in the facility assessment.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Food Safety
(Tag F0812)
Could have caused harm · This affected most or all residents
Based on observation, interview, and policy review, the facility failed to follow professional standards of practice for food safety to prevent the potential spread of foodborne illness. Specifically,...
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Based on observation, interview, and policy review, the facility failed to follow professional standards of practice for food safety to prevent the potential spread of foodborne illness. Specifically, the facility failed to:
1. Ensure staff wore hair restraints in the main kitchen, during meal preparation and service, per the Food Code of the Food and Drug Administration (FDA) to prevent hair from contacting food; and
2. Properly label and/or store food items in the main kitchen's alcove, walk-in refrigerator, and two of two double door refrigerators so it was used by the use-by date or discarded.
Findings include:
1. Review of section 2-402.11 of the Food and Drug Administration (FDA) Food Code, dated 2013, indicated but was not limited to the following:
-Food employees shall wear hair restraints such as hats, hair coverings or nets, beard restraints, and clothing that covers body hair, that are designed and worn to effectively keep their hair from contacting exposed food.
During the initial tour of the kitchen on 9/7/23 at 8:50 A.M., the surveyor observed the Food Service Director (FSD) in the main kitchen serving breakfast at the tray line. The FSD's hair was tied in front into two long pigtails extending down past her shoulders. A hair restraint was observed covering the crown of her head, not the pigtails while serving the food to help prevent potential contact with exposed food.
During an interview on 9/7/23 at 8:30 A.M., the FSD said her hair restraint should have been covering all her hair while serving food.
2. Review of the facility's policy titled Labeling and Dating Inservice, undated, indicated but was not limited to the following:
Importance of Labeling and Dating:
-Proper labeling and dating ensures that all foods are stored, rotated, and utilized in First In First Out manner. This will minimize waste and ensure that items that are passed their due date are discarded.
-Food labels must include the food item name, the date of preparation/receipt/removal from freezer, and the use by date as outlined in the attached guidelines.
-Leftovers must be labeled and dated with the date they are prepared and the use by date.
-Date of preparation or opening is considered Day 1 when establishing the use by date.
-Guidelines apply, regardless of storage location.
-All Ready-to Eat, Time/Temperature Control for Safety (TCS) foods that are to be held for more than 24 hours at a temperature of 40 degrees or less, will be labeled and dated with the prepared date (Day 1) and a use by date (Day 7).
Review of the facility document titled Food Storage and Retention Guide, undated, indicated but was not limited to the following:
Ready to Eat/Prepared Foods: (Food in a form that is edible without additional preparation to achieve food safety. Examples - leftovers, deli salads, cut produce)
-Up to 7 days, Day 1 is the day of preparation
Raw Meat/Poultry:
-All poultry - 1-2 days
-Beef or pork roasts - 3-5 days
During the initial tour of the kitchen with the FSD on 9/7/23 at 9:09 A.M., the surveyor observed the following:
Main Alcove off Kitchen:
-Large rectangular pan filled with cooked brownie, not labeled with food item name, date of preparation, or use-by date
During an interview on 9/7/23 at 9:09 A.M., the FSD said the brownie pan should have been labeled.
Walk-In Refrigerator:
-Small to medium sized ham portion wrapped in plastic wrap, dated 9/1, unclear if prepared date or use-by date
-Seven trays of single serve ready-to-eat portions of applesauce/fruit, not labeled
-One clear opened plastic bag of spinach tied in a knot, undated
-One open box of raw hotdogs with the packaging seal open, potentially exposing the contents to environmental contaminants, not labeled
During an interview on 9/7/23 at 9:10 A.M., the FSD said the hot dog packaging should not have been left open and should have been labeled. She said the hotdogs and ham should be tossed as well as the spinach which should have been labeled. The FSD said the trays of applesauce and fruit should have been labeled as to when they were prepared but weren't.
Double Door Refrigerator #1:
-One large plastic bucket filled with prepared chocolate pudding, dated 9/2/23, unclear as to if the prepared date or use-by date
-One bag of opened shredded mozzarella, dated 8/9, unclear as to if the prepared date or use-by date
-One plastic container of cut cantaloupe, not labeled
-Deli turkey slices wrapped in plastic wrap, dated 9/1, unclear as to if the prepared date or use-by date
-One large plastic container of hard-boiled eggs, dated 9/2, unclear as to if the prepared date or use-by date
During an interview on 9/7/23 at 9:16 A.M., the FSD said the mozzarella was past date and disposed of it. She said the turkey slices were not properly labeled and should be disposed of as well as the cantaloupe. The FSD said the chocolate pudding was no longer good and disposed of it as well as the eggs.
Double Door Refrigerator #2:
-One plastic pouring container of apple juice, not labeled
During an interview on 9/7/23 at 9:23 A.M., the FSD said the apple juice should have been labeled with the pour date and was only good for five days.
During a follow up observation visit to the kitchen on 9/13/23 at 8:20 A.M., the walk-in refrigerator was inspected to ensure that foods were being labeled and dated as required. A large metal rack was stored in the walk-in which housed numerous large metal baking sheet pans/trays. The trays contained various food items, one being a large roast beef (dated 9/10).
Stored directly below the roast beef was a tray containing individual salads that had been prepared for the lunchtime meal.
The Kitchen Consultant #1 was made aware of the defrosted roast beef stored over the salads. He immediately removed the salad trays and discarded the entire tray.
During an interview on 9/13/23 at 8:30 A.M., Kitchen Consultant #1 said that the staff should not have stored the roast beef above the salads due to the potential for contamination.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
QAPI Program
(Tag F0867)
Could have caused harm · This affected most or all residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Resident #20 was admitted to the facility in September 2022 with diagnoses including Behcet's disease (rare disorder causing ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Resident #20 was admitted to the facility in September 2022 with diagnoses including Behcet's disease (rare disorder causing inflammation of blood vessels), chronic peripheral venous insufficiency, morbid obesity, type II diabetes mellitus, chronic diastolic heart failure (CHF), peripheral vascular disease (PVD), chronic embolism and thrombosis of deep veins of left lower extremity, and recurrent urinary tract infections (UTIs).
Review of the medical record indicated Resident #20 had two midline catheters placed on 10/10/22 and 10/14/22 and two PICC lines placed on 10/18/22 and 11/1/22 for antibiotic therapy. The midline/PICCs were not appropriately monitored by nursing staff for signs and symptoms of IV related complications, catheter lumen flushing, dressing orders, needleless connector change frequency, tubing change frequency, and for any reports of pain or discomfort by the Resident per facility policy and professional standards of practice.
Resident #20 was admitted to the hospital from [DATE] through 11/8/22 after complaints of pain and swelling in the left arm, most significantly at the site of the PICC. Upon arrival to the emergency department (ED), a bilateral upper extremity (BUE) duplex (test used to evaluate blood clots and venous insufficiency) showed an acute occlusive left deep vein thrombosis (DVT) involving one of the paired brachial veins and left axillary vein surrounding the PICC line. Central extension of nonocclusive thrombus into the left subclavian vein surrounding the PICC was also seen. A new acute occlusive right sided DVT of the right subclavian vein was also noted, along with acute occlusive superficial thrombosis involving the left basilic and cephalic veins.
On 9/11/23 at 2:10 P.M., the surveyor requested documentation from the Director of Nursing (DON) that the facility had identified the adverse events related to the Resident's PICC/midline catheters and reported, investigated, and analyzed the data and information related to the adverse events to ensure improvements were realized and sustained. The DON said she didn't think she had any documentation to indicate the facility had identified the issue, attempted to correct it, or provided education to its nursing staff but would keep looking.
During an interview on 9/12/23 at 4:20 P.M., the DON said there was no documentation she could provide to the surveyor. She said there was no plan of correction or educational piece. She said she was not here at the time and was not aware of it until the surveyor brought it to her attention. She said nursing staff are expected to monitor the site to avoid any potential adverse outcomes.
During an interview on 9/12/23 at 5:19 P.M., the Administrator said the process was not followed for the documentation piece from last October and November. She said she believes they were aware, but the documentation piece was missing for a plan of correction or QAPI project.
No further documentation was provided to the surveyor prior to exiting the facility.
Based on interview, record review, policy review, and review of the quality assurance and performance improvement (QAPI) plan, the facility failed to ensure that the Quality Assurance Committee identified quality deficient areas and developed and implemented an appropriate corrective action plan to ensure satisfactory outcomes. Specifically, the facility failed to:
1. Track and analyze data, including the progress and outcome of projects identified in the facility's Quality Assurance and Performance Improvement Plan; and
2. For Resident #20, conduct performance improvement activities that included the identification of adverse events related to two out of two peripherally inserted central catheters (PICCs) (long, thin tube inserted through a vein in your arm and passed through to the larger veins near your heart that delivers fluids and/or medications) and two out of two midline (thin, soft tube that is placed into a vein at the level of the armpit that delivers fluids and/or medications directly into the vein) catheter devices used to receive intravenous (IV) antibiotics during the timeframe of 10/10/22 through 11/3/22.
Findings include:
Review of the facility's policy titled Quality Assurance Performance Improvement (QAPI), dated March 2023, indicated the following:
- Scope and Design: The scope of the QAPI program includes all systems of care and management practices. The ongoing and comprehensive plan will address clinical care, quality of life, resident choice, and care transitions through data collection, analysis, planning, implementation, and evaluation.
- Performance Improvement Projects: Conduct performance improvement projects (PIPs) that are designed to take a systemic approach to review and improve care or service in areas that we identify as needing attention.
- Conduct PIPs that will improve care and service delivery, increase efficiency, lead to improved staff and resident outcomes, and lead to greater staff, resident, and family satisfaction.
- An important aspect of your PIPs is to determine the effectiveness of our performance improvement activities and whether improvement is sustained.
During an interview with the Administrator and the Director of Nursing on 9/14/23 at 12:15 P.M., the Administrator discussed some of the concerns that were identified during the annual recertification (mail delivery, grievance policy, and pressure ulcer) and had already brought them to the QAPI team; however there was no tracking method, written goals, quarterly or previous annual comparison on any of these projects to demonstrate progress that has been made. The Administrator was unable to speak of any current QAPI projects or PIPs or to show any documentation of these projects or progress towards the goals. The Administrator said she was new to the facility in March 2023 and could not measure its success or track performance to ensure improvements were achieved and sustained because there were no completed projects. She said she needed to come up with a better plan to track the progress of the projects and document them accordingly.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected most or all residents
Based on document review, policy review, record review, and interviews, the facility failed to maintain an infection prevention and control program as indicated in their infection control plan and pol...
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Based on document review, policy review, record review, and interviews, the facility failed to maintain an infection prevention and control program as indicated in their infection control plan and policies. Specifically, the facility failed to maintain a complete and accurate system of surveillance and to analyze their collected surveillance data to identify any trends of actual or potential infections within the facility to validate the effectiveness of their program.
Findings include:
Review of the facility's policy titled Infection Prevention and Control Program, undated, indicated but was not limited to the following:
- outcome surveillance (incidence and prevalence of healthcare acquired infections) are used to measure the effectiveness of the infection prevention and control program (IPCP)
- surveillance tools are used for recognition of infection occurrence, record the frequency and numbers, detect outbreaks and epidemics, and monitor adherence to the IPCP
- data gathered during surveillance is used to oversee infections and spot trends
- the IP [Infection Preventionist] (or designee) records absolute numbers of infections and analyzes the data by manually calculating infections per 1000 resident days
- rates are calculated with adjustment for units and bed capacity and infection rates are calculated for comparison for each unit and the entire facility
- monthly rates can be plotted graphically or side by side to allow for trend comparison
- the analysis process allows for screening of clinically significant rates of infection
- the Medical Director will help design data collection instruments, infection reports and antibiotic usage forms
- criteria will be used to determine sporadic cases of infection versus outbreaks
During an interview on 9/8/23 at 1:07 P.M., the Director of Nurses (DON) said the facility uses the laboratory supplied surveillance line listing to document the surveillance of their potential or actual infections. She said the staff development coordinator (SDC) was assisting her with the tasks associated with the IPCP. She said the facility uses McGeer criteria to determine if an illness rises to the level of a true infection and have McGeer checklists for verification of criteria being met.
Review of the facility provided laboratory surveillance line listings and McGeer criteria sheets indicated but were not limited to the following:
May 2023
- Resident #44: category: skin (S), date of onset: 5/1/23; symptoms: drainage, redness, warmth; site: left great toe; status: healthcare acquired infection (HAI); count (required): blank
The surveillance data for Resident #44 was incomplete on the line listing and the completed McGeer checklist indicated the criteria was inaccurately completed indicating criteria for infection was not met.
July 2023
- Resident #69: category: S; date of onset: 7/21/23; symptoms: redness, pain, swelling; site: not identified; status: HAI; count (required): Yes
- Resident #3: category: upper respiratory infection (URI); date of onset: 7/10/23; symptoms: cough, congestion; status: HAI; count (required): Yes
- Resident #20: category: URI; date of onset: 7/6/23; symptoms: cough, phlegm, change in lung sounds; status: HAI; count (required): Yes
- Resident #20: category: URI; date of onset: 7/21/23; symptoms: cough, phlegm, change in lung sounds; status: HAI; count (required): Yes
Review of the McGeer criteria checklist in use by the facility, indicated but was not limited to the following:
Syndrome: Cellulitis, soft tissue, or wound infection (Skin)
Criteria: Must fulfill at least 1 of the criteria.
1. Pus at wound, skin, or soft tissue site
2. At least four of the following:
- New or increasing sign or symptom
- Heat (warmth) at affected site
- Redness (erythema) at affected site
- Swelling at affected site
- Tenderness or pain at affected site
- Serous drainage at the affected site
2A. At least one of the following (can be counted as part of the four in criteria #2)
- Fever
- Leukocytosis
- Acute changed in mental status
- Acute functional decline
Syndrome: Bronchitis/Tracheo-bronchitis (URI)
Criteria: Must fulfill 1, 2, AND 3.
1. Chest X-ray not performed, or negative for pneumonia or a new infiltrate
2. At least two of the following criteria
- New or increased cough
- New or increased sputum production
- Oxygen saturation (O2 sat) <94% on room air, or >3% decrease from baseline O2 sat
- New or changed lung exam abnormalities
- Pleuritic chest pain
- Respiratory rate >25 breaths/min
3. At least one of the following criteria
- Fever
- Leukocytosis
- Acute mental status change
- Acute functional decline
The McGeer criteria checklist completed for Resident #69 indicated the criteria for infection was not met on criteria review (requiring four symptoms) but was inaccurately checked as criteria met and inaccurately counted as an infection on the facility line listing surveillance.
The McGeer criteria checklist completed for Resident #3 indicated the criteria for infection was not met on criteria review (requiring all 3 criteria to be met) but was inaccurately checked as criteria met and inaccurately counted as an infection on the facility line listing surveillance.
The McGeer criteria checklist completed for Resident #20 on 7/6/23 indicated the criteria for infection was not met on criteria review (requiring all 3 criteria to be met) but was inaccurately checked as criteria met and inaccurately counted as an infection on the facility line listing surveillance, as was the McGeer checklist completed for this Resident on 7/21/23.
During an interview on 9/12/23 at 12:06 P.M., the DON and SDC reviewed the discrepancies between the surveillance line listings and McGeer criteria checklists for all four Residents and said the information did not match and the documents were not completed accurately but could not explain how the discrepancies may have occurred. Neither the DON nor the SDC could provide any tracking or trending information or speak to how trends of infections would be identified in the facility. The DON said there are no documented HAI rates for the facility completed monthly, no data comparisons from unit to unit or month to month and no overall analysis completed that she is aware of at the facility level and the lab provides them with look back data quarterly based off of the surveillance line listings submitted to the lab. She said there may be infection tracking and trending and analysis information available through the Quality Assurance Performance Improvement (QAPI) committee, but that the facility does not have an infection control committee. Neither the DON nor the SDC could speak to a potential increase or fluctuation in the facility HAI numbers or provide any plotting or trending of infections within the facility. The DON said she would review the QAPI information with the Administrator and provide the surveyors with any further information they could find.
During an interview on 9/13/23 at 10:47 A.M., the Administrator and the DON said the facility does not use their surveillance data in a manner to identify trends or potential outbreaks and the only information they have available is the quarterly lab look back information and no data analysis is completed monthly or in live time. The Administrator said the IPCP is not being followed the way it should be and the facility is lacking any evidence of data analysis or trending for actual or potential infections and outbreaks within the facility.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0941
(Tag F0941)
Could have caused harm · This affected most or all residents
Based on documentation review and interview, the facility failed to provide mandatory effective communications training for direct care staff.
Findings include:
Review of the facility's in-service a...
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Based on documentation review and interview, the facility failed to provide mandatory effective communications training for direct care staff.
Findings include:
Review of the facility's in-service and education records failed to indicate the facility provided in-servicing on effective communication for direct care staff.
During an interview on 9/14/23 at 11:43 A.M., the Staff Development Coordinator (SDC) said she was not able to locate any documentation of effective communications training and had not completed any herself but the training may be covered in the general orientation program.
During an interview on 9/14/23 at 1:31 P.M., the Human Resources Director (HRD) reviewed the new hire orientation packet with the surveyor and said there was no indication that effective communications was reviewed or discussed during the general orientation process.
During an interview on 9/14/23 at 2:01 P.M., the Regional Nurse said the training on effective communications had been developed but not implemented in the facility at this time and no documentation of staff training on effective communications could be provided.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0944
(Tag F0944)
Could have caused harm · This affected most or all residents
Based on documentation review and interview, the facility failed to provide training and education to their staff to outline elements and goals of the facility's Quality Assurance Performance Improvem...
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Based on documentation review and interview, the facility failed to provide training and education to their staff to outline elements and goals of the facility's Quality Assurance Performance Improvement (QAPI) program.
Findings include:
Review of the facility's in-service and education records failed to indicate the facility provided in-servicing to their staff to outline elements and goals of the facility QAPI program.
During an interview on 9/14/23 at 11:43 A.M., the Staff Development Coordinator (SDC) said she was not able to locate any documentation of QAPI trainings for staff and had not completed any herself.
During an interview on 9/14/23 at 1:51 P.M., the Administrator said she did not believe the facility had completed training on the QAPI program for their staff and no documents could be located for the surveyors to review.
During an interview on 9/14/23 at 2:01 P.M., the Regional Nurse said the QAPI program training had been developed but not implemented in the facility at this time and no documentation of staff training could be provided.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0949
(Tag F0949)
Could have caused harm · This affected most or all residents
Based on documentation review and interview, the facility failed to provide behavioral health training and education to their staff.
Findings include:
Review of the facility's in-service and educati...
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Based on documentation review and interview, the facility failed to provide behavioral health training and education to their staff.
Findings include:
Review of the facility's in-service and education records failed to indicate the facility provided in-servicing to their staff on behavioral health management.
Review of the Facility Assessment, dated as updated in August 2023, indicated but was not limited to the following:
Staff training/education and competencies (not an all-inclusive list)
The positions of RN, LPN and certified nurse assistant (CNA) training would occur upon orientation and annually to include:
- Caring for residents with mental and psychosocial disorders, as well as residents with trauma and post-traumatic stress disorder and implementing non-pharmacological interventions
During an interview on 9/14/23 at 11:43 A.M., the Staff Development Coordinator (SDC) said she was not able to locate any documentation of behavioral health training and had not completed any herself but the information may be covered in the general orientation program.
During an interview on 9/14/23 at 1:31 P.M., the Human Resources Director (HRD) reviewed the new hire orientation packet with the surveyor and said there was no indication that behavioral health trainings were part of the general orientation process.
During an interview on 9/14/23 at 1:51 P.M., the Administrator said she did not believe the facility had completed trainings on behavioral health management and it was not part of the general orientation process. She said no documents could be located for the surveyors to review as proof that any training on this topic had occurred.
During an interview on 9/14/23 at 2:01 P.M., the Regional Nurse said the behavioral health training had been developed but not implemented in the facility at this time and no documentation of staff training could be provided.
MINOR
(B)
Minor Issue - procedural, no safety impact
Deficiency F0582
(Tag F0582)
Minor procedural issue · This affected multiple residents
Based on the Beneficiary Protection Notification Review and interview, the facility failed to issue the appropriate Skilled Nursing Facility Advanced Beneficiary Notice (SNF ABN) and Notice of Medicar...
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Based on the Beneficiary Protection Notification Review and interview, the facility failed to issue the appropriate Skilled Nursing Facility Advanced Beneficiary Notice (SNF ABN) and Notice of Medicare Non-coverage (NOMNC) forms for two Residents (#39 and #1A), out of three residents sampled.
Findings include:
The SNF ABN notice is administered to a Medicare recipient when the facility determines the beneficiary no longer qualifies for Medicare Part A skilled services and the resident has not used all of the Medicare benefit days for that episode.
The NOMNC (form CMS-10123) provides information to convey notice to the beneficiary of his or her right to an expedited review of a Medicare service termination.
1. Resident #39's last covered day of skilled Medicare A services was 8/23/23. Resident #39 remained in the facility, but no longer required Skilled services covered under Medicare A.
The Resident was not provided with the SNF ABN or the NOMNC as required.
During an interview with Social Worker (SW) #1 said that he was under the impression that if the Resident comes off skilled services and remains in the facility that The Resident is now considered custodial care and would not require an ABN or NOMCN. Resident #39 did not receive any notification of the facilities decision to discontinue skilled Medicare A services and should have. He said that a notice should have been provided and was not.
2. For Resident #1A, the facility failed to provide the required notice to the Resident's Health Care Proxy (HCP) prior to being discharged from the facility on 9/1/23.
Resident #1A's HCP made the decision to initiate discharge from the facility on 8/31/23, which coincided with the Resident's last covered day of skilled services covered under Medicare A. The Resident was then discharged to the community on 9/1/23.
SW #1 said that the HCP initiated the discharge and because the HCP made the decision to discharge the Resident that a notice was not necessary.
Although the HCP initiated the discharge, it was not the same day as the Last Covered Day (LCD), the Resident was discharged the next day and the ABN /NOMNC should have been given a notice prior to the Residents last covered day and was not.
During an interview on 9/14/23 at 2:00 P.M., SW #1 said that Residents #39 and #1A should have been provided with the notices prior to the last covered Medicare A day but were not.
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
Notification of Changes
(Tag F0580)
Could have caused harm · This affected 1 resident
Based on records reviewed and interviews for one of three sampled residents (Resident #1), who had an activated Health Care Proxy (HCP) and experienced a significant change with a decline in medical s...
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Based on records reviewed and interviews for one of three sampled residents (Resident #1), who had an activated Health Care Proxy (HCP) and experienced a significant change with a decline in medical status, the Facility failed to ensure Resident #1's Health Care Agent (HCA) was notified of the change which included the worsening of wounds on his/her right foot with the development of an infection with new physician orders to start Resident #1 on an antibiotic, as well as new orders for the administration of an opioid medication to manage his/her pain.
Findings include:
Review of the Facility Policy titled Change in Condition, dated as last revised October 2022, indicated that upon identification of significant change findings the Nurse must document the following;
-Findings related to change in condition;
-Physician notification and responses;
-Family notification;
-Interventions; and
-Resident's disposition.
Resident #1 was admitted to the Facility in May 2023, diagnoses included dementia, peripheral vascular disease, peripheral arterial disease, and type II diabetes mellitus.
Review of Resident #1's admission Minimum Data Set (MDS) Assessment, dated 5/18/23, indicated he/she was severely cognitively impaired, had scored an 8 out of 15 (0-7 indicates severe cognitive impairment, 8-12 indicates moderate cognitive impairment, 13-15 indicates cognitively intact) on the Brief Interview for Mental Status.
Review of Resident #1's Document of Resident Incapacity, dated 2/10/23, indicated that Resident #1's Health Care Proxy was activated.
During an interview on 7/12/23 at 3:28 P.M., Resident #1's Family Friend said on 5/16/23, she and Resident #1's HCA went to visit Resident #1 at the facility, for the first time since he/she had been admitted . The Family Friend said Resident #1's HCA had been unable to visit Resident #1 before this due to medical reasons that compromised the HCA's own failing health.
The Family Friend said when they saw Resident #1 that day, the HCA said it was the first time seeing the actual wounds to Resident #1's right foot and that the HCA, as well as herself, could not believe what they looked like.
The Family Friend said she was close to and has been helping out Resident #1's HCA, and after taking the HCA to see Resident #1 at the facility on 5/16/23, and seeing Resident #1's condition, she filed a formal complaint on behalf of the HCA. The Family Friend said Resident #1's wounds appeared to be deep with an opening in the center of each wound, and that there were red marks on his/her ankles suggesting there may have been prolonged use of restraints.
Due to Resident #1's HCA's own pressing health care issues during this time, the Surveyor was unable to interview Resident #1's HCA directly.
Review of Resident #1's Facility Wound Evaluation Summary, dated 2/06/23, indicated he/she was being followed by a Wound Physician at his/her transferring skilled nursing facility prior to admission for multiple wounds. The Summary further indicated that Resident #1's right and left lower extremities appeared edematous, that both feet were warm with positive dorsalis pedis (top of the foot) pulses, and there was no indication of open areas to either foot.
Resident #1's Wound Evaluation Summaries, dated 2/17/23 through 5/26/23, indicated Resident #1 was evaluated to have the following new areas to his/her right foot;
-2/17/23, a new partial thickness arterial wound located on his/her right foot/heel;
-3/23/23, a new partial thickness arterial wound located on his/her right posterior ankle;
-3/31/23, worsening to a full thickness (below the epidermis into the subcutaneous tissue or beyond) arterial wound to his/her right foot/heel and worsening to a full thickness arterial wound to his/her right posterior ankle;
-5/05/23, new full thickness arterial wound to his/her right fifth toe; and
-5/12/23, new full thickness, autoimmune (a disease in which the body's own immune system attacks healthy cells) induced wound to his/her face.
Review of Resident #1's Medical Record, from 2/17/23 through 5/26/23, indicated there was no documentation to support that Nursing notified Resident #1's Health Care Agent (HCA) of any of the new areas on his/her right foot identified by the Wound Physician.
Review of Resident #1's Physician Order, dated 4/14/23, indicated he/she was to be administered Augmentin (antibiotic to treat infection) Oral Tablet 500-125 milligrams (mg), give 500 mg by mouth two times a day for a duration of seven days ending on 4/21/23, to treat his/her right foot infection.
Review of Resident #1's Nurse Progress Notes, dated 4/14/23 through 4/21/23, indicated there was no documentation to support Nursing notified his/her HCA of the initiation and administration of an antibiotic secondary to Resident #1's right foot infection.
Review of Resident #1's Nursing Progress Note, dated 5/04/23, indicated he/she exhibited significant pain to his/her right foot, especially when foot is touched with treatment or care.
Review of Resident #1's Physician Order, dated 5/04/23, indicated he/she was to be administered Oxycodone HCL (opioid, used to treat pain) 5 milligrams (mg) every 12 hours as needed for severe pain.
Review of Resident #1's Medical Record, indicated there was no documentation to support Nursing notified Resident #1's HCA of the initiation of Oxycodone.
During an interview on 7/13/23 at 11:18 A.M., Nurse #1 said she could not remember if Resident #1's Health Care Proxy was activated and does not remember speaking with Resident #1's HCA about any changes in his/her condition.
During an interview on 7/13/23 at 3:19 P.M., the Unit Manager said she only remembers speaking to the HCA when a gradual dose reduction of his/her Quetiapine (an antipsychotic medication) was done and when Resident #1 went out for his/her vascular appointment.
The Unit Manager said all Nursing staff should be notifying HCA's of any changes in condition identified with any resident such as change in treatments, start of any new medications, falls, and any other significant change in a residents' plan of care.
During an interview on 7/17/23 at 11:29 A.M., the Former Assistant Director of Nurses said she rounded with the wound doctor weekly and said she does not remember ever speaking to Resident #1's HCA about any changes in his/her wounds.
During an interview on 7/13/23 at 4:28 P.M., the Director of Nurses (DON) said the expectation is that nursing staff notify any activated HCA and/or family members of changes in Residents' status once identified.
Apr 2021
16 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0604
(Tag F0604)
Could have caused harm · This affected 1 resident
Based on policy review, observations, record review, and interviews, the facility failed to ensure that one Resident (#40), out of 18 sampled residents, had the least restrictive restraint device for ...
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Based on policy review, observations, record review, and interviews, the facility failed to ensure that one Resident (#40), out of 18 sampled residents, had the least restrictive restraint device for the least amount of time and failed to re-evaluate the need for the restraint.
Findings include:
Review of the restraint policy, updated January 2021, indicated when use of a restraint was indicated, the least restrictive alternative would be used for the least amount of time necessary.
Resident #40 had a diagnosis of dementia and was receiving hospice services.
On 4/21/21 at 9:00 A.M., the surveyor observed Resident #40 in a Broda chair (a high back reclining wheelchair) with a clip seat belt, intact, across his/her lap, while being fed breakfast by a certified nursing assistant. The Resident was observed sitting quietly, eating breakfast.
On 4/23/21 at 9:22 A.M., the surveyor observed Resident #40 seated in the Broda chair, with the clipped seat belt intact, being fed breakfast by Certified Nursing Assistant (CNA) #3. The Resident was observed to be still, not restless.
During an interview on 4/23/21 at 10:02 A.M., CNA #3 said she was not sure why Resident #40 had a clipped seatbelt and said she did not release the seat belt at any time.
On 4/23/21 at 12:45 P.M., the surveyor observed Resident #40 seated in the Broda chair with the clipped seat belt intact, being fed lunch by the Hospice CNA. The Resident had his/her eyes closed and was seated quietly. The Hospice CNA said Resident #40 had a history of trying to climb out of the Broda chair and the seatbelt was utilized as a restraint to prevent falls. The Hospice CNA said Resident #40 had this behavior sometimes.
During an interview on 4/27/21 at 11:39 A.M., the Hospice CNA said she does not unclip Resident #40's seatbelt when sitting with the Resident and always leaves the seatbelt intact. The Hospice CNA was observed to be seated directly next to the Resident at this time. Resident #40 was seated calmly in the Broda chair with his/her eyes closed; the clipped seatbelt was observed to be intact.
During an interview on 4/27/21 at 2:03 P.M., the Director of Nurses (DON) said a quarterly assessment was completed for any resident with a restraint to determine if the resident could self-release a device or if a restraint reduction could be done.
Review of the physical restraint assessment, dated 10/7/19, indicated Resident #40 had a change in mental status and was unable to release the seat belt on his/her own. A review of the electronic and paper medical record for Resident #40 failed to include any additional quarterly restraint assessments or self-release assessments.
During an interview on 4/27/21 at 2:36 P.M., the DON said Resident #40 was unable to release the clipped seat belt and the device was a restraint for the Resident. The DON said that the most recent assessment for the clipped seat belt was dated 10/7/19, and no additional assessments or attempts of reduction had been conducted since that time
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Abuse Prevention Policies
(Tag F0607)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, record review, document review, and interview, the facility failed to ensure staff implemented written p...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, record review, document review, and interview, the facility failed to ensure staff implemented written policies and procedures for an allegation of abuse for one Resident (#28) in a total sample of 18 residents.
Findings include:
Review of the facility's policy titled Reporting Abuse to Facility Management, updated December 2013, and indicated the following:
- Abuse is defined as the willful infliction of injury, unreasonable confinement, intimidation or punishment with resulting physical harm, pain, or mental anguish.
- An employee who suspects an alleged violation shall immediately notify the Executive Director and/or his/her designee.
- The Administrator or Director of Nurses must be immediately notified of suspected abuse or incidents of abuse. If such incidents are reported or discovered after hours, the Administrator and Director of Nurses must be called at home or must be paged and informed of such incident.
- If a family member, resident, or staff reports an incident of abuse/mistreatment/neglect, it is to be reported to the Director of Nursing Services or manager immediately and an Incident/Accident Report is to be completed.
Resident #28 was admitted to the facility with diagnoses which included peripheral vascular disease, diabetes with diabetic neuropathy, and amputation of the left lower leg.
Review of the Minimum Data Set (MDS), dated [DATE], indicated Resident #28 had a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which indicated he/she was cognitively intact.
During an interview on 4/21/21 at 12:00 P.M., Resident #28 said a Certified Nursing Assistant (CNA) attacked him/her or words to that effect. Resident #28 said on 4/14/21, during the overnight shift, he/she woke up and CNA #9 was standing at the foot of the bed and asked if he/she had called for assistance. Resident #28 said he/she was sleepy and groggy due to pain medication, but asked CNA #9 for the bedpan. Resident #28 said CNA #9 said, get up and get it; come on, you can do it, or words to that effect. Resident #28 said CNA #9 used her voice in a manner so as to mock him/her. Resident #28 said CNA #9 proceeded to raise the head and foot of the bed and scrunched me, or words to that effect. Resident #28 said CNA #9 took her own left hand and placed if over Resident #28's right hand which was resting on his/her chest, as in a manner to prevent the Resident from using his/her call light. Resident #28 said CNA #9 said, You are not going to call the nurse, or words to that effect. Resident #28 said the police were called and took statements from him/her and his/her roommate. Resident #28 said he/she knew CNA #9 was still employed at the facility and was afraid of her.
Review of the Facility Incident Report indicated that on 4/14/21 at 8:55 A.M., CNA #10 was in Resident #28's room speaking to the Resident prior to providing care. At that time, CNA #10 reported that Resident #28 was upset and told her that an overnight CNA had restrained him/her from calling the nurse. The incident report indicated CNA #10 informed the nurse on duty immediately and an investigation was initiated.
Review of Nurse #10's statement, who worked 4/14/21 on the 7:00 A.M. - 3:00 P.M. shift, indicated that Nurse #10 had been informed by CNA #10 of Resident #28's allegation. The statement indicated that on 4/14/21 at 8:55 A.M., CNA #10 reported Resident #28 alleged he/she was restrained by CNA #9 during the overnight shift. The statement indicated Nurse #10 spoke with the Resident who alleged on the overnight shift, he/she rang the call light for the bedpan and when CNA #9 came into the room, CNA #9 asked Resident #28 if he/she was able to get up to the commode. The statement indicated Resident #28 told CNA #9, he/she was unable to get up to the commode as he/she had only one leg, and CNA #9 responded with laughter. Resident #28 said he/she was unhappy with the care being provided by CNA #9, and told CNA #9, he/she was going to call the nurse and proceeded to reach for the call light. Further review of the statement indicated Resident #28 said CNA #9 grabbed his/her hand, held it against Resident #28's chest so the Resident could not reach the call light and CNA #9 said, No, don't call the nurse.
Further review of the Facility Incident Report included interviews and statements from all staff involved with the alleged incident.
The Facility Incident Report indicated Resident #28 was interviewed by the DON and Director of Social Services. Review of Resident #28's statement indicated that Resident #28 said CNA #9 came into his/her room for assistance with the bedpan. The statement indicated CNA #9 elevated the foot and head of the bed, and Resident #28 said he/she did not like the way CNA #9 was providing care and the Resident reached for the call light. The statement indicated CNA #9 grabbed Resident's left hand and restrained his/her hand on Resident's chest, and prevented Resident #28 from calling the nurse. The statement further indicated Resident #28 called for the nurse once CNA #9 left the room.
Further review of the Facility Incident Report and the investigative statements included a statement from Nurse #11, who worked the 11:00 P.M. - 7:00 A.M. shift, the evening of the alleged incident.
The statement indicated CNA #9 told Nurse #11 that Resident #28 wanted to speak with her. Nurse #11 went to speak with Resident #28, who requested pain medication as the Resident was uncomfortable and unable to sleep. The statement indicated Nurse #11 returned with medication for Resident #28 and repositioned the Resident to sit up in bed to take his/her medication. The statement indicated Nurse #11 asked the Resident if anything else was going on and Resident #28 said keep that other one away from me, she's not gentle, she's very abrupt. Nurse #11 asked Resident #28 what happened and the Resident said CNA #9 pushed the bed table, threw the Resident's call light on the floor and told him/her to stop calling, and go to sleep. The statement indicated Nurse #11 found Resident #28's call light hanging over the side of the bed and clipped to the bottom sheet where Resident #28 could not reach it. Nurse #22 positioned the call light so the Resident could reach it. The statement indicated Resident #28 said he/she did not want CNA #9 to enter the room and Nurse #11 said she would answer the call light for the remainder of the night.
During an interview on 4/27/21 at 2:45 P.M., the DON and the surveyor reviewed Nurse #11's written statement. The DON said the expectation would have been for Nurse #11 to call and notify her immediately of the allegation of abuse from Resident #28 according to the policy, and not wait until the 7:00 A.M. - 3:00 P.M. shift staff informed her of the incident. The DON said she was not immediately notified of the allegation per the facility policy and procedure.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Assessment Accuracy
(Tag F0641)
Could have caused harm · This affected 1 resident
Based on record review and interview, the facility failed to ensure the accuracy of the Minimum Data Set (MDS) assessment for one Resident (#40), out of a sample of 18 residents.
Findings include:
Re...
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Based on record review and interview, the facility failed to ensure the accuracy of the Minimum Data Set (MDS) assessment for one Resident (#40), out of a sample of 18 residents.
Findings include:
Resident #40 was admitted to the facility with a diagnosis of dementia. Review of the MDS assessments, dated 12/8/20 and 3/9/21, failed to indicate that Resident #40 had a trunk restraint.
On 4/21/21 at 9:00 A.M., the surveyor observed Resident #40 in a Broda chair (a high back reclining wheelchair) with a clip seat belt, intact, across his/her lap, while being fed breakfast by a certified nursing assistant.
On 4/23/21 at 12:45 P.M., the surveyor observed Resident #40 in the Broda chair with the clipped seat belt intact, being fed lunch by the Hospice CNA. The Hospice CNA said Resident #40 had a history of trying to climb out of the Broda chair and the seatbelt was utilized as a restraint to prevent falls.
Review of Resident #40's medical record indicated:
-a restraint consent signed by the responsible party on 10/26/19;
-an order dated 1/21/20 for the release of a seat belt every two hours; and
-a physical restraint assessment, dated 10/7/19, indicating Resident #40 had a change in mental status and was unable to release the seat belt on his/her own.
During an interview on 4/27/21 at 2:36 P.M., the Director of Nurses said the Resident was unable to release his/her clipped seat belt and the device was a restraint for Resident #40.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0658
(Tag F0658)
Could have caused harm · This affected 1 resident
2. For Resident #52, the facility staff failed to ensure a new alteration in skin integrity was identified, treated, and investigated as per facility protocol.
Review of the facility policy titled Mai...
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2. For Resident #52, the facility staff failed to ensure a new alteration in skin integrity was identified, treated, and investigated as per facility protocol.
Review of the facility policy titled Maintaining Skin Integrity, dated as reviewed April 2020, indicated:
-Nurses complete weekly skin evaluations to monitor skin integrity;
-alterations in skin integrity are evaluated weekly at risk meeting; and
-resident skin checks are conducted and documented by a licensed nurse weekly.
Review of the facility's policy titled Incident Reporting Policy, undated, indicated:
All incidents, accidents, and injuries of unknown origin must be reported to the Director of Nurses (DNS) and all must be investigated immediately and results reported to the DNS and, when appropriate, to the Administrator. The policy defined an accident as including but not limited to: fall, skin tear of known or unknown origin, bruise of known or unknown origin.
Resident #52 was admitted to the facility in February 2021 with diagnoses which included Type 2 Diabetes Mellitus without complications and repeated falls.
Review of Resident #52's Minimum Data Set (MDS) assessment, dated 3/25/21, indicated in Section M - Skin Conditions under question M1040: Other Ulcers, Wounds, and Skin problems: none present.
On 4/21/21, 4/22/21, 4/23/21, and 4/28/21, the surveyor observed an undated bordered dressing bandage to Resident #52's left lower extremity (LLE) high on the outer aspect of his/her ankle.
During an interview on 4/21/21 at 10:57 A.M., Resident #52 said he/she banged his/her leg on a branch while outside which caused a skin issue. The Resident said the incident happened, maybe a week or so ago and a nurse put a bandage on it.
Review of the Physician's Orders, dated 4/1/21 through 4/21/21, indicated no orders were in place for a treatment or dressing change to an area on Resident #52's LLE.
Review of the Incident Reports for Resident #52 for the prior three months, identified only two incident reports involving the Resident, both dated in March 2021. Review of the incident reports failed to include or indicate any skin integrity problem was identified to Resident's LLE by the high outer aspect to the ankle.
Review of Resident #52's Weekly Skin Assessments indicated Resident #52 was overdue for a Skin Assessment according to the Electronic Medical Record (EMR). The last identified completed Skin Assessment was dated 4/8/21, and indicated: Bilateral Lower Extremities with multiple dry scabs that patient picks at.
Further review of the Assessment Section failed to indicate that a completed Skin assessment was conducted on 4/15/21 or 4/22/21.
During an interview on 4/23/21 at 10:49 A.M., Unit Manager #2 said weekly skin assessments were on the TAR to prompt the nurse to the computerized skin assessment. She said the expectation was for the nurse to sign off the TAR and complete the skin assessment that coincided under assessments.
Review of Resident #52's TAR indicated the Skin Assessment was signed off by Nurse # 7.
During an interview on 4/23/21 at 11:08 A.M., Nurse #7 said the nurse was to complete the assessment in the EMR and sign it off on the TAR. She said the assessment in the EMR was to be completed regardless of any changes to the resident's skin.
During an interview on 4/23/21 at 3:42 P.M., the Director of Nurses (DON) said the nurse was expected to sign off the TAR, go to the Assessment section of the EMR and complete the assessment regardless of any change to the skin. She said if a new area was identified, the nurse was to alert the supervisor so the Resident could be added to wound rounds. The DON said a new identified area would be a bruise, skin tear, or pressure area and an investigation would be started for skin issue of known or unknown origin and an incident report would be completed. The DON said the Infection Preventionist (IP) kept all skin logs and was responsible to assure all recommendations were followed up on.
During an interview on 4/23/21 at 3:53 P.M., the IP said she maintained skin logs for both pressure and non-pressure areas. She said the Wound Physician followed all skin conditions in the facility and she updated the tracking sheets and ensured orders were updated. She said during weekly skin checks, any new skin area was reported to the resident's physician and the nurse was expected to initiate an investigation. She said the expectation for completing weekly skin assessments was for the nurse to sign off the TAR as a prompt to complete the assessment in the EMR.
Review of the facility Weekly Non-Pressure Area and Pressure Area Flow Record, dated April 2021, failed to indicate Resident # 52 had any identified skin conditions.
On 4/28/21 at 7:48 A.M., the surveyor observed Resident #52 lying in bed with an undated bordered dressing bandage on his/her LLE high on the outer aspect of his/her ankle.
During an interview on 4/28/21 at 8:13 A.M., the IP and the surveyor observed an unlabeled bordered bandage dressing, which was peeling off of Resident #52's LLE high on the outer aspect of the ankle. The IP removed the bandage and identified a skin tear under the bandage. The IP said this was an unknown area and there was no incident report. The IP said the process for identifying and reporting of new skin issues was not followed by staff.
Based on interview, observation, and record review, the facility failed to ensure staff provided care and services according to accepted standards of clinical practice for two Residents (#26 and #52), out of a total sample of 18 residents. Specifically,
1) for Resident #26, the facility staff failed to follow the physician's order; and
2) for Resident #52, the facility staff failed to identify, treat, and investigate an alteration in skin integrity.
Findings include:
1. For Resident #26, the facility staff failed to follow the Physician's order for the Resident to be returned to bed after meals.
Resident #26 was admitted to the facility with diagnoses which included dementia, diabetes,
and multiple sclerosis.
Review of Resident #26's medical record indicated that on 11/27/21 the Resident had developed a Stage 2 pressure area on the coccyx which measured 2.2 centimeters (cm) x 2.0 cm x 0.1 cm (facility acquired). A Stage 2 pressure injury is one in which there is partial thickness skin loss with exposed dermis (inner layer of the two main layers of skin) or has an intact or open/ ruptured serum-filled blister.
On 11/27/20, Resident #26 was seen by the wound consultant and the following recommendations were made:
- Up to (for) meals
- Calcium alginate (alginates absorb wound exudates (drainage) and form a gel-like covering over the wound, helping to maintain a moist wound healing environment to promote the healing process and minimize bleeding)
- Followed by a foam border dressing
- Skin prep to peri-wound
- Off-load (distribute the load to other areas which are not as susceptible to pressure) wound
- Reposition per facility protocol
- Gel cushion to chair
- Low air loss mattress
Review of the physician's orders, initiated 11/27/20 and current orders for April 2021, indicated a physician's order for the following:
- Resident to be out of bed for meals only then back to bed.
- Turn and reposition every 2 hours and as needed to refrain added pressure to coccyx area.
Further review of Resident #26's record indicated:
- The wound was documented as healed on 3/9/21 and re-opened on 4/9/21. The wound measurements on 4/8/21 were 1.0 cm x 1.0 cm x 0 (no depth to wound).
- The Resident was seen by the Wound consultant on 4/9/21 who recommended:
Calcium Alginate followed by a foam border dressing daily, apply skin prep peri-wound.
The surveyor made the following observations:
On 4/21/21, Resident #26 was out of bed for breakfast at 7:45 A.M., and still up in the wheelchair at 11:23 A.M., and had not been put back to bed after breakfast and did not get put back to bed until 1:30 P.M.
On 4/22/21, Resident #26 was out of bed for breakfast at 7:30 A.M., and did not get put back to bed until 1:30 P.M.
On 4/26/21, Resident #26 was out of bed for breakfast at 7:30 A.M., and did not get put back to bed until 1:15 P.M.
During an interview on 4/26/21 at 1:25 P.M., the surveyor reviewed the observations of Resident #26 not being put back to bed after breakfast with the Unit Manager. The surveyor accompanied Unit Manager into the Resident's room and the Unit Manager observed Resident #26 had not been put back to bed per the physician's orders.
On 4/27/21 at 10:40 A.M., the surveyor observed Resident #26 still out of bed after breakfast.
Review of the Treatment Administration Record indicated the following:
- Resident #26 is to only be out of bed for meals then back to bed at 9:00 A.M., 1:00 P.M. and 6:00 P.M. The licensed staff had been documenting that Resident #26 was back to bed at 9:00 A.M. when the above observations indicated the Resident had not been put back to bed after breakfast at 9:00 A.M.
During an interview on 4/27/21 at 10:45 A.M., the Infection Preventionist (IP), who was also responsible for wound management in the facility, said Resident #26's wound was improving as Resident was being put back to bed after meals. The surveyor made the Unit Manager and IP aware of the observations that Resident #26 was not being placed back to bed and staff failed to follow the physician's order for placing the Resident back to bed after meals.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Pressure Ulcer Prevention
(Tag F0686)
Could have caused harm · This affected 1 resident
Based on observation, interview and record review the facility failed to ensure pressure relieving devices were utilized in accordance with professional standards of practice to promote healing for on...
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Based on observation, interview and record review the facility failed to ensure pressure relieving devices were utilized in accordance with professional standards of practice to promote healing for one Resident (#40), in a total sample of 18 residents.
Finding include:
Review of Resident #40's medical record indicated a pressure area developed on his/her coccyx on 2/19/21.
On 4/21/21 at 11:00 A.M., the surveyor observed Resident #40 seated in a Broda chair, which had a strapping system to reduce the heat and moisture build-up which leads to skin breakdown. On the seat of the Broda chair there were straps. On top of the straps there was a thin white cushion, on top of the thin white cushion was a pressure relieving cushion, creating multiple layers and making the strapping system of the Broda chair ineffective.
On 4/23/21 at 9:22 A.M., the surveyor observed Resident #40 seated in the Broda chair, on top of a thin white cushion and a pressure relieving cushion.
On 4/27/21 at 11:39 A.M., the surveyor observed Resident #40 seated in the Broda chair, on top of a thin white cushion and a pressure relieving cushion.
During an interview on 4/27/21 at 12:08 P.M., the Staff Development Coordinator, who was responsible for wound management, said Resident #40 had a pressure area on his/her coccyx, but was unsure if she had reviewed the pressure relieving devices utilized for Resident #40 for seating.
On 4/27/21 at 12:20 P.M., the Staff Development Coordinator and the surveyor observed the Resident, up on the Broda chair with two cushions between the Broda straps and the Resident. The Staff Development Coordinator said the thin white cushion came with the Broda chair and on top of that was placed a pressure relieving cushion. She said she was not sure why the pressure relieving cushion had been placed on top of the Broda straps and the Broda supplied cushion. She said Resident #40 should not have had two cushions.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0688
(Tag F0688)
Could have caused harm · This affected 1 resident
Based on observations, interviews, and record review, the facility failed to implement the appropriate equipment of an inflatable hand carrot (used in the treatment of contractures. Contractures are t...
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Based on observations, interviews, and record review, the facility failed to implement the appropriate equipment of an inflatable hand carrot (used in the treatment of contractures. Contractures are the shortening and hardening of tissues leading to rigidity of joints.) for one Resident (#43) with limited range of motion, out of a total sample of 18 residents.
Findings include:
Resident #43 was admitted to the facility with a diagnosis of Cerebrovascular accident (CVA) (stroke) with right sided weakness.
Review of a communication form in Resident #43's medical record from therapy to nursing, dated 9/25/20, indicated a nurse was to perform gentle range of motion to the right shoulder, elbow, wrist, forearm, and hand prior to wearing a carrot. The form indicated that the Resident had a right hand contracture and was to wear the carrot for two to three hours daily.
Review of the Physician's Orders for Resident #43 indicated an order for a therapy carrot in the Resident's right hand for four hours (10:00 A.M. to 2:00 P.M.) for increased flexibility.
On 4/21/21 at 12:15 P.M., the surveyor observed Resident #43 and there was no carrot in his/her right hand.
During an observation and interview on 4/22/21 at 2:15 P.M., Resident #43 said he/she had not used the carrot on this day and said it's gone. The surveyor observed that Resident #43 did not have the therapy carrot in their right hand.
On 4/23/21 at 10:10 A.M., 12:48 P.M. and 3:00 P.M., the surveyor observed Resident #43 without a therapy carrot placed in his/her right hand.
Review of the electronic medical record on 4/23/21 at 1:00 P.M., indicated Nurse #3 had signed off that the carrot had been placed in the hand of Resident #43.
During an interview on 4/23/21 at 3:10 P.M., Nurse #3 said the therapy carrot for Resident #43 was in the medication room; she had not placed it in the Resident's hand as ordered today, because she had not had time to do all of her work.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0849
(Tag F0849)
Could have caused harm · This affected 1 resident
Based on interview, record review and observation, the facility failed to coordinate, collaborate and monitor the delivery of hospice services for one Resident (#52), out of a total sample of three re...
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Based on interview, record review and observation, the facility failed to coordinate, collaborate and monitor the delivery of hospice services for one Resident (#52), out of a total sample of three residents receiving hospice services. Specifically, the facility failed to
1) have a schedule of hospice services, including involvement and collaboration of the coordinated plan of care for Resident #52; and
2) monitor the delivery of hospice care, as there was no signed Hospice Physicians Plan of Care or Initial Hospice Certification available to facility staff.
Findings include:
Review of the nursing facility's service agreement with the elected hospice provider indicated Hospice and Facility would jointly develop and agree upon a coordinated plan of care.
Resident #52 was admitted to the facility in February 2021 with diagnoses which included centrilobular emphysema, Type 2 Diabetes Mellitus without complications, and repeated falls.
Review of the Minimum Data Set assessment, dated 3/25/21, indicated under Section O - Special treatments and programs, Question O0100: Resident was receiving hospice services.
Review of Resident #52's clinical record indicated the Hospice Initial Certification for Benefit period 3/19/21 through 6/16/21, was not signed by the Resident's physician. The Physician's Plan of Care for the Resident, signed by the hospice nurse on 3/19/21, also failed to include the required physician's signature.
During an interview on 4/23/21 at 11:37 A.M., Unit Manager #2 said there was no additional paperwork available regarding hospice services for Resident #52. Unit Manager #2 said, although she had seen hospice employees in the facility, she was unaware of an official schedule of hospice services.
During an interview on 4/23/21 at 11:41 A.M., Certified Nursing Assistant (CNA) #8 said she had never seen a hospice schedule for resident care on the resident units. She said when hospice staff are in the facility, they notify the unit staff of the residents they will provide care to.
During an interview on 4/23/21 at 11:47 A.M., Nurse #7 said she had never seen a hospice schedule of services posted on the resident unit. Nurse #7 reviewed the clinical record with the surveyor and reviewed the hospice paperwork. Nurse #7 said the hospice paperwork had not been signed by the physician, and said there was no additional paperwork available regarding hospice services being provided to Resident #52.
During an interview on 4/23/21 at 1:58 P.M., the Director of Social Services said the Director of Nurses (DON) coordinated and managed all hospice documentation including initial hospice certification, physician's plan of care, and schedules of provided services.
During an interview on 4/28/21 at 8:41 A.M., the DON said the plan of care should be collaborative and the physician should have already signed all the required paperwork but had not. The DON said there needed to be more communication and collaboration between the facility and the hospice provider.
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** Based on observations and interviews, the facility failed to ensure adequate maintenance services were provided to residents' ro...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations and interviews, the facility failed to ensure adequate maintenance services were provided to residents' rooms and living areas in order to maintain a safe, clean, comfortable, and homelike environment.
Findings include:
On 4/22/21 at 7:58 A.M., the surveyor observed a resident's bathroom in room [ROOM NUMBER] to have seven missing wall tiles and a hole in the wall that was approximately 2 feet long and 4 inches high. The flooring around the toilet had cracks around the caulking of the toilet base with an orange substance that appeared to be staining around the toilet and parallel wall.
During an interview on 04/22/21 at 08:09 A.M., Nurse #7 said staff would call the Maintenance Director with maintenance issues if he was present in the facility, and said on weekends or off time, staff could send an email. Nurse #7 said most people were not aware of the Maintenance Director's email address.
On 4/28/21 between 10:05 A.M. and 10:23 A.M., the surveyor made the following observations on the South Unit:
- room [ROOM NUMBER]: the bathroom had cracked and damaged wall tile under the sink and an orange substance stain covering more than half of the tile on the floor. The bathroom door was chipped with missing pieces of wood.
- room [ROOM NUMBER]: the window had a crack in the sealant between the tile and the window for the length of the window. In addition, the bathroom had a missing piece of floor tile next to the toilet with an orange substance stain area on the floor.
- room [ROOM NUMBER]: the bathroom toilet had an orange substance around the toilet hardware at the floor level and around the cracked sealant, and the bathroom sink was filled with water that would not drain.
- In the main hall, the hallway closet had a door off the track which was resting against the closet interior shelves.
- In the tub room, there was a missing piece of tile on the window ledge.
- In the resident atrium, there were exposed metal coils in the base board heating grate.
On 4/28/21 between 10:15 A.M. and 10:31 A.M., the surveyor made the following observations on the North Unit:
-room [ROOM NUMBER]: the heater vent was dust laden and rusted along the top edge and dented along the front side. Both resident overbed table tops were observed to be dirty with a dried type of sticky substance. There was chipped paint and areas of torn sheet rock along the lower walls behind both beds. The walls behind the beds were observed with numerous patched, unpainted holes. The kick plate along the wall behind Bed A was observed to have a black like dried substance along the top and bottom. The closet door was observed off the track and was unable to close.
During an interview on 4/28/21 at 10:41 A.M., Unit Manager #2 said the sink in room [ROOM NUMBER] had been clogged for a few days and the issue remained unresolved. She said when an issue is identified; the staff calls the Maintenance Director to let him know so he can take care of the issue.
During an interview on 4/28/21 at 11:03 A.M., the Maintenance Director and the surveyor reviewed the maintenance request (responses) email system from 3/24/21 through 4/21/21. The surveyor reviewed the observations of the resident rooms, care areas, and common areas with the Maintenance Director. He said staff typically put information into the computerized email system used to report maintenance issues or would call him so he could address the situation right away. The Maintenance Director said he tried to complete environmental rounds monthly, but did not have a formal system in place, or keep a log of issues. He said the clogged sink in room [ROOM NUMBER] was a common issue and he was unsure why staff had not informed him of the issue or why it was not in the email system request log.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Accident Prevention
(Tag F0689)
Could have caused harm · This affected multiple residents
Based on observation, interview, and record review, the facility failed to ensure that the resident's environment remained free of accident hazards. Specifically, the facility staff failed to:
1) clos...
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Based on observation, interview, and record review, the facility failed to ensure that the resident's environment remained free of accident hazards. Specifically, the facility staff failed to:
1) close and lock a medication cart, with narcotics, to prevent access from wandering residents;
2) ensure safe smoking equipment was utilized for three Residents (#27, #51, and #67) out of six residents who required a smoking apron; and
3) implement and monitor a Wanderguard for one Resident (#13), out of a total sample of 18 residents.
Findings include:
1. On 4/27/21 at 2:21 P.M. on the North Unit, a secure unit for some residents with a diagnosis of dementia with a behavior of wandering, the surveyor observed a medication cart up against the nurse's station with a drawer wide open and the flap to the narcotic box wide open. The drawer and the narcotic box were both observed to hold medications. The surveyor observed Nurse #3, who was assigned to this medication cart, seated at the nurse's station talking to another nurse and to a physician. Nurse #3, nor the nurse she was talking with, was within reach of the open medication cart and neither was observing the medication cart.
At 2:23 P.M., Resident #46 was observed ambulating down the hallway and headed toward the nurse's station. The surveyor stepped between the medication cart and the Resident to block the Resident from accessing any medications or narcotics. The surveyor then alerted Nurse #3, who turned around. When the nurse stood up, she saw the cart was open and said, Oh sorry, I had to get a prescription from the doctor so I went to the nurse's station.
Review of the Minimum Data Set (MDS) for Resident #46, dated 3/16/21, indicated a BIMS (Brief Interview for Mental Status) score of 2 out of 15 indicating the Resident had severe cognitive impairment and the behavior of wandering occurred daily.
The medication cart had not been closed and secured, creating a safety hazard to residents.
2. The facility staff failed to ensure the plan of care was followed for the utilization of safe smoking equipment for Residents #27, #51 and #67.
Review of the smoking policy, updated on 11/22/19, indicated:
-smoking aprons would be stored in close proximity to the resident smoking area;
-a specific care plan would be designed to meet the individual needs of the resident and reviewed for changes; and
-all safety interventions would be included in the care plan, such as a smoking apron.
A. Review of Resident #27's medical record indicated the Resident was a smoker. A functional smoking assessment, completed by the rehabilitation department, dated 4/7/21, indicated Resident #27 should utilize a smoking apron. Review of the smoking care plan for Resident #27 was not updated to include the smoking apron.
On 4/27/21 at 1:48 P.M., the surveyor observed Resident #27 outside being transported by Activity Assistant #1. Resident #27 was not observed to have a smoking apron. Activity Assistant #1 said she was unable to locate the smoking aprons so she had not utilized it while Resident #27 was smoking. She said there were three residents in the facility who wore smoking aprons.
B. Review of Resident #51's medical record indicated the Resident was a smoker. Review of the smoking assessment, dated 4/6/21, indicated the Resident had shaky hands and a smoking apron should be utilized. A functional smoking assessment, completed by the rehabilitation department, dated 4/10/21, indicated Resident #51 should utilize a smoking apron.
During an interview on 4/27/21 at 1:48 P.M., Activity Assistant #1 said Resident #51 should have been wearing a smoking apron while smoking, but she was unable to locate the smoking aprons.
On 4/28/21 at 10:53 A.M., the surveyor observed Resident #51 outside smoking with Activity Assistant #2. Resident #51 was not observed to be wearing a smoking apron.
C. Review of Resident #67's medical record indicated the Resident was a smoker. A review of the smoking care plan indicated Resident #67 should utilize a smoking apron.
On 4/28/21 at 10:53 A.M., the surveyor observed Resident #67 outside smoking with Activity Assistant #2. Resident #67 was not observed to be wearing a smoking apron.
During an interview on 4/28/21 at 12:26 P.M., the Activity Director said the activity staff was responsible for supervising resident smoking. She said the staff knew who required an apron for smoking because they had access to the smoking assessments in the electronic medical record, but the staff did not check the assessment prior to bringing residents outside. She said there was no documentation for the activity staff to access with the smoking materials that would indicate who required safety equipment for smoking.
During an interview on 4/28/21 at 1:22 P.M., the Director of Nurses said there were six residents in the facility who wore smoking aprons for safety. She said the activity staff knew who these residents were. She said there was verbal communication given to the staff, but no documentation had been given to the activity staff for reference. The Director of Nurses confirmed that all three of the observed Residents should have been wearing smoking aprons.
3. The facility staff failed to implement and monitor a Wanderguard for Resident #13.
Review of the facility's policy titled Resident Elopement and Wandering, dated January 2021, indicated the following:
- If it is determined a resident is at risk for elopement, resident will be evaluated for the use of a Wanderguard device in an effort to alert staff if the resident is attempting to leave the building.
- A completed Missing Resident Profile Form with photo will be placed in all yellow elopement binders.
- Resident's door label will be yellow
- Risk for elopement will be reassessed quarterly and the Nursing supervisor will review Elopement books on a regular basis
- The Nursing department shall implement interventions to prevent elopement as necessary
Resident #13 was admitted to the facility with diagnoses which included Wernicke's encephalopathy (the presence of neurological symptoms caused by biochemical lesions of the central nervous system after exhaustion of B-vitamin reserves, in particular thiamine), anxiety and depression.
Review of Resident #13's Minimum Data Set (MDS) assessment, dated 01/19/21, indicated a Brief Interview for Mental Status (BIMS) score of 12 out of 15 indicating the Resident had moderate cognitive impairment and was assessed as independent in his/her functional mobility and activities of daily living. Under Section P - Restraints, Question P0200 Alarms, the MDS indicated: wander/elopement alarm used daily.
Review of Resident #13's electronic medical record (EMR) indicated the COMS-Elopement Evaluation V 2, dated 10/23/20; the Resident was At Risk for elopement with a score of 2. The evaluation indicated a score of greater than 1 = At risk for elopement.
Review of the Physician's orders, dated 4/1/21 through 4/22/21, indicated Resident #13 had a Wanderguard on the left ankle and to check placement and function every evening shift.
Review of Resident #13's care plans on 4/22/21 indicated:
- Resident is an elopement risk related to a history of attempts to leave the facility unattended with an intervention in place of the electronic wander alert device to left ankle.
Review of Resident #13's Medication Administration Record (MAR) and Treatment Administration Record (TAR), dated 4/1/21 through 4/23/21, failed to indicate the monitoring of placement and function of the Wanderguard electronic device.
On 4/21/21, 4/22/21,4/23/21 and 4/28/21, the surveyor observed Resident #13 without a Wanderguard in place.
During an interview on 4/22/21 at 4:39 P.M., Resident #13 said he/she removed the Wanderguard bracelet about a year ago because it irritated his/her skin.
During an interview on 4/23/21 at 2:06 P.M., the Director of Social Services said she believed Resident #13 wore a Wanderguard bracelet but could not recall the last time she saw the Resident with the Wanderguard on.
During an interview on 4/23/21 at 2:56 P.M., Nurse #8 said she checked the Wanderguard placement and function for one resident with a Wanderguard on her assignment on the evening shift. Nurse #8 said Resident #13 was not the Resident identified on her assignment who had a Wanderguard in place.
During an interview on 4/23/21 at 3:11 P.M., Certified Nursing Assistant (CNA) #8 said she was unaware of Resident #13's behavior of elopement until she heard the nurses speaking about it today at change of shift. CNA #8 said Resident #13 does not wear a Wanderguard and escorted the surveyor to the room to verify that the Resident did not have a Wanderguard in place.
During an interview on 4/23/21 at 3:36 P.M., the Director of Nurses (DON) said residents are assessed quarterly for elopement and a plan is formulated if found to be at risk for elopement. She said there was an elopement binder on each unit which contained information on the residents who were evaluated as elopement risk. The DON said the nurses would sign off on placement and function [of the Wanderguard] on the MAR or TAR every shift.
Review of the South Unit Elopement binder identified Resident #13 as an elopement risk with a completed Missing Resident Profile Form.
During an interview on 4/28/21 at 8:58 A.M., the DON said Resident #13 was not currently wearing a Wanderguard. The DON said the process was not followed for ensuring the Resident had his/her device in place.
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 ensure food was properly stored in accordance with professional standards of practice for food safety in 3 out of 3 nourishment kitchens.
Fi...
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Based on observation and interview, the facility failed to ensure food was properly stored in accordance with professional standards of practice for food safety in 3 out of 3 nourishment kitchens.
Findings include:
The facility's policy titled Foods Brought by Family/Visitors, indicated containers would be labeled with the resident's name and the use by date and the nursing staff would be responsible for discarding perishable foods on or before the use by date.
1. On 4/23/21 at 2:17 P.M., the surveyor observed the following in the South unit nourishment kitchen:
-ranch dressing with an expiration date of 3/13/21 in the refrigerator
-two breakfast cups Just crack an egg in the freezer with expiration dates of 7/19/20, and not labeled with a resident name.
-a Go-Gurt with an expiration date of December 2020.
2. On 4/23/21 at 2:30 P.M., the surveyor observed the following in the East unit nourishment kitchen:
-a rod from one wall to the other, holding a jean jacket, a sweat jacket and two yellow PPE (personal protective equipment) gowns.
-the refrigerator thermometer was on the floor, outside of the refrigerator.
-the refrigerator door had food spills as evidenced by a sticky red substance.
-the floor had a piece of cookie covered with ants, there was an open cookie wrapper with half a cookie on top of the microwave and another open cookie on a tray of condiments.
-a review of the nourishment kitchen temperature log did not include refrigerator or freezer temperatures for 4/22/21 or for 7:00 A.M. on 4/23/21.
3. On 4/23/21 at 2:57 P.M., the surveyor observed the following in the North unit nourishment kitchen:
-There was a red sticky substance in the grooves of the refrigerator drawer and on the side of the refrigerator
- a review of the nourishment kitchen temperature log did not include refrigerator or freezer temperatures for 4/22/21 or for 7:00 A.M. on 4/23/21
During an interview on 4/27/21 at 7:26 A.M., the Food Service Director said the dietary staff were responsible to clean the refrigerators in the nourishment kitchens on Monday, Wednesday and Fridays. He said his staff were responsible for checking the temperatures of the refrigerators and the freezers and disposing of expired items. He said he was not sure why the expired items were not disposed of, the refrigerators were not cleaned and the temperatures were not taken. He also said the staff jackets and PPE should not be kept in the nourishment kitchens.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0885
(Tag F0885)
Could have caused harm · This affected multiple residents
Based on interview and document review, the facility failed to ensure staff followed the Centers for Medicare & Medicaid Services (CMS) published final rule, dated August 26, 2020, for Long Term Care ...
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Based on interview and document review, the facility failed to ensure staff followed the Centers for Medicare & Medicaid Services (CMS) published final rule, dated August 26, 2020, for Long Term Care (LTC) Facility Testing and Reporting Requirements for Residents and Staff during the COVID-19 pandemic. The facility staff failed to notify five Residents (#63,#1,#28, #22 and #36), out of a total sample of 18 residents, by 5:00 P.M. the following day of a new positive COVID case (staff or resident) as required.
Findings include:
On 4/26/21 at 7:00 A.M., the Administrator informed the surveyor that a facility staff member tested positive for COVID -19 over the weekend. The Administrator said the facility was notified of the confirmed infection for the staff member on 4/24/21 during regular surveillance testing.
The Administrator said he communicated to the families and some residents by a system he called a blast. (A blast is a notification mechanism that is called call um all, which is a text/ e-mail service that sends out updates to residents/staff/families.)
During an interview on 4/28/21 at 9:05 A.M., Resident #63 said he/she was not notified that a staff member tested positive for COVID-19 on 4/24/21, but said he/she figured it out as staff were now wearing yellow gowns again.
During an interview on 4/28/21 at 9:15 A.M., Resident #1 said he/she was not notified a staff member tested positive for COVID-19 on 4/24/21, but said he/she figured it out as staff was swabbing his/her nose again.
During an interview on 4/28/21 at 9:30 A.M., Resident #28 said he/she was not notified a staff member tested positive for COVID-19 on 4/24/21.
During an interview on 04/28/21 at 9:50 A.M., Resident #22 said he/she was not notified a staff member tested positive for COVID-19 on 4/24/21.
During an interview on 04/28/21 at 9:52 A.M., Resident #36 said he/she was not notified a staff member tested positive for COVID-19 on 4/24/21.
During an interview on 4/28/21 at 11:00 A.M., the Infection Preventionist (IP) said notification to the residents occurred when she went through the facility for the initial round of testing and told residents at that time someone tested positive for COVID-19. The IP said she assumed the residents were aware of the status as she was performing facility testing. The IP was made aware of the interviews with the five residents who had not been notified of the current COVID-19 status as required by the federal regulation. The IP had no response to the surveyor's findings.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0920
(Tag F0920)
Could have caused harm · This affected multiple residents
Based on observation and interview, the facility failed to ensure the resident activity room on one of three units was adequately furnished and provided sufficient space to accommodate the needs of th...
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Based on observation and interview, the facility failed to ensure the resident activity room on one of three units was adequately furnished and provided sufficient space to accommodate the needs of the residents.
Findings include:
A resident group meeting was held on 4/22/21 at 10:00 A.M., in the South unit day room. The five residents who attended the meeting said the facility had recently started having activities again and they had used this day room to watch movies. Resident #63 said he/she was happy the room was open again because the room contained a book shelf, however he/she was unable to reach the book shelf due to a large stationary bike in front of the book shelf.
During the meeting the surveyor observed the South unit day room to have the following items: a rolling walker, a recumbent bike, wooden therapy stairs, two folding chairs, a bed frame with no mattress, two commodes, and a privacy screen with coats hanging from it. The clock on the wall had a time of 5:40 and had been written on with marker who cares?
During an interview on 4/27/21 at 2:00 P.M., the Activity Director said the residents of the South unit had started using the day room again to watch movies or baseball games in the evenings and some had started to go in the room to use it for individual activities such as games or reading. She said she knew the items had remained in the room from when the room had been used by the rehabilitation department, but she was unsure why the items were still there and had not asked about the use of the room when it had re-opened for activities.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0838
(Tag F0838)
Could have caused harm · This affected most or all residents
Based on documentation review and interview, the facility failed to ensure staff accurately conducted and documented a Facility-wide assessment to determine what resources were necessary to care for i...
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Based on documentation review and interview, the facility failed to ensure staff accurately conducted and documented a Facility-wide assessment to determine what resources were necessary to care for its residents and to plan for resources needed for continued infection control practices during emergencies such as the current Public Health Emergency. The Assessment tool had multiple areas of inaccurate information and had not been updated annually as required.
Findings include:
Review of the Facility Assessment Tool indicated that information was missing or inaccurately documented as evidenced by the following:
1. The Facility Assessment failed to identify and list the current Administrator, Medical Director and Maintenance Director. The Facility Assessment indicated that it was last updated on 9/10/19, and not annually as required.
2. The Facility Assessment indicated the facility had 86 licensed beds and the average daily census was 70-82. The Administrator said the facility had 78 licensed beds.
3. The Assessment tool indicated the facility used medication aides or technicians, volunteers and students. Due to the COVID-19 pandemic declaration from March 2020, volunteers had not been used and the facility does not have medication aides working in the building.
4. The Assessment Tool indicated the facility had a dialysis chair/ station and a cafe/ snack bar/ bistro. The Administrator said the facility did not provide these services.
5. The Assessment Tool indicated the facility utilized Matrix Care as its electronic medical record system. The Administrator said the facility recently transitioned from Matrix Care to Point Click Care as its electronic medical record system.
6. The Assessment Tool failed to indicate an ongoing program was established to ensure continued infection prevention compliance during the COVID-19 pandemic. The tool failed to identify allocations of resources for the COVID-19 plan including:
-staffing needs for the required screening process;
-education for training/competency for mandated testing process including the swabbing process; and
-continued education for staff regarding appropriate use of personal protection equipment.
During an interview on 4/28/21 at 12:30 P.M., the Administrator said the direction and purpose of the Facility Assessment changed following the COVID-19 pandemic and the information needed to be changed. The Administrator said the assessment would require a total overhaul once the new Medical Director was in place.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected most or all residents
Based on observation, interview and record review, the facility failed to ensure staff implemented infection prevention and control practices and policies. Specifically, the facility failed to (1) ens...
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Based on observation, interview and record review, the facility failed to ensure staff implemented infection prevention and control practices and policies. Specifically, the facility failed to (1) ensure the appropriate Personal Protective Equipment (PPE) was donned (put on) when performing BinaxNOW (rapid testing), ensure the staff were competent to administer the test and ensure staff followed the Centers for Medicare and Medicaid Services (CMS) guidelines for social distancing during the testing;
(2) ensure staff utilized the appropriate PPE for four Residents (#172, #3, #323, and #61) on quarantine;
(3) utilize the appropriate Personal Protective Equipment (PPE) when providing high contact care, for Resident #63, during an outbreak of COVID-19 and failed to ensure PPE was readily available for all staff;
(4) follow the facility policy for the use of PPE in a resident care area
(5) follow infection control practices during the observation of a pressure ulcer treatment/dressing change;
(6) ensure infection control practices were followed while administering medications to residents, and
(7) ensure infection control practices were followed for a resident using ice on the unit
Findings include:
1. The facility staff failed to accurately perform COVID-19 testing for visitors by not wearing proper PPE, not obtaining samples as indicated, not conducting testing away from others, and the staff were not thoroughly trained on the procedure.
The facility offered BinaxNOW testing to visitors. BinaxNOW is a test where a nasal swab is obtained and tested for the detection of the protein antigen for the SARS-CoV-2 virus (COVID-19).
During an interview on 4/21/21 at 2:00 P.M. the Infection Preventionist said competencies had been completed on the all staff who performed the test on the visitors.
A review of the competencies provided by the Infection Preventionist (IP) indicated the following parts of the testing process:
- Follow appropriate infection control and PPE protocol of: N95 mask, eye protection, gown and gloves
-Review process before obtaining swab and complete specimen collection in an area that provides privacy
- Using a clean swab, insert into nostril until resistance is met at the level of the turbinates (less than one inch into the nostril).
- Rotate the swab five times or more against the nasal wall and then remove slowly
- Using the same swab, repeat the sample collection in the other nostril
- When process is complete: wash hands and doff PPE
On 4/21/21 at 1:15 P.M., the surveyors observed a group of visitors standing under the covered walkway just outside the front entrance. Activities Director was observed at a large folding table outside near the front entrance. The Activities Director was observed to complete the BinaxNOW testing with a group of visitors. The surveyor observed the area where the testing was being conducted was not in an area providing privacy to visitors having the specimen collection, and visitors failed to socially distance from each other during specimen collection and while waiting for testing results. The surveyor observed the Activities Director instruct a visitor to just swab one side, or words to that affect, while she continued to test other visitors standing at the folding table and did not observe the visitor complete the specimen collection.
The Activities Director did not don the proper PPE (gowns and gloves) while performing the testing according to the facility competency.
On 4/21/21 at 4:45 P.M., the surveyors observed the Activities Director and the Admissions Director perform the BinaxNOW testing on a group of visitors. The testing was performed in the same area and again, there was no social distancing in place. The Activities Director and the Admissions Director were observed to conduct the BinaxNOW testing without gloves and gowns on.
On 4/26/21 at 12:45 P.M., the surveyor observed three visitors enter the facility and be screened. The three visitors then proceeded into the North Dining room. The Admissions Director was observed to perform the BinaxNow swab on one of the visitors, without donning a gown or gloves.
During an interview on 4/26/21 at 2:05 P.M., the IP said staff were required to don gowns and gloves during the testing procedure. The Activities Director had a competency completed however the Admissions Director performed the testing without having been determined to be competent in the procedure. The IP said the facility staff failed to follow the policy/procedure for the BinaxNOW testing.
2. The facility failed to ensure staff and visitors wore the appropriate personal protective equipment (PPE) when entering quarantine rooms of four Residents (#172, #3, #323, and #61).
Review of the infection prevention and control COVID-19 policy, revised on 4/26/21, indicated for residents on quarantine (droplet/contact precautions) the staff entering the room should don (put on) full PPE of mask, eye protection, gown and gloves.
a: On 4/23/21 at 2:40 P.M., the surveyor observed the room of Resident #172 to have a sign which indicated the Resident was on quarantine (droplet/contact) precautions. The surveyor observed Resident #172 in bed and a visitor was seated on the bed, showing the Resident her phone. The visitor was wearing a mask, a face shield, and an isolation gown, which was observed to be opened in the front and not tied, exposing the visitor's clothing to the Resident. The visitor was not wearing gloves.
During an interview on 4/23/21 at 2:41 P.M., Unit Manager #1 said Resident #172 was on quarantine precautions related to being re-admitted from the hospital and said the quarantine sign was posted on the Resident's door.
On 4/23/21 at 2:45 P.M., the visitor was observed to leave the room of Resident #172 wearing the isolation gown and carrying the face shield in her hand. The visitor walked across the unit, past the nurse's station and started to exit the East unit. During this time, Unit Manager #1 and CNA #6 were at the nurse's station, neither intervened to educate the family on doffing (take off) PPE.
During an interview on 4/23/21 at 2:50 P.M., the Admissions Coordinator said she had brought the visitor of Resident #172 to the East unit. She said she did not provide any education regarding PPE use and did not watch the visitor don the PPE to ensure it was done correctly.
During an interview on 4/23/21 at 2:53 P.M., the Infection Preventionist (IP) said she had never educated the visitor of Resident #172 regarding the appropriate use of PPE and was unsure if any staff member had provided that education.
b: During an observation and interview on 4/21/21 at 9:12 A.M., the surveyor observed a sign on the door of Resident #3 indicating the resident was on quarantine (contact/droplet) precautions. Nurse #1 said Resident #3 was quarantined and full PPE should be utilized when entering the Resident's room.
On 4/21/21 at 12:13 P.M., the surveyor observed the Director of Social Services enter the Resident's room without donning a gown or gloves prior to entering.
On 4/21/21 at 4:11 P.M., the surveyor observed Nurse #6 enter the room of Resident #3 without donning a gown or gloves prior to entering.
On 4/22/21 at 2:10 P.M., the surveyor observed Resident #3 in the unit dining room attending an activity. There were six residents in the room attending the activity. Resident #3 was observed to be wearing a face mask, which was not covering his/her nose. At 3:04 P.M., the surveyor observed the Resident still attending the activity. At this time, there was another resident, who was not wearing a mask, seated at the table with Resident #3. The Residents were less than three feet apart.
During an interview on 4/27/21 at 1:43 P.M., the IP said Resident #3 was on quarantine and per the facility policy, should not have been attending a group activity outside of his/her room.
c. During an observation and interview on 4/23/21 at 9:08 A.M., the surveyor observed CNA #5 in a room with Resident #323 and another CNA who was wearing full PPE. The sign on the Resident's door indicated the Resident was on quarantine precautions. CNA #5 was observed to have her goggles in her hand, and she had no gown or gloves on. CNA #5 said she had forgotten to put on the appropriate PPE prior to entering the room and acknowledged the quarantine sign on the Resident's room.
d: On 4/23/21 at 9:10 A.M., the surveyor observed Unit Manager #1 in a room with Resident #61. The sign on the Resident's door indicated the Resident was on quarantine precautions. Unit Manager #1 was not observed to be wearing a gown or gloves. She was observed touching the Resident, who was in bed, come out of the room, go to the medication cart, and open the medication cart, all before performing hand hygiene.
3. The facility staff failed to don the correct PPE when providing high contact care activities and failed to have PPE readily available for staff use.
On 4/26/21 at 7:00 A.M., the surveyor was informed by the Administrator of a staff member who tested COVID -19 positive over the weekend. The Administrator said the facility was notified of the confirmed infection for the staff member on 4/24/21 during regular surveillance testing. The Administrator said the signage throughout the facility had been changed to reflect the change in PPE requirements and gowns and gloves were now required for all high contact care.
During an interview on 4/26/21 at 7:49 A.M. the Administrator and the IP said the facility had implemented gowns and gloves with high contact care and all the signage in the facility at the entrance to the residents rooms had been changed to PPE required with an outbreak in the facility within the last 14 days.
Review of the CDC guidance titled Preparing for COVID-19 in Nursing Homes, dated 11/20/2020, included:
Personal Protective Equipment (PPE):
-Perform and maintain an inventory of PPE in the facility.
-Make necessary PPE available in areas where resident care is provided.
-Consider designating staff responsible for stewarding those supplies and monitoring and providing just-in-time feedback promoting appropriate use by staff.
-Facilities should have supplies of facemask's, respirators (if available and the facility has a respiratory protection program with trained, medically cleared, and fit-tested HCP), gowns, gloves, and eye protection (i.e., face shield or goggles).
The CDC included these examples of high-contact resident care activities:
Dressing
Bathing/showering
Transferring
Providing hygiene
Changing linens
Changing briefs or assisting with toileting
Device care or use: central line, urinary catheter, feeding tube, tracheostomy/ventilator
Wound care: any skin opening requiring a dressing
On 4/27/21 at 10:40 A.M., the surveyor observed Certified Nursing Assistant (CNA) #7 enter Resident #63's room and close the door behind her. She had a face mask and eye protection donned. The surveyor knocked on the door and entered the room. CNA #7 was about to provide high contact care for the Resident without donning a gown and gloves. CNA #7 left the Resident's room to obtain a gown. CNA #7 had to walk behind the nurse's station and found two gowns hanging on the tub room door. When the surveyor asked CNA #7 about the availability of the gowns, CNA #7 said they bring the gowns up to the floor as soon as the laundry is done washing the gowns.
The surveyor observed that the two PPE carts on the South Unit did not have any yellow gowns stocked.
Unit Manager #2 and the IP were on the Unit at that time and were made aware CNA #7 did not don a gown before she provided high contact care for Resident # 63 and the gowns were not readily available for the staff to don.
4. The facility failed to ensure staff wore appropriate eye protection in resident areas.
Review of the infection prevention and control COVID-19 policy, updated on 4/26/21, indicated eye protection or face shield should be worn with all resident encounters and in all resident areas, including hallways.
a: On 4/22/21 at 8:41 A.M., the surveyor observed Certified Nursing Assistant (CNA) #2 on the North unit with her eye protection on the top of her head. CNA #2 was observed to enter and exit a resident room. She was then observed to approach Nurse #1 with the eye protection still on her head, there was no education provided by Nurse #1.
On 04/23/2 at 9:36 A.M., the surveyor observed CNA #2 walking around the North unit with her eye protection on the top of her head.
During an interview on 4/27/21 at 3:18 P.M., the Director of Nurses said CNA #2 tested positive for COVID-19 on 4/24/21.
b: On 4/22/21 at 3:10 P.M., the surveyor observed Unit Manager #1 and Nurse #5 at the nurse's station on the East unit, neither of them were wearing eye protection. There were two residents observed to be seated across the hall from the nurse's station at that time.
c: On 4/23/21 at 2:25 P.M., the surveyor observed CNA #3 on the North unit going from room to room to distribute coffee. CNA #3 had her eye protection on the top of her head. CNA #3 was observed to be across from two nurses who did not provide education on the proper use of eye protection.
d. During an observation and interview on 4/23/21 at 11:13 A.M., the surveyor observed CNA #5 remove her eye protection while at the South unit nurse's station. CNA #5 said she knew she was required to wear eye protection on the resident unit, but it was habit to remove the protection when not in a resident room.
5. For Resident # 26 the facility staff failed to ensure that infection control practices were followed as per facility policy while performing a treatment/dressing change to the Resident's pressure ulcer.
The facility policy/procedure for Dressings, Dry/Clean, dated as revised November 2018, included:
- Clean the bedside stand. Establish a clean field
- Place the clean equipment on the clean field. Arrange the supplies so they can be easily reached
- Tape a biohazard or plastic bag on the bedside stand or use a waste basket below the clean field
- Put on clean gloves. Loosen and remove soiled dressing
- Pull glove over dressing and discard.
- Wash and dry hands thoroughly.
- Put on clean gloves
- Assess wound
- Cleanse the wound with ordered cleanser
- If using gauze, use clean gauze for each cleansing stroke. Clean from the least contaminated area to the most contaminated area.
- Use dry gauze to pat the wound dry
On 4/28/21 at 7:45 A.M., the surveyor observed Nurse # 4 perform the dressing change for Resident # 26.
The physician's order for the treatment to the Resident's pressure ulcer indicated:
- Wash right buttocks wound with Normal Saline (NS) followed by Calcium Alginate (alginates absorbs wound exudates and form a gel-like covering over the wound, helping to maintain a moist wound healing environment, promote the healing process and minimize bleeding) and followed with a Foam dressing, Change dressing every day and as needed.
Resident #26 was in the bed, placed on her/his side. Nurse #4 had prepared the dressing supplies and the supplies were located on the overbed table.
The gauze had been directly placed on the overbed table along with a sealed bottle of Normal Saline. The border dressing was on the table, still in its sealed package and a small piece of calcium alginate had been prepared/ cut according to the size of the wound and was sitting on top of the sealed package.
Nurse #4 opened the NS and applied it to the gauze. Nurse #4 placed the clean gauze on the under pad/ bed protector on the Resident's bed She then removed the old dressing. She finished removing the old dressing and began to pick up the gauze which had been on the Resident's bed and was going to wash the area. At this time the surveyor asked Nurse #4 about placing the gauze on an area that had not been cleaned. Nurse #4 said to the the surveyor that the area was not considered clean and discarded the gauze inside her gloves and went to retrieve more gauze. Nurse #4 came back into the room and initiated the treatment again. Nurse #4 initially placed the gauze on the overbed table and then moved it on top of the sealed package. She then proceeded with the dressing change. Once finished, Nurse #4 was asked if she had cleaned the overbed table before she started the treatment. Nurse #4 said she had not cleaned the overbed table.
During an interview on 4/28/21 at 8:15 A.M., Nurse #4 said she had not established a clean field and should not have placed the gauze on the Resident's bed and overbed table as those areas were not considered a clean field. Nurse #4 said she had not performed the Resident's treatment according to the facility policy/procedure for performing a clean dressing change and had breached infection control standards by placing the gauze on areas that had not been cleaned.
6: a. On 4/21/21 at 8:51 A.M., the surveyor observed Nurse #1 at the medication cart. The nurse placed medication into a plastic sleeve. The surveyor observed Nurse #1 drop the plastic sleeve on the ground and medications fell out of the sleeve and on to the floor. The nurse picked up the medication and placed it back in the plastic sleeve. Nurse #1 was observed to take this same plastic sleeve, with the medications that fell on the floor, crush the medications and then add them to applesauce in a medication cup.
Nurse #1 was then observed to walk to the room of Resident #40, the surveyor followed. The nurse confirmed she was going to give the medications in the cup to Resident #40. Nurse #1 confirmed these were the same medications that had fallen on to the floor. The surveyor intervened by telling the nurse she could not administer medications that were on the floor, Nurse #1 replied, Oh, I can't?
b. On 4/22/21 at 9:42 A.M., the surveyor observed Nurse #1 drop a pill on top of the medication cart, pick the pill up with her bare hand and administer the pill to a resident.
During an interview on 4/22/21 at 10:04 A.M., Nurse #1 said it was a habit and she did not even realize she had picked up the pill with her bare hand.
7: On 4/21/21 at 12:16 P.M., the surveyor observed Resident #68 approach the ice bin used to store drinks on the South Unit. Resident #68 was observed to use his/her bare hand to remove ice from the bin and placed it in a cup for him/her to drink from. The surveyor interviewed the Resident and he/she said it was the only way he/she was able to get ice for drinks and often removed the ice with his/her bare hand.
On 04/22/21 at 04:38 P.M., the surveyor observed Resident #68 use his/her bare hand to scoop ice from an ice storage bucket containing drink containers on the South Unit and placed the ice his/her drinking cup while Nurse #8 observed the Resident scoop the ice. Nurse #8 did not intervene.
During an interview on 4/22/21 at 4:43 P.M., Nurse #8 said Resident #69 used his/her hands in the ice bin frequently and she tried to explain to the Resident in the past there was clean ice available but the Resident continued to take ice in this manner. Nurse #8 said she realized it was not a clean habit. 7. On 4/21/21 at 12:16 P.M., the surveyor observed Resident #68 approach the ice bin used to store drinks on the South Unit. Resident #68 was observed to use his/her bare hand to remove ice from the bin and placed it in a cup for him/her to drink from. The surveyor interviewed the Resident and he/she said it was the only way he/she was able to get ice for drinks and often removed the ice with his/her bare hand.
On 4/22/21 at 9:42 A.M., the surveyor observed Nurse #1 drop a pill on top of the medication cart, pick the pill up with her bare hand and administered the pill to a resident.
During an interview on 4/22/21 at 10:04 A.M., Nurse #1 said it was a habit and she did not even realize she had picked up the pill with her bare hand.
On 04/22/21 at 04:38 P.M., the surveyor observed Resident #68 use his/her bare hand to scoop ice from an ice storage bucket containing drink containers on the South Unit and placed the ice his/her drinking cup while Nurse #8 observed the Resident scoop the ice. Nurse #8 did not intervene.
During an interview on 4/22/21 at 4:43 P.M., Nurse #8 said Resident #69 used his/her hands in the ice bin frequently and she tried to explain to the Resident in the past there was clean ice available but the Resident continued to take ice in this manner. Nurse #8 said she realized it was not a clean habit and proceeded to remove the ice storage cart from the unit.
On 4/23/21 at 11:13 A.M., CNA #5 was observed to remove her eye protection while at the South unit nurses station. CNA #5 said she knew she was required to wear eye protection on the resident unit, but it was habit to remove the protection when not in a resident room.
On 4/28/21 at 10:01 A.M., the surveyor observed the South Unit tub room with a green type of coiled tubing in the tub, not protected by any type of packaging.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0886
(Tag F0886)
Could have caused harm · This affected most or all residents
Based on interview and policy review, the facility failed to ensure surveillance testing of all staff was implemented within 48 hours of a Covid-19 outbreak at the facility as required by the Centers ...
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Based on interview and policy review, the facility failed to ensure surveillance testing of all staff was implemented within 48 hours of a Covid-19 outbreak at the facility as required by the Centers for Medicare & Medicaid Services (CMS) and the facility's policy.
Findings include:
Review of the facility's policy titled Infection Prevention and Control-COVID-19 for Surveillance Testing and Outbreak Testing, dated as revised 4/26/21, included, but is not limited to:
- Long-term care facilities must conduct weekly testing of all staff
- If the staff testing results indicate a positive COVID-19 staff member(s), then the provider must conduct outbreak testing of all residents and staff to ensure there are no resident cases and to assist in proper cohorting of residents.
- Testing must take place as soon as possible and within 48 hours.
- Routine Testing (Replaces Surveillance testing)-Federal Guideline
- Test all staff based on county positivity rates
- Facilities are to monitor rates weekly
- Massachusetts-Testing based on county positivity rates:
- All Staff weekly if <5%
- All Staff twice a week if >10%
- Outbreak Testing:
- Federal regulation-test all staff and residents in response to an outbreak. An outbreak consists of a single new infection in staff or any nursing home onset infection in a resident. Staff and residents are to be tested every three to seven days until no positive cases for 14 days, excluding staff not working during the testing period or residents on a leave of absence during the testing period.
- State regulation-test all residents and staff with PCR test within 48 hours of initial positive result.
Test residents and staff every three days until no positive cases for 14 days.
Review of the Centers for Medicare and Medicaid Services (CMS) Interim Final Rule (IFC), CMS-3401-IFC, dated August 26, 2020, indicated the following:
- An outbreak is defined as a new COVID-19 infection in any healthcare personnel (HCP) or any nursing home-onset COVID-19 infection in a resident.
- In an outbreak investigation, rapid identification and isolation of new cases is critical in stopping further viral transmission.
- Upon identification of a single new case of COVID-19 infection in any staff or residents, all staff and residents should be tested, and all staff and residents that tested negative should be retested every three to seven days until testing identifies no new cases of COVID-19 infection among staff or residents for a period of at least 14 days since the most recent positive result.
On 4/26/21 at 7:00 A.M., the Administrator informed the surveyor that a facility staff member tested positive for COVID-19 over the weekend. The Administrator said the facility was notified of the confirmed infection for the staff member on 4/24/21 during regular surveillance testing.
During an interview on 4/26/21 at 7:49 A.M., the Administrator and the Infection Preventionist (IP) told the surveyor:
- All staff and residents were tested on Saturday, 4/24/21, with negative results and all staff and residents had testing done on Sunday, 4/25/21.
- The facility was now in outbreak testing, which would be performed every Monday, Wednesday and Friday.
During an interview on 4/28/21 at 11:00 A.M., the IP said the surveillance testing from 4/25/21 was negative, and she would continue the outbreak testing of all staff and residents. The surveyor asked the IP if all staff had been initially tested, and if not, had those staff members worked since the outbreak testing was initiated. The IP was unable to verify all staff on the schedule had been tested prior to starting their scheduled work assignment today (4/28/21).
On 4/28/21 at 2:00 P.M., the surveyor and the IP reviewed the testing results and cross referenced with the list of licensed employees who worked since the initial outbreak; three staff members were identified as not having been tested as per the outbreak procedure/protocol.
The surveyor requested the IP provide the surveyor with schedules for all departments. The IP provided the surveyor with her tracking list for testing. Review of the tracking form with the IP indicated:
- There were 22 staff members who had worked on/or after Sunday 4/25/21 and who had still not had initial testing as per facility procedures/protocols for outbreak testing.
- There were 41 staff members that were working on 4/28/21, and should have had been tested and were not.
During an interview on 4/28/21 at 2:30 P.M., the IP said the facility staff failed to implement surveillance testing requirements during the facility's Covid-19 outbreak, as required by Centers for Medicare & Medicaid Services (CMS) and the facility's policy.
MINOR
(C)
Minor Issue - procedural, no safety impact
Staffing Information
(Tag F0732)
Minor procedural issue · This affected most or all residents
Based on interview and observation, the facility failed to ensure that the staff posted the Nurse Staffing Data on a daily basis at the beginning of each shift as required.
Findings include:
On 4/21/...
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Based on interview and observation, the facility failed to ensure that the staff posted the Nurse Staffing Data on a daily basis at the beginning of each shift as required.
Findings include:
On 4/21/21 at 7:00 A.M., upon entering the main lobby of the facility, the surveyor was unable to locate the Nurse Staffing Data for 4/21/21.
During subsequent observations made upon entrance to the main lobby at 7:00 A.M., on 4/22/21, 4/23/21, 4/27/21, and 4/28/21, the surveyor was unable to locate the Nurse Staffing Data.
During an interview on 4/28/21 at 8:39 A.M., the Infection Preventionist said the Nurse Staffing Data was usually posted in a plastic type frame on the screening desk at the main door, but the frame broke at some point and needed to be replaced. She said Nurse Staffing Data was not posted at this time.
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
- "What changes have you made since the serious inspection findings?"
- "Why is there high staff turnover? How do you retain staff?"
- "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: 2 life-threatening violation(s), 4 harm violation(s), $114,868 in fines. Review inspection reports carefully.
- • 57 deficiencies on record, including 2 critical (life-threatening) violations. These warrant careful review before choosing this facility.
- • $114,868 in fines. Extremely high, among the most fined facilities in Massachusetts. Major compliance failures.
- • Grade F (0/100). Below average facility with significant concerns.
Bottom line: Trust Score of 0/100 indicates significant concerns. Thoroughly evaluate alternatives.
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About This Facility
What is Royal Norwell Nursing & Rehabilitation Center Llc's CMS Rating?
CMS assigns ROYAL NORWELL NURSING & REHABILITATION CENTER LLC 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 Royal Norwell Nursing & Rehabilitation Center Llc Staffed?
CMS rates ROYAL NORWELL NURSING & REHABILITATION CENTER LLC's staffing level at 3 out of 5 stars, which is average compared to other nursing homes. Staff turnover is 56%, which is 10 percentage points above the Massachusetts average of 46%. High turnover can affect care consistency as new staff learn residents' individual needs. RN turnover specifically is 69%, which is notably high. RNs provide skilled clinical oversight, so turnover in this role can affect medical care quality.
What Have Inspectors Found at Royal Norwell Nursing & Rehabilitation Center Llc?
State health inspectors documented 57 deficiencies at ROYAL NORWELL NURSING & REHABILITATION CENTER LLC during 2021 to 2025. These included: 2 Immediate Jeopardy (the most serious level, indicating potential for serious harm or death), 4 that caused actual resident harm, 49 with potential for harm, and 2 minor or isolated issues. Immediate Jeopardy findings are rare and represent the most serious regulatory concerns. They require immediate corrective action.
Who Owns and Operates Royal Norwell Nursing & Rehabilitation Center Llc?
ROYAL NORWELL NURSING & REHABILITATION CENTER LLC 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 ROYAL HEALTH GROUP, a chain that manages multiple nursing homes. With 86 certified beds and approximately 68 residents (about 79% occupancy), it is a smaller facility located in NORWELL, Massachusetts.
How Does Royal Norwell Nursing & Rehabilitation Center Llc Compare to Other Massachusetts Nursing Homes?
Compared to the 100 nursing homes in Massachusetts, ROYAL NORWELL NURSING & REHABILITATION CENTER LLC's overall rating (1 stars) is below the state average of 2.9, staff turnover (56%) 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 Royal Norwell Nursing & Rehabilitation Center Llc?
Based on this facility's data, families visiting should ask: "What changes have been made since the serious inspection findings, and how are you preventing similar issues?" "How do you ensure continuity of care given staff turnover, and what is your staff retention strategy?" "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?" These questions are particularly relevant given the facility's Immediate Jeopardy citations and the facility's high staff turnover rate.
Is Royal Norwell Nursing & Rehabilitation Center Llc Safe?
Based on CMS inspection data, ROYAL NORWELL NURSING & REHABILITATION CENTER LLC has documented safety concerns. Inspectors have issued 2 Immediate Jeopardy citations (the most serious violation level indicating risk of serious injury or death). The facility has a 1-star overall rating and ranks #100 of 100 nursing homes in Massachusetts. Families considering this facility should ask detailed questions about what corrective actions have been taken since these incidents.
Do Nurses at Royal Norwell Nursing & Rehabilitation Center Llc Stick Around?
Staff turnover at ROYAL NORWELL NURSING & REHABILITATION CENTER LLC is high. At 56%, the facility is 10 percentage points above the Massachusetts average of 46%. Registered Nurse turnover is particularly concerning at 69%. RNs handle complex medical decisions and coordinate care — frequent RN changes can directly impact care quality. High turnover means new staff may not know residents' individual needs, medications, or preferences. It can also be disorienting for residents, especially those with dementia who rely on familiar faces. Families should ask: What is causing the turnover? What retention programs are in place? How do you ensure care continuity during staff transitions?
Was Royal Norwell Nursing & Rehabilitation Center Llc Ever Fined?
ROYAL NORWELL NURSING & REHABILITATION CENTER LLC has been fined $114,868 across 2 penalty actions. This is 3.4x the Massachusetts average of $34,228. 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 Royal Norwell Nursing & Rehabilitation Center Llc on Any Federal Watch List?
ROYAL NORWELL NURSING & REHABILITATION CENTER LLC 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.