ALLIANCE HEALTH AT ROSEWOOD
Non profit - Corporation
135 Beds
ALLIANCE HEALTH & HUMAN SERVICES
Data: November 2025
Trust Grade
48/100
#130 of 338 in MA
Photo by Alliance Health at Rosewood
Photo by Alliance Health at Rosewood
Photo by Alliance Health at Rosewood
1 / 5 photos
Last Inspection: January 2025
Within standard 12-15 month inspection cycle. Federal law requires annual inspections.
Overview
Alliance Health at Rosewood has a Trust Grade of D, indicating below average performance with some significant concerns. They rank #130 out of 338 nursing homes in Massachusetts, placing them in the top half, and #20 out of 44 in Essex County, suggesting only one local facility is better. The facility is showing an improving trend, as issues decreased from 11 in 2024 to 9 in 2025. Staffing is average with a 3/5 rating and a turnover rate of 48%, which is close to the state average. However, they have good RN coverage, exceeding 86% of Massachusetts facilities, which is a positive aspect as RNs can catch issues that CNAs may overlook. There have been some serious incidents reported, including a medication error that led to a resident requiring hospitalization after receiving another resident's medication upon discharge. Additionally, a pressure injury developed on a resident due to a lack of proper assessments and communication with the physician. There were also sanitation concerns related to food storage and glove use, which could pose risks for residents. While there are strengths in RN coverage, the facility still has notable weaknesses that families should consider.
- Trust Score
- D
- In Massachusetts
- #130/338
- Safety Record
- Moderate
- Inspections
- Getting Better
- Staff Stability ⚠ Watch
- 48% turnover. Above average. Higher turnover means staff may not know residents' routines.
- Penalties ⚠ Watch
- $8,824 in fines. Higher than 82% of Massachusetts facilities, suggesting repeated 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
- 42 deficiencies on record. Higher than average. Multiple issues found across inspections.
48/100
Top 38%
Needs review
11 → 9 violations
★★★☆☆
3.0
Overall Rating
★★★☆☆
3.0
Staff Levels
★★★☆☆
3.0
Care Quality
★★★☆☆
3.0
Inspection Score
↔
Stable
2024: 11 issues
2025: 9 issues
The Good
-
Full Sprinkler Coverage · Fire safety systems throughout facility
-
No fines on record
Facility shows strength in fire safety.
The Bad
3-Star Overall Rating
Near Massachusetts average (2.9)
Meets federal standards, typical of most facilities
Staff Turnover: 48%
Near Massachusetts avg (46%)
Higher turnover may affect care consistency
Federal Fines: $8,824
Below median ($33,413)
Minor penalties assessed
Chain: ALLIANCE HEALTH & HUMAN SERVICES
Part of a multi-facility chain
Ask about local staffing decisions and management
The Ugly 42 deficiencies on record
2 actual harm
Jan 2025
9 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Report Alleged Abuse
(Tag F0609)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to report an allegation of abuse for one Resident (#101) out of a tota...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to report an allegation of abuse for one Resident (#101) out of a total of 25 sampled Residents.
Findings include:
Review of the Abuse Prohibition Policy dated 10/11/22 indicated: All alleged violations of incidents included within the definition of abuses, mistreatment, neglect, involuntary seclusion or misappropriation of resident property shall be reported to the Department of Public Health, upon receipt of the facility's report of basic findings. The facility must then begin an internal investigation of the incident. The Executive Director will be included in the immediate notification of the alleged incident.
Resident #101 was admitted to the facility in February 2024 with diagnoses including muscle weakness and aftercare following joint replacement surgery.
Review of the Minimum Data Set Assessment (MDS) dated [DATE] indicated Resident #101 was cognitively intact evidenced by a score of 15 out of a possible 15 on the Brief Interview for Mental Status exam.
During an interview on 1/21/25 at 8:06 A.M., Resident #101 said that yesterday (1/20/25) a Certified Nursing Assistant (CNA) yelled at him/her at 2:30 p.m. after he/she rang his/her call light. Resident #101 said that the CNA came into his/her room and asked him/her why he/she was always calling for help and that the CNA was the only one working, was diabetic and needed to eat something and was supposed to be on break. Resident #101 said that it made him/her upset and he/she shouldn't be afraid to use his/her call light. Resident #101 said he told a nurse about it this morning, but could not remember who it was.
During an interview on 1/21/25 at approximately 1:00 P.M., Unit Manager #1 said she was not aware of Resident #101's report of being yelled at and she would take care of it.
During interviews on 1/22/25 at 7:39 A.M., at 1:18 P.M., the Administrator said she had just learned of Resident #101's allegation and a report was being made to the state agency. The Administrator said that Unit Manager #1 was given education about the two hour requirement for allegations of abuse.
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
Based on observations, interviews and record review, the facility failed to ensure staff implemented a comprehensive person-centered care plan for one Resident (#25), out of a total sample of 25 resid...
Read full inspector narrative →
Based on observations, interviews and record review, the facility failed to ensure staff implemented a comprehensive person-centered care plan for one Resident (#25), out of a total sample of 25 residents. Specifically, for Resident #25:
a.) The facility failed to ensure nursing implemented a care plan intervention for use of a motion detector alarm for fall prevention.
b.) The facility failed to ensure nursing implemented a care plan intervention for seizure pads.
Findings include:
Resident #25 was admitted to the facility in October 2024 with diagnoses including epilepsy (a seizure disorder), vascular dementia with agitation, and restlessness.
Review of the most recent Minimum Data Set (MDS) assessment, dated 10/30/24, indicated Resident #25 had severe cognitive impairment as evidenced by a Brief Interview for Mental Status (BIMS) score of 3 out of 15.
a.) Review of the facility policy titled 'Fall Management Program', revised 10/13/22, indicated:
- Residents identified at high risk for falls (score of 10 or higher of the assessment) will have an appropriate fall prevention care plan developed, implemented, and revised as necessary.
Review of Resident #25 assessment titled 'Alliance Fall Risk', dated 12/13/24, indicated the Resident was at high risk for falls as evidenced by a score of 14.
Review of Resident #25's active physicians orders, initiated 10/24/24, indicated:
- S/P (status post) FALL MONITOR, every shift, initiated 11/8/24.
- Fall: Initiate Fall Prevention Program, every shift, initiated 12/11/24.
Review of Resident #25's plan of care related to falls, revised 12/26/2024, indicated:
- Use a motion detector when Resident #25 is in the room.
On 1/21/25 at 1:02 P.M., 1/21/25 at 2:09 P.M., 1/21/25 at 4:22 P.M., 1/22/25 at 6:54 A.M., and 1/22/25 at 7:55 A.M, the surveyor observed Resident #25 alone in his/her room without any staff within view. The motion detector alarm power switch was in the 'off' position. The surveyor waved a hand in front of the motion detector alarm sensor multiple times, and it did not activate any alarm sound.
During an interview on 1/22/25 at 7:59 A.M., Certified Nurse Assistant (CNA) #1 said CNAs are expected to check the care plan and ensure interventions, such as motion detector alarms, are put into place. CNA #1 said she was unaware Resident #25 required motion detector alarms and never turned it on. CNA #1 observed the motion detector alarm in Resident #25's room with the surveyor and confirmed it was not on. At this time Resident #25 was in the bed in his/her room.
During an interview on 1/22/25 at 8:03 A.M., Nurse #4 said care plan interventions, such as motion detector alarms, should always be implemented as listed in the active care plan. Nurse #4 said she was unaware Resident #25 required motion detector alarms and never turned it on. Nurse #4 reviewed Resident #25's active care plan and said based on the care plan indicating to use a motion detector when Resident #25 is in the room, the motion detector should be turned on and used. Nurse #4 observed the motion detector alarm in Resident #25's room with the surveyor and confirmed it was not on. Nurse #4 turned it on, and said it should have been turned on because Resident #25 was in his/her room alone.
During an interview on 1/23/25 at 7:37 A.M., the Assistant Director of Nursing (ADON) said all care plan interventions listed in a resident's care plan should be implemented. The ADON said Resident #25 should have had the motion detector turned on when in his/her room because it was an intervention listed on his/her active care plan.
b.) Review of the facility policy titled 'Seizure Precautions', revised 8/5/23, indicated:
- Every resident/patient assessed to be at risk for seizures will have protective measures taken to ensure their safety.
- Formulate plan of care with interventions focused on prevention of injury and airway maintenance.
- Should a resident have a seizure while in bed, pad side rails with pads or bath blankets.
Review of Resident #25's active physicians orders, initiated 10/24/24, indicated:
-Keppra (a medication used to control seizures) 1250 mg, twice daily.
Review of Resident #25's plan of care related his/her seizure disorder, revised 10/24/24, indicated:
- PROBLEM: Resident has a seizure disorder.
- GOAL: Resident will not injure self secondary to seizure disorder.
- APPROACH: Pad siderails.
On 1/21/25 at 1:02 P.M., 1/21/25 at 2:09 P.M., 1/21/25 at 4:22 P.M., 1/22/25 at 6:54 A.M., and 1/22/25 at 7:55 A.M., the surveyor observed Resident #25 in bed without seizure pads on bilateral side rails.
During an interview on 1/22/25 at 7:59 A.M., CNA #1 said CNAs are expected to check the care plan and ensure interventions, such as seizure pads on side rails, are put into place. CNA #1 said she was unaware Resident #25 required seizure pads on his/her side rails, and they never applied them. CNA #1 observed Resident #25's room with the surveyor and said there were no seizure pads located anywhere in the Resident's room. At this time Resident #25 was in the bed in his/her room with unpadded bilateral side rails.
During an interview on 1/22/25 at 8:03 A.M., Nurse #4 said Resident #25 was on seizure precautions because he/she has a seizure disorder. Nurse #4 said care plan interventions, such as seizure pads on side rails, should always be implemented as listed in the active care plan. Nurse #4 said she was unaware Resident #25 required seizure pads on his/her side rails. Nurse #4 reviewed Resident #25's active care plan and said based on the care plan indicating to pad siderails, the side rails should have seizure pads but did not. Nurse #4 observed Resident #25's room with the surveyor and said there were no seizure pads located anywhere in the Resident's room.
During an interview on 1/23/25 at 7:37 A.M., the Assistant Director of Nursing (ADON) said all care plan interventions listed in a resident's care plan should be implemented. The ADON said Resident #25 should have had seizure pads on his/her side rails because it was an intervention listed on his/her active care plan.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
ADL Care
(Tag F0677)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews, the facility failed to provide assistance with showers for one Resident (#107) out of a ...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews, the facility failed to provide assistance with showers for one Resident (#107) out of a total sample of 25 residents.
Findings include:
Review of the facility policy titled, Activities of Daily Living, dated 1/10/23, indicated the following:
-A program of activities of daily living (ADL) is provided to residents by the following method: the ability of each resident to meet the demands of daily living is assessed by a licensed nurse and/or members of the interdisciplinary team. A program of assistance and instruction in ADL skills is implemented. Assistive devices and adaptive equipment are provided by occupational therapy services. Education is provided to resident and family.
-Purpose: To prevent disability and return residents to a maximum level of independence.
-Process: 1.6 Frequent showers or baths are scheduled, and assistance is provided when required.
Resident #107 was admitted to the facility in September 2024 with diagnoses including macular degeneration.
Review of Resident #107's most recent Minimum Data Set (MDS) dated [DATE], indicated the Resident had a Brief Interview for Mental Status (BIMS) score of 15 out of a possible 15, indicating he/she is cognitively intact. The MDS also indicated Resident #107 required assistance from staff for bathing tasks.
During an interview on 1/21/25 at 8:38 A.M., Resident #107 said he/she is legally blind and needs assistance with bathing tasks. Resident #107 says he/she had not taken a shower in a long time and would love one because he/she feels more clean when given a shower.
Review of Resident #107's Activity of Daily Living (ADL) care plan last revised 1/15/25, indicated the following:
-Bathing: Assistance level required is substantial maximum assist (assistance) of one.
Review of the shower list on the unit indicated Resident #107 is scheduled for a weekly shower on Tuesdays during the 7:00 A.M. and 3:00 P.M. shift.
Review of the ADL documentation for the months of December 2024 and January 2025 indicated Resident #107 has been given only one shower in two months.
Review of the nursing documentation failed to indicate Resident #107 refused showers in the months of December 2024 and January 2025.
During a follow-up interview on 1/23/25 at 7:53 A.M., Resident #107 said he/she did not receive a shower this week on Tuesday and would really like weekly showers.
During an interview on 1/23/25 at 7:55 A.M., Certified Nursing Assistants (CNA) #3 and #4 said all residents are scheduled for at least one weekly shower and can have a shower whenever they request one. CNAs #3 and #4 said Resident #107 does not refuse care and requires assistance with all bathing tasks. CNA #3 and #4 could not remember the last time Resident #107 was given a shower.
During an interview on 1/23/25 at 8:37 A.M., Unit Manager #3 said all residents are provided with weekly showers and if a resident were to refuse a shower the nursing staff would document the refusal. Unit Manager #3 was unable to say the last time Resident #107 was provided with a shower.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Incontinence Care
(Tag F0690)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record review, the facility failed maintain professional standards in the managing and car...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record review, the facility failed maintain professional standards in the managing and caring for urinary catheter devices for two Residents (#105 and #71) out of a total sample of 25 residents. Specifically,
1.) For Resident #105, the facility failed to provide the appropriate care and services to prevent urinary tract infections to the extent possible. The facility failed to ensure the Resident's urinary catheter drainage system, including the tubing, was not placed directly on the floor.
2.) For Resident #71, the facility failed to ensure physicians orders and care plans related to the use of a catheter were implemented.
Findings include:
Review of facility policy titled 'Catheter Care of Indwelling Urinary', revised 11/5/23, indicated:
- Always keep the drainage bag below the level of the bladder and off the floor.
1.) Resident #105 was admitted to the facility in October 2024 with diagnoses including obstructive uropathy (a disorder of the urinary tract that occurs due to obstructed urinary flow) and vascular dementia.
Review of the most recent Minimum Data Set (MDS) assessment, dated 1/13/25, indicated that Resident #105 had severe cognitive impairment as evidenced by a Brief Interview for Mental Status (BIMS) score of 3 out of 15. This MDS also indicated Resident #105 had an indwelling catheter and was dependent on staff for all bed mobility, toileting, and transfer tasks.
Review of Resident #105's physician's order, initiated 11/1/24, indicated:
- Foley Catheter Care, every shift.
Review of Resident #105's plan of care related to his/her indwelling catheter, revised 11/11/24, indicated:
- Do not allow tubing or any part of the drainage system to touch the floor.
On 1/21/25 at 8:12 A.M., the surveyor observed Resident #105 in bed with his/her urinary catheter drainage bag attached to the bed frame by a dignity bag cover. This entire urinary catheter drainage system was laying on its side directly touching the floor. The tubing was also directly laying on the floor. The urinary catheter drainage bag was half full of cloudy, yellow urine. Resident #41 was unable to answer questions about his/her urinary catheter.
On 1/21/25 at 2:07 P.M., the surveyor observed Resident #105 in bed with his/her urinary catheter drainage bag attached to the bed frame by a dignity bag cover. This entire urinary catheter drainage system was laying on its side directly touching the floor. The tubing was also directly laying on the floor.
During an interview on 2:10 P.M., Resident #105's family member said they visit almost every day, and they are concerned Resident #105 has a urinary tract infection. Resident #105's family member said the urinary catheter drainage system, including the tubing, is almost always directly touching the floor. Resident #105's family member said Resident #105 is unable to adjust the height of the bed or reach the urinary catheter drainage bag on the bed frame without assistance.
On 1/23/25 at 7:19 A.M., Unit Manager #1 and Certified Nurse Assistant (CNA) #2 observed Resident #105's urinary catheter drainage bag with the surveyor. Resident #105 was in bed with his/her urinary catheter drainage bag attached to the bed frame by a dignity bag cover and was directly touching the floor. They said the dignity bag straps were not adjusted so urinary catheter drainage system was directly touching the floor but should not be. They said the dignity bag is part of the urinary catheter drainage system and should never touch the floor.
During a follow-up interview on 1/23/25 at 7:25 A.M., Unit Manager #1 said Resident #105 was unable to unable to adjust the height of the bed and was dependent on staff for urinary catheter care.
During a follow-up interview on 1/23/25 at 7:30 A.M., CNA #2 said CNAs are expected to round shiftly and also throughout the shift to check on Resident #105's urinary catheter drainage system. CNA #2 said this includes checking to make sure it was elevated off the floor. CNA #2 said if it is ever noted to be touching the floor, CNAs are expected to elevate it off the floor.
During an interview on 1/23/25 at 7:37 A.M., the Assistant Director of Nursing (ADON) said the urinary catheter drainage system should never be directly touching the floor, including the dignity bag cover. The ADON said she would expect the straps to be adjusted to ensure the entire urinary catheter drainage system is elevated off the floor.
2.) Resident # 71 was initially admitted to the facility in December 2024 with diagnoses including sepsis, pneumonia, and diabetes.
Review of the Minimum Data Set Assessment (MDS) 12/19/24 indicated Resident #71 scored 14 out of a possible 15 on the Brief Interview for Mental Status exam (MDS) indicating intact cognition. The MDS also indicated Resident #71 requires assistance toileting and had occasional urinary incontinence.
On 1/21/25 at 8:09 A.M., the surveyor observed Resident #71 resting in bed with a catheter bag hanging off the side of the bed.
Review of Resident #71's physician's orders, dated 1/21/25, failed to indicate any orders in place regarding the use or care of a catheter.
Review of Resident #71's care plans, dated 1/16/25, indicated:
Urinary Incontinence: Interventions: Apply moisture barrier to skin. Check for incontinent episodes at least every two hours. Ensure adequate bowel elimination. Provide incontinence care after each incontinent episode. Report any signs of skin breakdown. Use brief when resident in bed. Use brief when resident is out of bed. Weekly body audit.
ADL's (activities of daily living) Functional Status/ Rehabilitation Potential. Interventions: Bladder: Specify level of function: occasionally incontinent. Toileting: assistance level required: substantial maximum assist of one.
Resident #71's care plans failed to indicate any plan for use or care of a catheter.
Review of Resident #71's hospital Discharge summary, dated [DATE], indicated Foley placed for acute urinary retention. Failed voiding trial and Foley reinserted on 1/15/25.
Review of Resident #71's nursing progress note, dated 1/16/25, indicated Foley catheter noted to be draining clear yellow urine to collection bag.
Review of physician's progress note, dated 1/21/25, indicated:
Urinary Retention.
Foley placed for acute urinary retention.
Failed voiding trial and Foley reinserted on 1/15/25.
During an interview on 1/22/25 at 10:38 A.M., Unit Manager #2 said that Resident #71 had returned from the hospital with a catheter and that she would expect a resident with a catheter to have physician orders and a plan of care in place to care for the catheter.
During an interview on 1/23/24 at 7:58 A.M., the Director of Nursing said that a Resident with catheter should have physician orders and care plan in place for care, management, and monitoring of the catheter.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Medication Errors
(Tag F0758)
Could have caused harm · This affected 1 resident
Based on record review and interviews, the facility failed to ensure the drug regimen for residents was free of unnecessary psychotropic medications one Resident (#1) out of a total sample of 25 resid...
Read full inspector narrative →
Based on record review and interviews, the facility failed to ensure the drug regimen for residents was free of unnecessary psychotropic medications one Resident (#1) out of a total sample of 25 residents. Specifically, the facility failed to ensure a PRN (as needed) order for alprazolam (a psychotropic medication) was limited to 14 days, when first ordered on 11/6/24, and failed to include a duration for it's use for Resident #1.
Findings include:
Review of the facility policy titled 'Psychotropic Medication Management', revised 8/5/23, indicated:
- Psychoactive medication management will include behavioral interventions, gradual dose reduction attempts, and adequate monitoring that complies with Federal and State guidelines.
- PRN orders for psychotropic drugs are limited to 14 days (except as noted below) if the prescribing MD (physician) or practitioner believes it is appropriate for the PRN order to extend beyond 14 days. The MD will document his/her rational in the resident's medical record and indicate the duration for the PRN order.
Resident #1 was admitted to the facility in November 2024 with diagnoses including generalized anxiety disorder.
Review of the most recent Minimum Data Set (MDS) assessment, dated 11/12/24, indicated that Resident #1 was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) score of 15 out of 15. This MDS indicated Resident #1 received antianxiety medication.
Review of Resident #1's physician's order, initiated 11/6/24, indicated:
- Alprazolam 0.5 mg (milligram), take one tablet by mouth two times a day as needed for anxiety, without any stop date.
Review of Resident #1's January 2025 Medication Administration Record (MAR) indicated the Resident received a PRN dose of alprazolam on 1/1/25, 1/3/25, 1/5/25, 1/9/25, 1/11/25, 1/12/25, 1/14/25, 1/16/25, and 1/20/25.
Review of the form titled 'Consultant Pharmacist Recommendation to Prescriber', dated 12/17/24, indicated:
- Resident is receiving the following PRN psychotropic medication. Please note these medications are required to be re-evaluated after 14 days. If therapy is to continue, please note medical justification for continued use in Progress Note and specify the # of days the PRN order is to continue.
- Alprazolam.
- Physician/Prescriber Response: Continue Alprazolam, signed and dated 12/19/24.
Review of Resident #1's medical record failed to indicate any stop date, medical justification for continued use, or any other re-evaluation for the use of as needed (PRN) alprazolam since the Resident's admission to the facility.
During an interview on 1/21/25 at 1:09 P.M., Unit Manager #1 said PRN psychotropic medication, including alprazolam, should be limited to 14 days when initially ordered and must be re-evaluated by the physician for continued use at that time. Unit Manager #1 said Resident #1's alprazolam was initially ordered on 11/6/24 without any stop date or re-evaluation date but should have.
During an interview on 1/23/25 at 7:37 A.M., the Assistant Director of Nursing (ADON) said all PRN psychotropic medications need to have a stop date. The ADON said any PRN psychotropic medication should be limited to 14 days when initially ordered and must be re-evaluated by the physician for continued use at that time. The ADON said after the initial 14 day physician re-evaluation date, the physician may extend it for a longer amount of time, but still requires a stop date. The ADON said the duration of Resident #1's PRN alprazolam should have included a stop date for re-evaluation, with medical justification for continued use documented, but did not.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Medical Records
(Tag F0842)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews, the facility failed to complete daily documentation for one Resident (#107) out of a tot...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews, the facility failed to complete daily documentation for one Resident (#107) out of a total sample of 25 residents.
Findings include:
Resident #107 was admitted to the facility in September 2024 with diagnoses including macular degeneration.
Review of Resident #107's most recent Minimum Data Set (MDS) dated [DATE], indicated the Resident had a Brief Interview for Mental Status (BIMS) score of 15 out of a possible 15, indicating he/she is cognitively intact. The MDS also indicated Resident #107 required assistance from staff for bathing tasks.
Review of the ADL documentation for the month of December 2024 indicated the following missing documentation:
-60 out of 93 grooming/shower opportunities for documentation were missing.
-60 out of 93 dressing/undressing opportunities for documentation were missing.
-58 out of 93 bladder care opportunities for documentation were missing.
-58 out of 93 bladder care opportunities for documentation were missing.
-7 out of 93 for feeding opportunities for documentation were missing.
-7 out of 93 for toileting, sit-lying opportunities for documentation were missing.
-6 out of 93 for sit to stand opportunities for documentation were missing.
-60 out of 93 chair to bed transfer opportunities for documentation were missing.
-60 out of 93 for toilet transfer opportunities for documentation were missing.
Review of the ADL documentation for the month of January 2025 indicated the following missing documentation:
-37 out of 63 grooming/shower opportunities for documentation were missing.
-37 out of 63 for dressing/undressing opportunities for documentation were missing.
-37 out of 63 for sit-lying opportunities for documentation were missing.
-37 out of 63 for sit to stand opportunities for documentation were missing.
-37 out of 63 chair to bed opportunities for documentation were missing.
-37 out of 63 for toilet transfers opportunities for documentation were missing.
-37 out of 63 bladder care opportunities for documentation were missing.
-37 out of 63 bladder care opportunities for documentation were missing.
-37 out of 63 for feeding opportunities for documentation were missing.
-37 out of 63 for toileting opportunities for documentation were missing.
During an interview on 1/23/25 at 7:55 A.M., Certified Nursing Assistants (CNA) #3 and #4 said all care provided should be documented on all shifts.
During an interview on 1/23/25 at 8:37 A.M., Unit Manager #3 said all care provided should be documented on all shifts. Unit Manager #3 said there was recent education provided to the staff about the need to document on all shifts.
During an interview on 1/23/25 at 10:02 A.M., the Assistant Director of Nursing said the facility is using new flow sheets and have done education with staff about needing to document care provided on all shifts.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0658
(Tag F0658)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview, the facility failed to implement physician's orders related to wound care for...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview, the facility failed to implement physician's orders related to wound care for one Resident (#64) out of a total of 25 sampled Residents. Specifically, the facility failed to implement would treatments as recommended by the Wound Physician and Wound Clinic.
Findings include:
Review of the Massachusetts Board of Registration in Nursing Advisory Ruling on Nursing Practice, dated as revised April 11, 2018, indicated the following: Nurse's Responsibility and Accountability: Licensed nurses accept, verify, transcribe, and implement orders from duly authorized prescriber that are received by a variety of methods (i.e., written, verbal/telephone, standing orders/protocols, pre-printed order sets, electronic) in emergent and non-emergent situations. Licensed nurses in a management role must ensure an infrastructure is in place, consistent with current standards of care, to minimize error.
Review of the facility's Skin Management Program, dated 6/13/19 indicated:
Purpose: To minimize the development of any type of ulcers and other skin issues through systematic and regular inspection of the resident's skin, and to ensure early detection and intervention for all skin problems.
Policy: 2. Residents will undergo a weekly body check by the licensed nurse. The facility will utilize the weekly body check form in the EHR (electronic health record). 6. If skin breakdown is identified, the physician will be notified, and a treatment will be obtained. 14. The Licensed Nurse responsible for the treatments on each unit will observe each ulcer in conjunction with treatment times and document the observation of the ulcer and or surrounding tissue on the Treatment Sheet in the EHR.
Resident #64 was admitted to the facility in October 2023 with diagnoses including cancer and cerebrovascular accident.
Review of the Minimum Data Set Assessment (MDS) dated [DATE] indicated Resident #64 was cognitively intact evidenced by a score of 15 out of a possible 15 on the Brief Interview for Mental Status (BIMS) exam. The MDS also indicated Resident #64 required physical assistance for dressing and bathing and utilized a catheter.
During interviews on 1/21/25 at 9:24 A.M., and 1/23/25 at 8:34 A.M., Resident #64 said that he/she has a wound on his/her leg and staff have been taking care of it. Resident #64 said he/she now goes out to the wound clinic instead of seeing the in-house Wound Physician, and that they seem to be more efficient. Resident #64 said it has taken a long time for his/her wound to heal and it still feels sore.
Review of Resident #64's Clinical Care Plan indicated:
Problem: Resident has a non-pressure wound requiring treatment, initiated 8/15/24
Goal: Resident wound will heal without complications (infection, hemorrhage, dehiscence, etc)
Approach: Obtain wound MD consult as indicated. Follow recommendations as directed. Record the amount, type, consistency, color and odor of drainage from the wound. Record the location, size (length, width and depth) color and presence/absence of granulation tissue and epithelization of wound.
Review of the Wound Physician's notes dated 8/6/24, 8/13/24 and 8/20/24 indicated:
Non-pressure wound of the right upper lateral leg. Etiology: Trauma/Injury. Dressing treatment plan: Dermablue foam (a highly absorbent vertically-wicking foam primary dressing embedded with three antimicrobials) apply every two days, cut to fit. Gauze island with bdr (border) apply every two days.
Review of the August 2024 Treatment Administration Record (TAR) indicated:
To right upper lateral leg non-pressure wound: normal saline wash, skin prep to wound edges, Dermablue to wound bed cut to fit and cover with allevyn (an alginate dressing utilized for absorbing drainage) foam every two days: Once A Day on Sun, Mon, Thu. (Active 8/3/2024 through 10/2/2024)
The wound treatments included the use of allevyn which was not indicated by the Wound Physician and were not completed every two days per the Wound Physician.
Review of the Wound Physician Notes dated 8/27/24 and 9/3/24 indicated: Non-pressure wound of the right upper lateral leg. Etiology: Trauma/Injury Dressing treatment plan: Alginate rope (a dressing used to absorb fluid and prevent contamination) apply once daily, Mupirocin topical 2% (a topical ointment used for infections) apply once daily, Superabsorbent gelling fiber (wound covers that help manage drainage and removal of dead, damaged and infected tissue from the wound), apply once daily.
Review of the August 2024 and September 2024 TAR's indicated: To right upper lateral leg non-pressure wound: normal saline wash, skin prep to wound edges, dermablue to wound bed cut to fit and cover with allevyn foam every two days: Once A Day on Sun, Mon, Thu. (Active 8/3/2024 through 10/02/2024.)
The treatment orders failed to include the use of alginate rope, Mupirocin 2%, Superabsorbent gel fiber, and failed to occur daily per the Wound Physician.
Review of Nurse Practitioner #1's note, dated 9/10/24, indicated: Continues with alginate dressing to wound.We will continue with the recommended dressing, monitor for s/sx (signs and symptoms) of infection.He/She will continue to be followed by wound specialist.
Review of the Wound Physician's notes dated 9/10/24 and 9/17/24 indicated: Non-pressure wound of the right upper lateral leg. Etiology: Trauma/Injury: Dressing treatment plan: Dermabluefoam apply every two days, Superabsorbent gelling fiber every two days.
Review of the September 2024 TAR indicated: To right upper lateral leg non-pressure wound: normal saline wash, skin prep to wound edges, dermablue to wound bed cut to fit and cover with allevyn foam every two days: Once A Day on Sun, Mon, Thu. (8/3/2024 - 10/02/2024)
Review of the hospital Discharge summary dated [DATE] indicated Resident #64 had been hospitalized on [DATE] and recommendations upon discharged included the use of a wound vac (also referred to as negative pressure wound therapy, a method of decreasing air pressure around a wound to assist healing) and for follow up at the wound clinic.
Review of the Wound Clinic Note dated 10/31/24 indicated: Wound injury: right lateral leg.
Assessment and plan: cleanse wounds with normal saline. Discontinue wound vac. Medihoney to lateral leg wound, cover with gauze and gauze roll, change three times per week or as needed for increased drainage.
Review of the November 2024 TAR indicated there were no active treatments in place for Resident right leg wound from 10/31/24 through 11/13/24.
During an interview on 1/22/25 at 10:06 A.M., Nurse Practitioner (NP) #1 said that when the Wound Physician makes recommendations, they are communicated to team and then approved by the attending. Nurse Practitioner #1 said that she could not recall a time when she had declined a treatment recommendation made by the Wound Physician. Nurse Practitioner #1 said that Resident #64's wound was being followed by the Wound Physician and the Resident now goes to the Wound Clinic. Nurse Practitioner #1 said she was not aware that Resident #64's treatment orders did not match the orders indicated by the Wound Physician. Nurse Practitioner #1 said that at that time, there had been a different and new Unit Manager who may not have known the process for reviewing orders or inputting them.
During an interview on 1/22/25 at 2:21 P.M., the Wound Physician said that when he would round at the facility staff would usually round with him and the treatments were implemented after his notes were uploaded. The Wound Physician said that he was not aware that Resident #64 was not receiving the treatments he indicated during his visits.
During an interview on 1/23/25 at 9:36 A.M., the Assistant Director of Nursing (ADON) said that the previous Director of Nursing would round with the Wound Physician, would inform the Nurse Practitioner of the orders and input orders into the record. The ADON said that if the NP does not agree with the orders, it should be documented. The ADON said that other staff would round with the Wound Physician and the orders would be communicated in his report. The ADON was not aware that Resident #64's treatment orders were not implemented as indicated by the wound physician or the wound clinic and that staff were expected to implement the orders after they had been reviewed by the provider.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0804
(Tag F0804)
Could have caused harm · This affected multiple residents
Based on observation and interviews, the facility failed to serve food that was palatable, and at a safe and appetizing temperature, on three out of three units.
Findings include:
During the initial t...
Read full inspector narrative →
Based on observation and interviews, the facility failed to serve food that was palatable, and at a safe and appetizing temperature, on three out of three units.
Findings include:
During the initial tour of the facility on 1/21/25 the surveyors met with the residents and the following concerns were expressed:
- Seven residents on the first floor said that the food was often served cold and tasted bad.
- One Resident on the second floor said the quality of the food was terrible and that the food was high in sodium.
- Five residents on the first floor said that the food was often cold and tasted bad.
During the resident group meeting on 1/22/25 at 10:31 A.M. a Resident said the food was served cold.
On 1/23/25 at 12:30 P.M., the 3rd floor food truck arrived to the resident care unit. After all resident trays were served the surveyor received the test tray at 12:38 P.M., and the following was recorded and observed:
- Meatballs were 132.8 degrees Fahrenheit and tasted lukewarm not hot; the meatballs had good flavor.
- Pasta was 137.7 degrees Fahrenheit and tasted lukewarm not hot; the pasta had a metallic flavor and was not palatable.
-Green beans were 116 degrees Fahrenheit and tasted cool not hot; the green beans were not palatable.
-Soup was 115 degrees Fahrenheit and tasted cool not hot; the soup was not palatable.
-Garlic Bread was 104 degrees Fahrenheit and tasted warm.
-Raspberry Sherbert was 25 degrees Fahrenheit and tasted cold.
-Milk was 38 degrees Fahrenheit and tasted cold.
On 1/23/25 at 1:29 P.M., the 2nd floor food truck arrived to the resident care unit. After all resident trays were served the surveyor received the test tray at 1:42 P.M., and the following was recorded and observed:
- Meatballs were 124.4 degrees Fahrenheit and tasted warm not hot, the meatballs had good flavor.
- Pasta was 124.7 degrees Fahrenheit and tasted warm not hot.
-Garlic bread was 123.1 degrees Fahrenheit and had a spongy texture.
-Green beans were 97.6 degrees Fahrenheit and tasted warm not hot.
-Soup was 137.8 degrees Fahrenheit and tasted warm not hot.
-Raspberry Sherbert was 22.2 degrees Fahrenheit but was melting.
On 1/23/25 at 1:29 P.M., the 1st floor food truck arrived to the resident care unit. After all resident trays were served the surveyor received the test tray at 1:42 P.M., and the following was recorded and observed:
- Shrimp was 125 degrees Fahrenheit and tasted warm not hot, the texture of the shrimp was chewy consistent with overcooking.
- Pasta was 122.5 degrees Fahrenheit and tasted lukewarm not hot, the pasta was oily.
-Garlic bread was 112.2 degrees Fahrenheit and tasted lukewarm, the texture was soggy.
-Green beans and carrots were 117 degrees Fahrenheit and tasted lukewarm not hot.
-Soup was 131.8 degrees Fahrenheit and tasted warm but was not palatable; the soup had an unpleasantly thick texture and a bitter flavor.
-Raspberry Sherbert was 23.4 degrees Fahrenheit but was melting.
-Cranberry Juice was 45 degrees Fahrenheit and tasted cold.
Review of the Tray Line Check, dated 1/14/2025, indicated that a test tray was conducted, and that the entrée and vegetable temperatures at time of service were 130 degrees Fahrenheit.
During an interview on 1/22/25 at 3:46 P.M., the Registered Dietitian (RD) said that she would expect hot food to be, at a minimum, 135 degrees Fahrenheit when it arrives to a resident; the RD said she would expect certain foods, such as soups, to be much hotter than 135 degrees Fahrenheit. The Food Service Director (FSD) said it would be the goal for residents to receive hot food around 160 degrees Fahrenheit. The RD said the temperature of the food received by the surveyors was lower than what she would expect.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected multiple residents
Based on observation, interview, and policy review, the facility failed to ensure that infection control and prevention measures were followed during preparation of medication for administration. Spec...
Read full inspector narrative →
Based on observation, interview, and policy review, the facility failed to ensure that infection control and prevention measures were followed during preparation of medication for administration. Specifically,
1.) Nurse #2 contaminated resident medications by touching pills with her bare hand.
2.) Nurse #3 stored an open, coffee cup in the medication cart with bottles of medications directly touching all sides of the cup.
Findings include:
Review of the facility policy titled 'Medication Administration - General Guidelines', revised 2024, indicated:
- Handwashing and Hand Sanitization: The person administering medications adheres to good hand hygiene, which includes washing hands thoroughly: prior to handling any medication.
- Hands are washed with soap and water or alcohol gel [and examination gloves worn] prior to handling tablets and examination gloves must be worn to prevent touching of tablets during the process.
1.) On 1/22/25 at 9:43 A.M., the surveyor observed Nurse #2 prepare medication for Resident #79 on the first floor side a medication cart. The following observations were made by the surveyor:
- Nurse #2 touched multiple medication cards, medication bottles, laptop screen, laptop keyboard, and the medication cart drawer handle with her bare hands. The Resident had a physician order for vitamin B 12. When preparing this medication, Nurse #2 accidentally poured an extra vitamin b 12 pill into the medication cup filled with other pills that had previously been prepared. Nurse #2 inserted her bare finger into the medication cup to remove the vitamin B 12, which she then put back into the medication bottle. Nurse #2 did not sanitize her hands or apply a protective barrier to her hand to prevent contaminating the rest of the medications she had already poured for the Resident.
- Nurse #2 continued to prepare additional medication without sanitizing her hands. Nurse #2 continued to touch multiple medication cards, medication bottles, laptop screen, laptop keyboard, and the medication cart drawer handle with her bare hands. The Resident had a physician order for a multivitamin. When preparing this medication, Nurse #2 accidentally poured an extra multivitamin pill into the medication cup filled with other pills that had previously been prepared. Nurse #2 inserted her bare finger into the medication cup to remove the multivitamin, which she then put back into the medication bottle. Nurse #2 did not sanitize her hands or apply a protective barrier to her hand to prevent contaminating the rest of the medications she had already poured for the Resident.
During an interview on 1/22/25 at 10:23 A.M., Nurse #2 said she should not have touched resident medications with her bare hand and put contaminated pills back into the medication bottles.
During an interview on 1/22/25 at 1:50 P.M., the Regional Clinical Specialist said medications should not be touched with a bare hand.
During an interview on 1/23/25 at 7:37 A.M., the Assistant Director of Nursing (ADON) said medications should not be touched with a bare hand. The ADON said the nurse should have used a glove and should have disposed of the pills instead of placing back into the medication bottles.
2.) On 1/22/25 at 8:22 A.M., the surveyor observed Nurse #3 prepare morning medications from the third floor side b medication cart. There was a plastic coffee cup with open drinking spout stored in one of the drawers with bottles of resident medications directly touching all sides of the cup.
During an interview on 1/22/25 at 8:23 A.M., Nurse #3 said it was her coffee cup. Nurse #3 said she is not supposed to store her coffee cup inside the medication cart.
During an interview on 1/22/25 at 1:50 P.M., the Regional Clinical Specialist said staff members coffee cups should not be stored in medication carts touching medications.
During an interview on 1/23/25 at 7:37 A.M., the Assistant Director of Nursing (ADON) said staff members coffee cups should not be stored in medication carts touching medications because of infection control concerns.
Mar 2024
2 deficiencies
1 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
Deficiency F0760
(Tag F0760)
A resident was harmed · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and records reviewed, for one of three sampled residents (Resident #1) who had a planned discharge to return...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and records reviewed, for one of three sampled residents (Resident #1) who had a planned discharge to return home, the Facility failed to ensure Resident #1 was free from a significant medication error, when the medications provided to him/her upon discharge were not accurately reconciled by nursing. One of the medications, Lisinopril (used to lower blood pressure) was sent home with Resident #1, belonged to another facility resident, (Resident #2), and was not a medication Resident #1 was prescribed by his/her physician. Resident #1 took the Lisinopril, along with all the other medications he/she was sent home with the next morning, he/she experienced mental status changes, required transfer to the Hospital Emergency Department for evaluation, and was admitted to the Intensive Care Unit due to extremely low blood pressure.
Findings include:
The Facility Policy, titled 72-Hour Discharge Planning/Discharge to Identified Living Arrangements, dated 08/23/23, indicated medications on discharge would be reconciled by nursing.
According to MayoClinic.org:
- Blood pressure is determined by the amount of blood the heart pumps and the amount of resistance to blood flow in the arteries. A blood pressure measurement is give in millimeters of mercury (mm Hg).
- Ideal blood pressure is usually lower than 120 mm Hg/80 mm Hg.
- Low blood pressure is a blood pressure reading lower than 90 mm Hg for the top number (systolic) or 60 mm Hg for the bottom number (diastolic), and extreme low blood pressure can lead to a condition called shock, which can be life threatening.
Review of the Facility's Medication Error Report Form, dated 01/18/24, indicated Resident #1 was discharged home from the Facility on 01/17/24, and on 01/18/24 the Facility was notified that he/she was sent home with a medication card for Lisinopril which belonged to another resident (later identified as Resident #2).
Review of the Photograph provided by the Home Care Agency of the Medication Card indicated it contained Lisinopril, 20 mg, by mouth once daily, and Resident #2's name was clearly indicated on the card.
Resident #1 was admitted to the Facility in December 2023, diagnoses included Cerebral Infarction, Alcohol Dependence, Congestive Heart Failure, History of Cardiac Implants, and Atrial Fibrillation.
Review of Resident #1's Facility's Vitals Report, for the month of January 2024, indicated that Resident #1's lowest measured blood pressure reading had been 90 mm Hg/60 mm Hg.
Review of Resident #1's Physician's Order Summary Report, dated 12/15/23, indicated he/she was admitted to the Facility with physician's orders that included (but not limited to) the following:
-Torsemide (diuretic) 20 milligrams (mg),
-Atorvastatin (lowers cholesterol) 80 mg, and
-Metoprolol (lowers blood pressure) Extended Release, 25 mg.
Review of Resident #1's Discharge Medication Release Form, dated 01/17/24, and signed by Nurse #1 and Resident #1, indicated Resident #1 medications upon discharge included (but not limited to) the following:
-Torsemide 20 mg,
-Atorvastatin 80 mg, and
-Metoprolol Extended Release, 25 mg.
Further review of the Resident #1's admission Physician's Orders and Discharge Medication Release Form indicated Resident #1 did not have physician's orders for Lisinopril.
Resident #2 was admitted to the Facility in January 2024, diagnoses included hypertension, and aortic valve insufficiency.
Review of Resident #2's Physician Order Report indicated he/she had a physician's order, dated 01/13/24 for Lisinopril 20 mg by mouth once daily.
During a telephone interview on 03/06/24 at 12:36 P.M., Nurse #1 said that on 01/17/24, she was the nurse assigned to Resident #1, and said she reviewed and prepared his/her medication cards that he/she was taking home. Nurse #1 said she put Resident #1's medication cards in a bag and handed them to Unit Manager #1, who then brought them to the Nurses' Station to discharge Resident #1. Nurse #1 said she did not follow Unit Manager #1 to the Nurses' Station and did not have a second nurse double check the medications before putting them in the bag. Nurse #1 said she was notified the next day that Resident #1 had been accidentally discharged with another resident's medication, and said it was possible that the card could have been stuck to Resident #1's medication cards.
During a telephone interview on 03/05/24 at 3:15 P.M., the Home Care Agency (HCA) Nurse said that on 01/18/24 she was the nurse assigned to visit Resident #1 in his/her home. The HCA Nurse said when she reconciled Resident #1's medications she noticed there was a medication card with the Lisinopril 20 mg tablets, and that the card was labeled with another person's name. The HCA Nurse said according to the discharge summary Resident #1 was not prescribed Lisinopril.
The HCA Nurse said Resident #1 told her he/she had taken one of each of the medications he/she was sent home with from the Facility, including the Lisinopril earlier that morning. The HCA Nurse said she assessed Resident #1, notified his/her physician of the medication error, and also alerted the HCA Physical Therapist (PT) regarding the medication error because the HCA PT was scheduled to see Resident #1 later that same day.
During a telephone interview on 03/07/24 at 12:36 P.M., the HCA Physical Therapist (PT) said that she was assigned to visit Resident #1 in his/her home on [DATE], that she arrived at Resident #1's home at 2:15 P.M., and noted he/she was having difficulty focusing on simple tasks, was lethargic, and complained of feeling dizzy. The HCA PT said she checked Resident #1's blood pressure and it was 60 mm Hg/40 mm Hg (very low), so she called 911 and Resident #1 was transferred to the Hospital Emergency Department via ambulance.
Review of Resident #1's Hospital Emergency Department History and Physical, (H&P) dated 01/18/24, indicated Resident #1 had been discharged from the Facility with another resident's Lisinopril, and had accidentally taken a dose. The H&P indicated Resident #1's blood pressure was 76 mm Hg/40 mm Hg (very low).
Review of Resident #1's Hospital Care Timeline Report indicated he/she diagnosed with hypotension (low blood pressure) as a result of accidental ingestion of Lisinopril, and was admitted to the Hospital's Intensive Care Unit on 01/19/24.
During an interview on 03/05/24 at 8:24 A.M., the Director of Nurses (DON) said this incident was an unfortunate mistake, and that Nursing should have been more careful when giving Resident #1 his/her medications on discharge.
On 03/05/24, the Facility was found to be in Past Non-Compliance and provided the Surveyor with a plan of correction which addressed the area of concern as evidenced by:
A. 01/18/14, The Quality Assessment Performance Improvement (QAPI) Plan indicated Facility leadership developed a plan to correct the deficient practice and ensure that residents would be discharged with the correct medications.
B. 01/18/24, The Education Sheet indicated nursing staff were educated by the Director of Nurses and Assistant Director of Nurses to review discharge medications with two nursing staff.
C. 01/18/24, A Discharge Medication Accuracy Form was implemented to include review and signatures required by two licensed nurses for all residents discharged with medications.
D. 01/22/24, Weekly audits by the Director of Nurses or designee of discharged residents were implemented to ensure discharge process and documentation included that two licensed nurses verified that the correct medications were sent home in the event of a home discharge.
E. 02/22/24, The concern area was reviewed by the QAPI committee to determine compliance with the new discharge medication process, and if goals met.
F. Weekly audits of discharge medication verifications will be conducted by the Director of Nurses and/or designee indefinitely and compliance reviewed at monthly QAPI meetings.
G. The Director of Nurses and/or designee are responsible for ongoing compliance.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0660
(Tag F0660)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and records reviewed, for one of three sampled residents (Resident #1) who had a planned discharge to return...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and records reviewed, for one of three sampled residents (Resident #1) who had a planned discharge to return home, the Facility failed to ensure Resident #1's discharge was safe, and that the medications provided to him/her upon discharge were accurately reconciled by nursing, when one of the medications (Lisinopril, used to lower blood pressure) sent home with Resident #1 belonged to another facility resident, (Resident #2), and was not a medication Resident #1 was prescribed by his/her physician. Resident #1 took the Lisinopril, along with all the other medications he/she was sent home with the next morning, he/she experienced mental status changes, required transfer to the Hospital Emergency Department for evaluation, and was admitted to the Intensive Care Unit due to extremely low blood pressure.
Findings include:
The Facility Policy, titled 72-Hour Discharge Planning/Discharge to Identified Living Arrangements, dated 08/23/23, indicated medications on discharge would be reconciled by nursing.
According to MayoClinic.org:
- Blood pressure is determined by the amount of blood the heart pumps and the amount of resistance to blood flow in the arteries. A blood pressure measurement is give in millimeters of mercury (mm Hg).
- Ideal blood pressure is usually lower than 120 mm Hg/80 mm Hg.
- Low blood pressure is a blood pressure reading lower than 90 mm Hg for the top number (systolic) or 60 mm Hg for the bottom number (diastolic), and extreme low blood pressure can lead to a condition called shock, which can be life threatening.
Review of the Facility's Medication Error Report Form, dated 01/18/24, indicated Resident #1 was discharged home from the Facility on 01/17/24, and on 01/18/24 the Facility was notified that he/she was sent home with a medication card for Lisinopril which belonged to another resident (later identified as Resident #2).
Review of the Photograph provided by the Home Care Agency of the Medication Card indicated it contained Lisinopril, 20 mg, by mouth once daily, and Resident #2's name was clearly indicated on the card.
Resident #1 was admitted to the Facility in December 2023, diagnoses included Cerebral Infarction, Alcohol Dependence, Congestive Heart Failure, History of Cardiac Implants, and Atrial Fibrillation.
Review of Resident #1's Facility's Vitals Report, for the month of January 2024, indicated that Resident #1's lowest measured blood pressure reading had been 90 mm Hg/60 mm Hg.
Review of Resident #1's Physician's Order Summary Report, dated 12/15/23, indicated he/she was admitted to the Facility with physician's orders that included (but not limited to) the following:
-Torsemide (diuretic) 20 milligrams (mg),
-Atorvastatin (lowers cholesterol) 80 mg, and
-Metoprolol (lowers blood pressure) Extended Release, 25 mg.
Review of Resident #1's Discharge Medication Release Form, dated 01/17/24, and signed by Nurse #1 and Resident #1, indicated Resident #1 medications upon discharge included (but not limited to) the following:
-Torsemide 20 mg,
-Atorvastatin 80 mg, and
-Metoprolol Extended Release, 25 mg.
Further review of the Resident #1's admission Physician's Orders and Discharge Medication Release Form indicated Resident #1 did not have physician's orders for Lisinopril.
Resident #2 was admitted to the Facility in January 2024, diagnoses included hypertension, and aortic valve insufficiency.
Review of Resident #2's Physician Order Report indicated he/she had a physician's order, dated 01/13/24 for Lisinopril 20 mg by mouth once daily.
During a telephone interview on 03/06/24 at 12:36 P.M., Nurse #1 said that on 01/17/24, she was the nurse assigned to Resident #1, and said she reviewed and prepared his/her medication cards that he/she was taking home. Nurse #1 said she put Resident #1's medication cards in a bag and handed them to Unit Manager #1, who then brought them to the Nurses' Station to discharge Resident #1. Nurse #1 said she did not follow Unit Manager #1 to the Nurses' Station and did not have a second nurse double check the medications before putting them in the bag. Nurse #1 said she was notified the next day that Resident #1 had been accidentally discharged with another resident's medication, and said it was possible that the card could have been stuck to Resident #1's medication cards.
During a telephone interview on 03/05/24 at 3:15 P.M., the Home Care Agency (HCA) Nurse said that on 01/18/24 she was the nurse assigned to visit Resident #1 in his/her home. The HCA Nurse said when she reconciled Resident #1's medications she noticed there was a medication card with the Lisinopril 20 mg tablets, and that the card was labeled with another person's name. The HCA Nurse said according to the discharge summary Resident #1 was not prescribed Lisinopril.
The HCA Nurse said Resident #1 told her he/she had taken one of each of the medications he/she was sent home with from the Facility, including the Lisinopril earlier that morning. The HCA Nurse said she assessed Resident #1, notified his/her physician of the medication error, and also alerted the HCA Physical Therapist (PT) regarding the medication error because the HCA PT was scheduled to see Resident #1 later that same day.
During a telephone interview on 03/07/24 at 12:36 P.M., the HCA Physical Therapist (PT) said that she was assigned to visit Resident #1 in his/her home on [DATE], that she arrived at Resident #1's home at 2:15 P.M., and noted he/she was having difficulty focusing on simple tasks, was lethargic, and complained of feeling dizzy. The HCA PT said she checked Resident #1's blood pressure and it was 60 mm Hg/40 mm Hg (very low), so she called 911 and Resident #1 was transferred to the Hospital Emergency Department via ambulance.
Review of Resident #1's Hospital Emergency Department History and Physical, (H&P) dated 01/18/24, indicated Resident #1 had been discharged from the Facility with another resident's Lisinopril, and had accidentally taken a dose. The H&P indicated Resident #1's blood pressure was 76 mm Hg/40 mm Hg (very low).
Review of Resident #1's Hospital Care Timeline Report indicated he/she diagnosed with hypotension (low blood pressure) as a result of accidental ingestion of Lisinopril, and was admitted to the Hospital's Intensive Care Unit on 01/19/24.
During an interview on 03/05/24 at 8:24 A.M., the Director of Nurses (DON) said this incident was an unfortunate mistake, and that Nursing should have been more careful when giving Resident #1 his/her medications on discharge.
On 03/05/24, the Facility was found to be in Past Non-Compliance and provided the Surveyor with a plan of correction which addressed the area of concern as evidenced by:
A. 01/18/14, The Quality Assessment Performance Improvement (QAPI) Plan indicated Facility leadership developed a plan to correct the deficient practice and ensure that residents would be discharged with the correct medications.
B. 01/18/24, The Education Sheet indicated nursing staff were educated by the Director of Nurses and Assistant Director of Nurses to review discharge medications with two nursing staff.
C. 01/18/24, A Discharge Medication Accuracy Form was implemented to include review and signatures required by two licensed nurses for all residents discharged with medications.
D. 01/22/24, Weekly audits by the Director of Nurses or designee of discharged residents were implemented to ensure discharge process and documentation included that two licensed nurses verified that the correct medications were sent home in the event of a home discharge.
E. 02/22/24, The concern area was reviewed by the QAPI committee to determine compliance with the new discharge medication process, and if goals met.
F. Weekly audits of discharge medication verifications will be conducted by the Director of Nurses and/or designee indefinitely and compliance reviewed at monthly QAPI meetings.
G. The Director of Nurses and/or designee are responsible for ongoing compliance.
Jan 2024
9 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Comprehensive Care Plan
(Tag F0656)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2). Resident #55 was admitted to the facility in October 2023 with diagnoses including dysphagia (difficulty swallowing) orophar...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2). Resident #55 was admitted to the facility in October 2023 with diagnoses including dysphagia (difficulty swallowing) oropharyngeal phase, Parkinson's disease, and dementia.
Review of Resident #55's Minimum Data Set (MDS), dated [DATE], indicated the Resident scored 5 out of 15 on the Brief Interview of Mental Status indicating he/she has severely impaired cognition. The MDS further indicated that the Resident required supervision or touching assistance while eating and was on a mechanically altered diet.
On 1/2/24 at 8:38 A.M., the surveyor observed Resident #55 in his/her room eating alone and the Resident was observed drooling and coughing while eating. The Resident said he/she has difficulties with swallowing at times.
On 1/2/24 at 12:33 P.M., the surveyor observed the Resident in the dining room sitting alone at the table having his/her lunch. The Resident did not have 1:1 supervision during the meal.
On 1/3/24 at 8:15 A.M., the surveyor observed a nurse deliver a tray to the Resident who was in his/her room. The Resident did not receive 1:1 supervision with his/her meal.
On 1/3/24 at 12:10 P.M., the surveyor observed a Certified Nursing Assistant (CNA) deliver the lunch tray to Resident #55 in his/her room and then walked away. The Resident did not receive supervision with his/her lunch.
Review of the current physician's order report dated 12/4/23- 1/4/24 indicated the following order:
-Diet- cut up solids with ground meat and thin liquids at breakfast, lunch, and dinner. No straw.
Special instructions: 1:1 supervision for meals due to high aspiration risk, out of bed for all meals.
Review of Resident #55's aspiration risk care plan last revised 11/16/23 indicated the following interventions:
-Provide meals per MD order.
-Observe for sign and symptoms of aspiration: coughing, tearing, wet vocal tone, runny nose, difficulty breathing or pocketing food. Notify the medical director/nurse practitioner.
-Supervise to assist as needed at meals if he/she becomes fatigued during meals.
During an interview on 1/3/24 at 12:16 P.M., CNA #2 said Resident #55 is always in the dining room for all meals because he/she is supervised with the meals. CNA #2 said the Resident does not need a 1:1 supervision. She further said that the Resident should not be in his/her room without supervision for meals.
During an interview on 1/4/24 at 8:16 A.M., the Speech Language Pathologist (SLP) said Resident #55 should be receiving supervised dining. The SLP said she had changed the orders from 1:1 supervision to supervision only and the orders should have been placed in the electronic medical record by the nursing staff.
During an interview on 1/4/24 at 9:16 A.M., the Director of Nursing said Resident #55 should have received supervision with all his/her meals, and the orders should have been entered correctly in the electronic medical record.
Based on observations, interviews, and record review the facility failed to implement the plan of care to provide supervision with meals for 2 Residents (#27 and #55), who are at risk for aspiration, out of a total sample of 29 residents.
Findings include:
Review of the facility's policy entitled Aspiration Precautions dated April 20, 2022, included but not limited to the following:
Policy: Aspiration precautions will be utilized to reduce the risk of aspiration of food or liquid into a resident's lungs.
Procedure:
-A resident with significant risk of aspiration, which is not completely controlled by current diet modifications, will require Aspiration Precautions by the Interdisciplinary Team.
-Residents needing Aspiration Precautions will have individualized approach to their care to meet their needs.
-The resident must be assessed by the Speech Language Pathologist (SLP) for the Aspiration Precautions to be discontinued.
-A plan of care will be developed with the feeding strategies per speech therapy recommendations.
-Any signs/symptoms of aspiration, e.g. increased temperature, abnormal lung sounds, increased coughing will be further assessed, and MD (medical doctor) notified.
Guideline for general feeding precautions for residents that are at risk for aspiration:
-Place resident in an upright position with any ingestion of food, fluids, or medication
-Remain with resident during meal
-Immediately stop feeding if individual chokes, coughs, become weak or drowsy or develops garbled speech.
-Encourage the resident to maintain an upright position for at least 30 minutes after ingesting food fluids or medications.
-Monitor for swallow difficulty during meals, medication, and snack passes.
Recommendations are individualized for each resident based on the SPL (sic) recommendations.
1). Resident #27 was admitted to the facility in December 2020 with diagnoses that include hemiplegia and hemiparesis following a cerebral infarction and end stage renal disease.
Review of Resident #27's Minimum Data Set assessment (MDS) dated [DATE] indicated Resident #27 scored a 6 out of 15 on the Brief Interview for Mental Status indicating a severe cognitive impairment and requires partial/moderate assistance for eating.
Review of Resident #27's clinical record indicated the following:
-A Nutritional risk care plan, dated 1/3/2021 and edited 10/18/23, indicated Resident #27 is at nutritional risk due to dysphagia (a condition with difficulty in swallowing food or liquid), with need for mechanically altered diet, and therapeutic diet restrictions for chronic disease management.
-ADLS (activities of daily living) functional status/rehabilitation potential, dated 1/8/2021, edited 10/18/23, Eating: requires continual supervision to assist with eating, inconsistently self feeds, spills foods and forgets to eat. Edited 8/2/2023.
-A physician's order; Aspiration Precautions, dated 2/23/2021.
Review of the CNA (Certified Nursing Assistant) Care Card (a form indicating the level of care needed), date updated 6/28/21 Diet: puree/nectar thick (liquids), Eating: physical assist.
On 1/02/24 at 9:05 A.M., Resident #27 was observed in bed. He/she was leaning to his/her right side and was not upright. The clothing protector Resident #27 was wearing had food particles on it, and some liquid was in the corner of his/her mouth. The plate in front of Resident #27 consisted of partially consumed pureed eggs and a mound of pureed french toast barley consumed. No staff was present in the room or nearby. The surveyors were unable to understand what Resident #27 said when he/she spoke with a faint voice.
On 1/3/24 the following observations were made by the surveyor:
-At 7:57 A.M., Resident #27 was observed resting in his/her bed.
-At 8:04 A.M., staff entered Resident #27's room, provided a boost to an upright position and the regional nurse delivered and set up Resident #27's tray and exited the room, which was at 8:09 A.M., The breakfast tray consisted of a bowl of hot cereal, pureed eggs, a pureed mound of toast, thickened milk, and thickened juice.
-Resident #27 using his/her right hand fed him/herself eggs, with some eggs dropping from his/her mouth on to the front of him/her.
-At 8:19 A.M., Resident #27 continued to eat in a slow fashion, did not drink any liquids and no staff were present or in the vicinity.
-At 8:20 A.M., Resident #27 looked to his/her right in the hall and leaned to the right side. Resident #27 stopped eating and was looking towards the hallway. No beverages were consumed and limited food was consumed.
-At 8:22 A.M., staff entered Resident #27's room and provided attention to his/her roommate and did not provide supervision or assistance to Resident #27.
-At 8:26 A.M., Resident #27 was staring at his/her television holding his/her spoon, not actively eating, eggs observed to be partially eaten, a very small dent in the mound of pureed toast and the hot cereal and beverages were untouched. Resident #27 was leaning and not in the same upright position as in the beginning of the observation.
-At 8:29. A.M., Resident #27 was observed and heard coughing a few times and raised his/her hand briefly.
-At 8:32 A.M., Resident #27 ate a spoonful of hot cereal.
-At 8:37 A.M., Resident #27 was not actively eating, no beverages were consumed, and no staff came in to check on, provide assistance or supervision.
- At 8:44 A.M., Resident #27 was staring and not actively eating and did not consume any beverages.
-At 8:45 A.M., 36 minutes after Resident #27 began eating, CNA #5 entered Resident #27's room, pulled down the shade, provided a boost upright, covered the Resident with a johnny (as a clothing protector), did not encourage fluids or eating and exited the room.
-At 8:47 A.M., CNAs began going room to room to collect breakfast trays.
-8:51 A.M., Resident #27 breakfast tray remained. He/she was not actively eating, and no beverages had been consumed.
-At 8:58 A.M., Resident #27 was slowly spooning hot cereal into his/her mouth. No beverages were consumed, and no staff was providing supervision.
During an interview on 1/03/24 at 9:05 A.M., CNA #5 said Resident #27 dozes during meals and needs to be supervised. CNA #5 said Resident #27 does not like physical assistance with meals but can be tired and weak at times because he/she goes out for dialysis. CNA #5 said Resident #27 eats slow and needs to be checked on during meals because he/she will hold food and drinks in his/her mouth and then let's it go. When asked what let's it go means CNA #5 said it is when he/she finally swallows. Further, CNA #5 said Resident #27 needs supervision during meals because she is on aspiration precautions, may get watery eyes and cough, and may lean to his/her right side. CNA #5 said when he/she coughs, Resident #27 knows to put his/her hands up. CNA #5 said she did not provide supervision with breakfast because she was in the dining room. CNA #5 said she went in once to reposition and pull down the shade (thirty-six minutes into Resident #27 eating).
During an interview on 1/3/24 at 10:25 A.M., the Speech Language Pathologist (SLP) said for residents who require aspiration precautions they need to be in an upright position, awake and alert for their meals and staff are to observe to notice any changes or issues with eating and notify her of any changes. Resident #27 is on a speech therapy program currently for communication related to expressive aphasia and voice disorder. The SLP said there is a period of times when Resident #27 may need more assistance and as of late he/she has done okay. The SLP said Resident #27 takes a long time to eat, needs to be upright, his/her diet is for pureed food and nectar thick liquids. The SLP said she would at least expect intermittent supervision during meals to pick up on any aspiration concerns.
Review of the SLP Discharge summary dated [DATE] indicated the following: discharge recommendations and status: Strategies, Upright position for all intakes, recommend out of bed to chair if tolerated. Small bites of solids. Slow rate of intake. Staff assistance for feeding as needed due to fatigue and initiation. Remain upright for 30 minutes after intake. Aspiration precautions in place.
Review of the SLP progress note dated 1/3/24 indicated Precautions: Aspiration precautions.
During an interview on 1/3/24 at 11:11 A.M., the Director of Nursing (DON) said residents on aspiration precautions would indicate the need for supervision during meals. The DON said the care plans are reviewed quarterly and as needed and the plan of care for continuous supervision for Resident #27 should be provided unless re-evaluated and the care plan is updated.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0658
(Tag F0658)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review and interviews, the facility failed to ensure a physician's order to implement a bolster bl...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review and interviews, the facility failed to ensure a physician's order to implement a bolster block for foot positioning while in bed was followed for one Resident (#75) out of a total sample of 29 residents.
Findings include:
Resident #75 was admitted to the facility in March 2020 with diagnoses including vascular dementia, hemiplegia/hemiparesis and type 2 diabetes mellitus.
Review of Resident #75's most recent Minimum Data Set Assessment (MDS) dated [DATE] indicated that Resident #75 had a Brief Interview for Mental Status score of 14 out of a possible 15 which indicated that he/she is cognitively intact. Further review of the Resident's MDS indicated that he/she is dependent for care on all activities of daily living.
The surveyor made the following observations on 1/2/24 at 7:55 A.M. and 1/3/24 at 7:06 A.M. and 11:02 A.M.:
-Resident #75 was observed sleeping in bed. There was a sign hanging on the wall above the Resident's bed stating: When in bed, please place bolster cushion at the end of bed to support feet. Two bolster cushions were observed in the corner of Resident #75's room, not at the end of his/her bed.
Review of Resident #75's physician's order dated 9/30/20 indicated the following:
-While resident is in bed: position bilateral feet against blue bolster block in bed. Special instructions: To promote bilateral lower extremity dorsi-flexion. Every shift.
During an interview on 1/2/24 at 12:40 P.M., Resident #75 said he/she is supposed to have the bolster at the end of his/her bed so his/her feet don't bend forward. The Resident continued to say staff don't always put the bolster at the end of the bed.
During an interview on 1/3/24 at 11:07 A.M., Unit Manager #2 said Resident #75's bolsters should be in place when he/she is in bed so his/her feet do not bend forward.
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
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, records reviewed and interviews the facility failed to ensure nursing provided care consistent with profe...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, records reviewed and interviews the facility failed to ensure nursing provided care consistent with professional standards of practice to prevent new pressure ulcers from developing for one Resident (#256) out of 29 sampled residents. Specifically for Resident #256, who was assessed by nursing to be at risk for skin breakdown, the facility failed to ensure nursing consistently implemented his/her physician's ordered prevalon boots (heel protectors that help reduce the risk of pressure ulcers by keeping the heels floated, relieving pressure) Subsequently, Resident #256's right heel pressure ulcer developed and was first observed by nursing, almost 29 hours after the surveyor first observed the wound.
Findings include:
Review of the facility policy titled, Skin Management Program, dated as revised 6/13/19, indicated to minimize the development of any type of ulcers and other skin issues through the systematic and regular inspection of the skin, and to ensure early detection and intervention for all skin problems.
2. Residents will undergo weekly body check by the licensed nurse.
3. Certified Nursing Assistants will inspect the skin of each resident during daily care and whenever skin care is provided and report to the licensed nurse of any skin changes to the resident's skin.
Resident #256 was admitted to the facility in December 2023 with diagnoses including hemiplegia and hemiparesis following cerebral infarction and pain in the left knee.
Review of the Minimum Data Set (MDS) assessment, dated 12/22/23, indicated Resident #256 had a Brief Interview of Mental Status (BIMS) score of 12 out of a possible 15 which indicated moderate cognitive impairment. The MDS indicated he/she did not have any pressure ulcers and was dependent of staff for bed mobility. The MDS indicated a functional limitation in range of motion on both sides of his/her lower extremities.
On 1/2/24 at 8:16 A.M., Resident #256 was in bed with his/her heels directly touching the mattress. There were a pair of prevalon boots on the floor next to the nightstand. Resident #256 said that staff do not put on the prevalon boots but said he/she would wear them if staff would put them on. Resident #256 said he/she did not have any skin issues on his/her feet and allowed the surveyor to observe his/her feet. Resident #256 was noted to have an unstageable pressure ulcer on his/her right heel the size of a dime and there was visible slough (moist dead tissue) and eschar (hard dead tissue, appearing like a scab) and the surrounding tissue was red.
On 1/2/24 at 3:31 P.M., Resident #256 was in bed and his/her heels were directly touching the mattress. Two prevalon boots were observed on the floor and not applied to the Resident's feet. Resident #256 asked the surveyor to place a pillow under his/her heels because they were sore.
On 1/2/24 at 5:02 P.M., Resident #256 was in bed and his/her heels were directly touching the mattress. Two prevalon boots were observed on the floor and not applied to the Resident's feet.
On 1/3/24 at 6:32 A.M., Resident #256 was in bed and his/her heels were directly touching the mattress. Two prevalon boots were observed on the floor and not applied to the Resident's feet.
On 1/3/24 at 7:30 A.M., Resident #256 was in bed and his/her heels were directly touching the mattress. Two prevalon boots were observed on the floor and not applied to the Resident's feet.
On 1/3/24 at 9:03 A.M., Resident #256 was in bed and his/her heels were directly touching the mattress. Two prevalon boots were observed on the floor and not applied to the Resident's feet.
Review of the Certified Nurse Assistant Care Card (a form indicating the level of care needed and equipment needed for a resident), dated as updated on 12/16/23, indicated:
- pressure ulcer prevention: heel protectors.
Review of the handwritten physician's order in the medical record, dated 12/16/23 (implemented two days later on 12/18/23), indicated:
- Prevalon boots when in bed secondary to pink/ reddened heels.
Review of the transcribed physician's order in the electronic medical record, dated 12/18/23, indicated:
- Prevalon boots while in bed.
Review of the Treatment Administration Record, dated January 2023, indicated the prevalon boots were applied as ordered on 1/2/24 and 1/3/24.
Review of the admission Assessment, dated 12/15/23 indicated:
- [NAME] Total Score: 14 which indicated Resident #256 was at risk for skin breakdown.
- Feet and heels very dry. Heels pink, intact and blanchable.
Review of the Weekly Skin Focused Observation, dated 12/28/23, indicated:
- No alterations in skin.
Review of the plan of care related to skin breakdown, dated 12/30/23, indicated:
- Avoid shearing resident's skin during positioning, transferring, and turning.
- Conduct a systematic skin inspection weekly, Pay particular attention to the bony prominences.
- Report any signs of skin breakdown (sore, tender, red, or broken areas).
- Apply moisture barrier to skin.
Review of the nursing practitioner note, dated 1/2/24, indicated:
-Reports discomfort to BLE (bilateral lower extremities).
-Skin Assessment: Negative.
During an interview on 1/3/24 at 10:57 A.M., Certified Nurse Assistant (CNA) #1 said she was assigned for Resident #256 on 1/2/24 and 1/3/24 during the day shift (7:00 A.M. to 3:00 P.M.), CNA #1 said that she completed Resident #256's care around 10:00 A.M., CNA #1 said that during care on 1/2/23 she applied to lotion to Resident #256's legs and feet, CNA #1 said this is part of her usual routine for care. CNA #1 said she looked at Resident #256 during care and did not identify any new open areas on his/her feet or heels. CNA #1 said that Resident #256 wears booties and knows he/she should wear them because the prevalon boots are on his/her care card.
During an interview with 1/3/24 at 1:41 P.M., Nurse #1 said that Resident #256 requires prevalon boots on while in bed for pressure ulcer prevention. Nurse #1 said nurses or CNAs will apply the prevalon boots with care. Nurse #1 said that Resident #256 is compliant with wearing the prevalon boots.
On 1/3/24 at 1:45 P.M., Nurse #1 and two surveyors went into Resident #256's room. Nurse #1 said that Resident #256 has a new unstageable pressure ulcer to his/her right heel. Nurse #1 said Resident #256 should wear the prevalon boots for pressure ulcer prevention.
During an interview on 1/3/24 at 1:49 P.M., Unit Manager #1 said that nurses should follow and implement the physicians order for prevalon boots. Unit Manager #1 said the prevalon boots are for pressure ulcer prevention and nurses and CNAs should ensure they are applied.
On 1/3/24 at 1:53 P.M., the Unit Manager #1 and Nurse #1 went into Resident #256's room. Unit Manager said that Resident #256 had a new pressure ulcer to his/her right heel. Resident #256 said to Unit Manager #1 and Nurse #1 that he/she would wear his/her prevalon boots if nursing applied them.
During an interview on 1/3/24 at 3:55 P.M., the Nurse Practitioner said she evaluated Resident #256 on 1/3/23 for a new pressure ulcer.
Review of the skin check on 1/3/24, indicated:
-New 0.5 by 0.5 centimeter (cm) unstageable area noted to right heel. Wound bed 100% eschar.
During an interview on 1/3/24 at 4:05 P.M., the Director of Nursing said Resident #256 had developed a new pressure ulcer to his/her left heel. The DON said nursing should have implemented the physician's ordered prevalon boots for pressure ulcer prevention.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0692
(Tag F0692)
Could have caused harm · This affected 1 resident
Based on observations, interviews, and record review, the facility failed to consistently implement the nutritional care plan interventions for one Resident (#257), out of a total sample of 29 residen...
Read full inspector narrative →
Based on observations, interviews, and record review, the facility failed to consistently implement the nutritional care plan interventions for one Resident (#257), out of a total sample of 29 residents. Specifically, for Resident #257 the facility failed to implement sugar free ice cream as ordered by the physician.
Findings include:
Review of the facility policy titled, Nutritional Management Policy, dated as revised 6/13/19, indicated residents will have their nutritional needs assessed and receive diets and prescribed by the physician.
1. Residents will receive diets and supplemental feeds prescribed by their attending physician.
Resident #257 was admitted to the facility in December 2023 with diagnoses including sepsis, cholecystitis and diabetes.
Review of Nursing admission assessment, dated 12/26/23, indicated Resident #257 had a Brief Interview of Mental Status (BIMS) score of 15 out of a possible 15 which indicated he/she was cognitively intact.
Review of the initial nutrition assessment note, dated 12/30/23, indicated: Resident reports poor appetite and 20 pound weight loss x 1 month. Etiology for significant change in status likely multifactorial, i.e., poor dentition (w/ 4 extracted teeth), complaints of swallowing difficulty/discomfort, acute illness with recent hospitalization. Resident evaluated by Speech Language Pathologist (SLP) with altered texture recommended. Appetite remains fair to poor per Resident report. Resident diagnosed with diabetes. He/she is receiving a therapeutic diet and prescribed glipizide, Jardiance and Trulicity to optimize glycemic control. Fasting blood glucose range over the past few days 146-190 milligrams per deciliter (mg/dL). Given diminished appetite and rapid change in weight Resident is at risk for malnutrition.
Plan: Diet and texture as ordered. Add Glucerna 237 milliliters (ml) twice daily (BID), and sugar free (SF) ice cream at lunch for nutrition support. Offer meal substitute or as needed (PRN) supplement with intakes less than 50%.
Review of the physician's order, dated 1/2/24, indicated:
-Diet: sugar free ice cream at lunch.
On 1/2/24 at 1:06 P.M., Resident #257 said that she just ate his/her ice cream. Resident #257 said the ice cream was not sugar free, but he/she ate it anyways because the food is plain. Resident #257 said he/she would prefer sugar free ice cream but would take whatever is given to him/her because he/she doesn't eat the facility food.
On 1/3/24 at 12:17 P.M., Resident #257 was in his/her room and was eating ice cream. Resident #257 said the ice cream was not sugar free, but he/she ate it anyways because he/she had difficulty chewing. Resident #257 said he/she would prefer sugar free ice cream but would take whatever is given to him/her because he/she doesn't eat the facility food.
On 1/3/24 at 11:30 A.M., during the kitchen tour, two surveyors observed sugar free ice cream in the kitchen freezer, available for resident consumption.
During an interview on 1/3/24 at 1:15 P.M., the Food Service Director said that there is sugar free available for Resident #257. The Food Service Director said that Resident #257 was not provided sugar free ice cream on 1/2/24 and 1/3/24.
During an interview on 1/3/24 at 1:16 PM the Dietician said that Resident #257 is diabetic and should receive sugar free ice cream with his/her lunch.
During an interview on 1/3/24 at 1:49 P.M., Unit Manger #1 said the kitchen should have provided Resident #257 with sugar free ice cream at lunch.
During an interview on 1/3/24 at 4:15 P.M., the Director of Nursing said that the kitchen should have provided Resident #257 with sugar free ice cream.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0694
(Tag F0694)
Could have caused harm · This affected 1 resident
Based on interview, policy review, and record review, the facility failed to provide care and maintenance of a peripherally inserted central catheter (PICC), consistent with professional standards of ...
Read full inspector narrative →
Based on interview, policy review, and record review, the facility failed to provide care and maintenance of a peripherally inserted central catheter (PICC), consistent with professional standards of practice for one Resident (#412), out of a total sample of 29 residents. Specifically, for Resident #412, the facility failed to implement a physician's order for routine dressing changes, as required.
Findings include:
Review of the facility policy titled, Central Venous Access Device (CVAD) Catheter Dressing Change, dated January 2022, indicated:
2. The IV (intravenous) therapy order for care and maintenance is required.
3. Refer to the IV Order Form for dressing change frequency.
Resident #412 was admitted to the facility in December 2023 with diagnoses including urinary tract infection and sepsis.
Review of Resident #412's active physician's orders indicated:
-PICC: Change dressing Q (quaque, Latin for every) week and measure and document external catheter length, initiated 12/22/23.
-PICC: Change dressing PRN (pro re nata, Latin for as needed) if lifting, wet, loose or soiled or has gauze or you are unable to inspect insertion site, initiated 12/22/23.
On 1/2/23 at 9:39 A.M., the surveyor observed Resident #412's PICC dressing dated 12/22/23, which was 11 days prior to this observation.
Review of Resident #412's medication administration record, dated 12/29/23, indicated nursing implemented the PICC dressing change as ordered.
Review of Resident #412's nursing progress notes, dated 12/22/23 to 1/3/24, failed to indicate rationale for the PICC dressing not being changed.
During an interview on 1/3/24 at 8:55 A.M., Unit Manager #1 said Resident #412's the PICC dressing, dated 12/22/23, should not have been in place for 11 days and should have been changed every seven days.
During an interview on 1/3/24 at 11:12 P.M., the Director of Nursing (DON) said Resident #412's PICC dressing should have been changed every seven days and that it should not have been documented as changed since it was not.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0698
(Tag F0698)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, and record review the facility failed to implement a physician's order to give phosphate binde...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, and record review the facility failed to implement a physician's order to give phosphate binders (a medication to absorb phosphate from the food you eat) in accordance with the physician's orders for one Resident (#27), who requires dialysis, out of a total sample of 29 residents.
Findings include:
Resident #27 was admitted to the facility in December 2020 with diagnoses that include hemiplegia and hemiparesis following a cerebral infarction and end stage renal disease.
Review of Resident #27's Minimum Data Set assessment (MDS) dated [DATE] indicated Resident #27 scored a 6 out of 15 on the Brief Interview for Mental Status which indicated he/she had severe cognitive impairment and requires partial/moderate assistance for eating, and is dependent for bathing, dressing and hygiene. The MDS also indicated Resident #27 received dialysis treatment.
Review of Resident #27's physician's orders indicated the following:
-An order dated 10/4/23 Renvela (sevelamer carbonate) powder in a packet; 2.4 grams; amount to administer: 1 packet; oral with meals on Sunay, Mon, Wed, Fri. Time: 8:30 A.M., 12:30 P.M. and 5:30 P.M. (mealtimes) .
-An order dated 10/4/23 Renvela (sevelamer carbonate) powder in packet; 2.4 gram; amount to administer: 1 packet; oral twice a day on Tue, Thu, Sat. Time: 8:30 A.M., and 5:30 P.M. (mealtimes),
On 1/03/24 at 7:22 A.M., Resident #27 was observed resting in his/her bed.
During an interview on 1/03/24 at 8:18 A.M., Nurse # 2 said he was just starting the morning medication pass for his residents.
On 1/3/24 at 8:04 A.M., Resident #27 was provided with his/her breakfast tray. The surveyors observed Resident #27 from 8:04 A.M., through 8:58 A.M., and at no time during the observation was Resident #27 administered any medications by Nurse #2.
Review of the Medication Administration Report (MAR) dated 1/3/24 at 9:54 A.M.,10:57 A.M. and 1:50 P.M., failed to indicate Resident #27 was administered his/her 8:30 A.M., dose of Renvela powder. Further, the MAR dated 1/3/24 failed to indicate the 12:30 P.M. Renvela was administered.
During an interview on 1/3/23 at 2:10 P.M., Nurse #2 said Resident #27 was administered his/her morning dose of Renvela and that he did not complete the documentation on the EMR (electronic medical record), and said it was around 8:00 A.M. (which would be before he started the med pass at 8:18 A.M.). Nurse #2 said Resident #27 is a dialysis patient and that Renvela is to be administered with meals. Nurse #2 said he did not administer Resident #27 his/her 12:30 P.M. dose of Renvela.
Review of the 1/3/24 Medication Administration History report, dated 1/3/23, run at 2:32 P.M., indicated the 12:30 P.M., dose of Renvela powder was not administered.
During an interview on 1/3/24 at 2:22 P.M. the Nursing Clinical Coordinator said Renvela should be administered with meals for effectiveness and as indicated by the physician's orders.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0790
(Tag F0790)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review and interview, the facility failed to provide dental services to one Resident (#75) out of ...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review and interview, the facility failed to provide dental services to one Resident (#75) out of a total sample of 29 residents. Specifically, the facility failed to follow up with the dentist to provide Resident #75 with partial dentures resulting in the Resident not receiving them.
Findings include:
Review of the facility policy titled Dental Services, dated and revised 10/20/23, indicated the following:
-Licensed Nursing staff are responsible for the supervision of and carrying out orders of the attending physician or dentist concerning medication, treatment and oral hygiene as written on the resident's chart and signed.
Resident #75 was admitted to the facility in March 2020 with diagnoses including vascular dementia, hemiplegia and hemiparesis and type 2 diabetes mellitus.
Review of Resident #75's most recent Minimum Data Set Assessment (MDS) dated [DATE], indicated that Resident #75 had a Brief Interview for Mental Status score of 14 out of a possible 15, which indicated that he/she is cognitively intact. Further review of the Resident's MDS indicated that he/she is dependent for care on all activities of daily living.
During an interview on 1/2/24 at 12:40 P.M., Resident #75 was observed missing multiple upper and lower teeth. Resident #75 said he/she got dental impressions for partial dentures last year, but he/she never received the dentures. The Resident continued to say it is hard to eat without dentures but he/she has gotten used to it.
Review of Resident #75's physician's order dated 3/10/20 indicated the following: Dentist consult as needed.
Review of Resident #75's visits from the facility's contracted dental service indicated the following from the dental hygienist:
-Exam Date 2/1/22: Treatment Notes: Resident said he/she would like to replace missing/broken lowers (bottom teeth) - rec (recommend) discussing with dentist.
-Exam Date 6/21/21: Treatment Notes: Patient request new denture(s); Reviewed dental fabrication steps with patient; Recommend FMX (full mouth x-ray) for insurance approval of partial denture. Recommend fabrication of upper RPD (removable partial denture) to replace existing ill-fitting and worn denture to allow improvement in chewing ability and quality of life. Patient complains of top teeth hurt (sore) when eating. Recommended Treatment: Fabrication of full upper denture (DFU).
-Exam date 8/9/22: Patient was scheduled today but was not treated. Patient requires premedication for treatment but premedication was not administered.
-Exam date 8/30/22: Patient was scheduled today to be treated today but was not treated. Patient was unavailable.
Review of Resident #75's Quarterly Nutritional assessment dated [DATE] at 3:50 P.M. indicated the following:
-He/she was inquiring about his/her dental appointment for partial top dentures, notified RN (registered nurse) unit manager.
During an interview on 1/3/24 at 10:17 A.M., Social Worker #1 said the facility has a contracted dental company who comes to the facility every 1-2 months. Residents sign a consent to be treated form upon admission and there is a form on the units to track upcoming appointments.
During an interview on 1/3/23 10:47 A.M., Unit Manager #2 said the contracted dental company emails the facility when they are coming and what services each resident needs. Unit Manager #2 said she will read the recommendations from the dental service and follow up on them. Unit Manager #2 was not aware that Resident #75 has been requesting to have dentures fabricated.
During an interview on 1/3/24 at 12:13 P.M., Resident #75 said he/she started the process of getting dentures but is not sure what happened and why he/she never heard back and has not received them.
During an interview on 1/3/24 at 1:36 P.M., the Director of Nursing (DON) said she is not sure why the contracted dental company has not provided Resident #75 with his/her dentures yet. The DON continued to say she thinks there should have been some follow up by now since Resident #75 asked about dentures over a year ago.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Medical Records
(Tag F0842)
Could have caused harm · This affected multiple residents
Based on records reviewed and interviews for 5 of 29 sampled Residents (#256, #257, #259, #41 and #412), the facility failed to ensure they maintained complete and accurate medical records related to ...
Read full inspector narrative →
Based on records reviewed and interviews for 5 of 29 sampled Residents (#256, #257, #259, #41 and #412), the facility failed to ensure they maintained complete and accurate medical records related to activities of daily living documentation.
Findings include:
1.) For Resident #256, Certified Nurse Aide (CNA) Activity of Daily Living (ADL) documentation was not consistently completed for the months of December 2023 and January 2024.
Resident #256 was admitted to the facility in December 2023 with diagnoses including hemiplegia and hemiparesis following cerebral infarction and pain in the left knee.
Review of the CNA ADL documentation dated, December 2023 and January 2024, indicated Resident #256's CNA ADL Flow Sheets for eating, toilet hygiene, grooming, dressing, ambulation, decubitus prevention, bladder care, bowel care and positioning records were left blank on the following dates and shifts:
-12/16/23, 11:00 P.M.-7:00 A.M.
-12/17/23, 11:00 P.M.-7:00 A.M.
-12/18/23, 11:00 P.M.-7:00 A.M.
-12/19/23, 7:00 A.M.-3:00 P.M., 3:00 P.M.-11:00 P.M. and 11:00 P.M.-7:00 A.M.
-12/20/23, 7:00 A.M.-3:00 P.M. and 11:00 P.M.-7:00 A.M.
-12/21/23, 7:00 A.M.-3:00 P.M., 3:00 P.M.-11:00 P.M. and 11:00 P.M.-7:00 A.M.
-12/22/23, 7:00 A.M.-3:00 P.M., and 3:00 P.M.-11:00 P.M
-12/23/23, 7:00 A.M.-3:00 P.M., 3:00 P.M.-11:00 P.M. and 11:00 P.M.-7:00 A.M.
-12/24/23, 7:00 A.M.-3:00 P.M., 3:00 P.M.-11:00 P.M. and 11:00 P.M.-7:00 A.M.
-12/25/23, 3:00 P.M.-11:00 P.M. and 11:00 P.M.-7:00 A.M.
-12/26/23, 7:00 A.M.-3:00 P.M., 3:00 P.M.-11:00 P.M. and 11:00 P.M.-7:00 A.M.
-12/27/23, 7:00 A.M.-3:00 P.M., 3:00 P.M.-11:00 P.M. and 11:00 P.M.-7:00 A.M.
-12/28/23, 3:00 P.M.-11:00 P.M. and 11:00 P.M.-7:00 A.M.
-12/29/23, 7:00 A.M.-3:00 P.M., and 3:00 P.M.-11:00 P.M.
-12/31/23, 7:00 A.M.-3:00 P.M., and 11:00 P.M.-7:00 A.M.
-1/1/24, 7:00 A.M.-3:00 P.M., 3:00 P.M.-11:00 P.M. and 11:00 P.M.-7:00 A.M.
-1/2/24, 7:00 A.M.-3:00 P.M. and 11:00 P.M.-7:00 A.M.
-1/3/24, 11:00 P.M.-7:00 A.M.
2.) For Resident #257, Certified Nurse Aide (CNA) Activity of Daily Living (ADL) documentation was not consistently completed for the months of December 2023 and January 2024.
Resident #257 was admitted to the facility in December 2023 with diagnoses including sepsis, cholecystitis and diabetes.
Review of the CNA ADL documentation dated, December 2023 and January 2024, indicated Resident #257's CNA ADL Flow Sheets for eating, toilet hygiene, grooming, dressing, ambulation, decubitus prevention, bladder care, bowel care and positioning records were left blank on the following dates and shifts:
-12/26/23, 7:00 A.M.-3:00 P.M., 3:00 P.M.-11:00 P.M. and 11:00 P.M.-7:00 A.M.
-12/27/23, 7:00 A.M.-3:00 P.M., 3:00 P.M.-11:00 P.M. and 11:00 P.M.-7:00 A.M.
-12/28/23, 7:00 A.M.-3:00 P.M., 3:00 P.M.-11:00 P.M. and 11:00 P.M.-7:00 A.M.
-12/29/23, 7:00 A.M.-3:00 P.M., 3:00 P.M.-11:00 P.M. and 11:00 P.M.-7:00 A.M.
-12/31/23, 7:00 A.M.-3:00 P.M., 3:00 P.M.-11:00 P.M. and 11:00 P.M.-7:00 A.M.
-1/1/24, 7:00 A.M.-3:00 P.M., 3:00 P.M.-11:00 P.M. and 11:00 P.M.-7:00 A.M.
-1/2/24, 7:00 A.M.-3:00 P.M., 3:00 P.M.-11:00 P.M. and 11:00 P.M.-7:00 A.M.
3.) For Resident #259, Certified Nurse Aide (CNA) Activity of Daily Living (ADL) documentation was not consistently completed for the months of December 2023 and January 2024.
Resident #259 was admitted to the facility in December 2023 with diagnoses including pulmonary embolism, anxiety, and diabetes.
Review of the CNA ADL documentation dated, December 2023 and January 2024, indicated Resident #259's CNA ADL Flow Sheets for eating, toilet hygiene, grooming, dressing, ambulation, decubitus prevention, bladder care, bowel care and positioning records were left blank on the following dates and shifts:
-12/31/23, 7:00 A.M.-3:00 P.M., 3:00 P.M.-11:00 P.M. and 11:00 P.M.-7:00 A.M.
-1/1/24, 7:00 A.M.-3:00 P.M., 3:00 P.M.-11:00 P.M. and 11:00 P.M.-7:00 A.M.
-1/2/24, 7:00 A.M.-3:00 P.M., 3:00 P.M.-11:00 P.M. and 11:00 P.M.-7:00 A.M.
4.) For Resident #41, Certified Nurse Aide (CNA) Activity of Daily Living (ADL) documentation was not consistently completed for the months of December 2023 and January 2024.
Resident #41 was admitted to the facility in December 2023 with diagnoses including hypertension and diabetes.
Review of the CNA ADL documentation dated, December 2023 and January 2024, indicated Resident #41's CNA ADL Flow Sheets for eating, toilet hygiene, grooming, dressing, ambulation, decubitus prevention, bladder care, bowel care and positioning records were left blank on the following dates and shifts:
-12/1/23, 11:00 P.M.-7:00 A.M.
-12/3/23, 11:00 P.M.-7:00 A.M.
-12/4/23, 3:00 P.M.-11:00 P.M.
-12/6/23, 3:00 P.M.-11:00 P.M.
-12/7/23, 3:00 P.M.-11:00 P.M.
-12/8/23, 11:00 P.M.-7:00 A.M.
-12/9/23, 3:00 P.M.-11:00 P.M.
-12/11/23, 3:00 P.M.-11:00 P.M.
-12/12/23, 3:00 P.M.-11:00 P.M.
-12/14/23, 7:00 A.M.-3:00 P.M.
-12/15/23, 3:00 P.M.-11:00 P.M. and 11:00 P.M.-7:00 A.M.
-12/16/23, 7:00 A.M.-3:00 P.M. and 11:00 P.M.-7:00 A.M.
-12/17/23, 7:00 A.M.-3:00 P.M., 3:00 P.M.-11:00 P.M., and 11:00 P.M.-7:00 A.M.
-12/18/23, 3:00 P.M.-11:00 P.M.
-12/19/23, 3:00 P.M.-11:00 P.M.
-12/20/23, 7:00 A.M.-3:00 P.M. and 3:00 P.M.-11:00 P.M
-12/21/23, 7:00 A.M.-3:00 P.M. and 11:00 P.M.-7:00 A.M.
-12/22/23, 7:00 A.M.-3:00 P.M. and 3:00 P.M.-11:00 P.M
-12/23/23, 7:00 A.M.-3:00 P.M. and 3:00 P.M.-11:00 P.M
-12/24/23, 3:00 P.M.-11:00 P.M.
-12/25/23, 7:00 A.M.-3:00 P.M.
-12/26/23, 7:00 A.M.-3:00 P.M. and 3:00 P.M.-11:00 P.M
-12/27/23, 7:00 A.M.-3:00 P.M., 3:00 P.M.-11:00 P.M., and 11:00 P.M.-7:00 A.M.
-12/28/23, 3:00 P.M.-11:00 P.M. and 11:00 P.M.-7:00 A.M.
-12/29/23, 7:00 A.M.-3:00 P.M.
-12/30/23, 7:00 A.M.-3:00 P.M. and 3:00 P.M.-11:00 P.M
-12/31/23, 7:00 A.M.-3:00 P.M., 3:00 P.M.-11:00 P.M., and 11:00 P.M.-7:00 A.M.
-1/1/24, 7:00 A.M.-3:00 P.M., 3:00 P.M.-11:00 P.M., and 11:00 P.M.-7:00 A.M.
-1/2/24, 11:00 P.M.-7:00 A.M.
5.) For Resident #412, Certified Nurse Aide (CNA) Activity of Daily Living (ADL) documentation was not consistently completed for the months of December 2023 and January 2024.
Resident #412 was admitted to the facility in December 2023 with diagnoses including urinary tract infection and sepsis.
Review of the CNA ADL documentation dated, December 2023 and January 2024, indicated Resident #412's CNA ADL Flow Sheets for eating, toilet hygiene, grooming, dressing, ambulation, decubitus prevention, bladder care, bowel care and positioning records were left blank on the following dates and shifts:
-12/23/23, 11:00 P.M.-7:00 A.M.
-12/24/23, 3:00 P.M.-11:00 P.M.
-12/25/23, 7:00 A.M.-3:00 P.M.
-12/26/23, 7:00 A.M.-3:00 P.M.
-12/27/23, 7:00 A.M.-3:00 P.M. and 3:00 P.M.-11:00 P.M.
-12/28/23, 3:00 P.M.-11:00 P.M. and 11:00 P.M.-7:00 A.M.
-12/29/23, 7:00 A.M.-3:00 P.M.
-12/30/23, 7:00 A.M.-3:00 P.M. and 3:00 P.M.-11:00 P.M
-12/31/23, 7:00 A.M.-3:00 P.M., 3:00 P.M.-11:00 P.M., and 11:00 P.M.-7:00 A.M.
-1/1/24, 7:00 A.M.-3:00 P.M., 3:00 P.M.-11:00 P.M., and 11:00 P.M.-7:00 A.M.
-1/2/24, 11:00 P.M.-7:00 A.M.
During an interview on 1/3/24 at 1:14 P.M., CNA #1 said that ADL documentation should be completed by the end of the shift.
During an interview on 1/4/24 at 1:14 P.M., CNA #4 said that ADL documentation should be completed by the end of the shift.
During an interview on 1/3/24 at 1:48 P.M., Unit Manager #1 said ADL documentation needs to be completed by the end of the shift.
During an interview on 1/3/24 at 1:55 P.M., the MDS Coordinator said ADL documentation is not being filled out entirely but should be completed by CNAs before the end of the shift.
During an interview on 1/3/24 at 2:09 P.M., the Director of Nursing (DON) said ADL documentation needs to be completed by the end of the shift.
During a follow up interview on 1/3/24 at 5:30 P.M., the DON said there was no policy on completing ADL documentation.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected multiple residents
Based on observation, record review and interview the facility failed to adhere to standards of infection control practices to prevent infection by failing to don and doff personal protective equipmen...
Read full inspector narrative →
Based on observation, record review and interview the facility failed to adhere to standards of infection control practices to prevent infection by failing to don and doff personal protective equipment (PPE) as required on two out of three resident care units, failing to ensure potentially contaminated gloves were removed and hand hygiene was performed after being in contact with a resident's environment on 1 out of 3 resident care units.
Findings include:
Review of the facility's policy entitled, Section I-The infection Prevention Program, dated August 2017 indicated the following:
-This facility has developed and maintains an Infection Prevention Program that provides a safe, sanitary, and comfortable environment to help prevent the development and transmission of infection. The goal of the infection prevention program is to prevent, recognize, and control, to the extent possible, the onset and spread of infection within the facility.
Further review of the policy included but not limited to the following: Hand Hygiene, When to Wash Hands (at a minimum)
-Before and after direct patient/resident contact.
-After contact with items/surfaces in patient/resident areas.
During an interview on 1/2/23 at 7:10 A.M., the surveyors were informed by staff that the facility had residents currently infected with COVID-19 and transmission-based precautions were in effect for those residents.
During the survey the following observations were made on the first-floor resident care unit:
On 1/2/24 at 8:19 A.M., the Minimum Data Set (MDS) nurse entered a resident room identified as requiring COVID/droplet precautions. The MDS nurse was not wearing an N95 mask and did not put on a gown or eye protection. The MDS nurse adjusted the resident's positioning in bed and turned off the call light. She then left the room and entered another resident's room.
During an interview on 1/2/24 at 8:20 A.M., the MDS nurse said she entered the precaution room without wearing the proper PPE. The MDS nurse said she should have put on a gown, eye protection, and an N95 mask. The MDS nurse said she just instinctively entered the room to respond to the call light.
On 1/02/24 at 8:28 A.M., Certified Nursing Aid (CNA) entered a resident room with COVID/droplet precautions. The CNA did not put on a gown or eye protection.
During an interview on 1/02/24 at 8:29 A.M., CNA #3 said she should have worn a gown and eye protection but forgot.
During the survey the following observations were made on the third-floor resident care unit:
On 1/03/24 at 11:23 A.M., Nurse #2 was observed in a resident room, identified by a sign on the door as requiring isolation precautions, with instructions of what PPE to don (put on). Nurse #2 was standing near the end of the bed of the resident holding a glucometer in his hand. Nurse #2 was not wearing a gown, an N95 mask, or eye protection. Nurse #2 exited the room.
A housekeeper was in the same room, occupied with a resident identified as being positive for Covid-19. The housekeeper was observed to be wearing a surgical mask and no eye protection. The housekeeper with gloved hands, removed a bag of trash, placed the bag in the housekeeping cart located in the doorway, touched the cart, and with the same potentially contaminated gloves, pulled out a mop, using the gloved hands repositioned the pad on the bottom of the mop, entered the room, moved the resident's tray table and walker, and continued to mop. At no time between tasks and encountering the resident's environment did the housekeeper remove her gloves and perform hand hygiene. The housekeeper doffed (removed) the gloves and gown over the threshold, just outside of the room and placed the contaminated PPE in the housekeeping cart trash bin.
During an interview on 103/24 at 11:49 A, M, Nurse #2 said he did a blood sugar in a resident's room and that the resident was positive for Covid-19. Nurse #2 said he had removed the gown and did not have eye protection when he did the resident's blood sugar. Nurse #2 said there was no available eye protection in the cart located outside the resident's room.
During an interview on 1/4/23 at 10:00 A.M., the surveyor shared the observations made of staff not wearing PPE and not performing hand hygiene with the Infection Preventionist (IP). The IP nurse said all staff should be following the transmission-based precautions, including wearing the appropriate PPE and performing hand hygiene.
Nov 2022
22 deficiencies
1 Harm
SERIOUS
(G)
Actual Harm - a resident was hurt due to facility failures
Pressure Ulcer Prevention
(Tag F0686)
A resident was harmed · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review and observation, the facility failed to: inform the physician of a newly identified pressure i...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review and observation, the facility failed to: inform the physician of a newly identified pressure injury or conduct weekly skin assessments as ordered by the physician, resulting in the development of a Stage II wound, for one Resident (#163) of 28 sampled residents.
Findings include:
Review of the facility's policy Skin Management Program, dated 10/12/22, indicated:
* Residents at risk for developing and/or who has a PI/PU [pressure injury/pressure ulcer} will be identified. This will be followed by implementation of appropriate individualized interventions to assist with avoiding the development/promoting healing of a PI/PU.
* Resident will undergo a weekly body check by the licensed nurse. The facility will utilize the weekly body check in the EHR [electronic health record].
Resident #163 was admitted to the facility on [DATE] and had diagnoses which included intercranial hemorrhage, expressive and receptive aphasia, right-sided hemiparesis, obesity and right great toe wound.
Review of Resident #163's physician orders, dated 5/19/22, indicated weekly skin check (order remained active from prior admission to facility), and apply protective cream to coccyx twice a day.
Resident #168's weekly skin assessment, dated 10/20/22, indicated his/her skin was intact. Review of Resident #168's medical record indicated a weekly skin assessment was not done on 10/27/22, or any other date prior to 11/2/22 (date of survey).
Resident #168's physician order, dated 10/20/22, indicated an order for an air mattress related to obesity, decreased mobility and a bariatric bed to assist with oxygen status.
Resident #163's nurse's note, dated 10/22/22 indicated Resident alert to self, toe dressing completed. New area was found on left buttocks, denies any pain.
Resident #163's Skin Incident Report, dated 10/22/22, indicated nursing staff discovered an unstageable wound on his/her right buttock. The wound was described as tear/friction shear. The Report indicated Treatment order obtained: Wound MD to see. Protective cream. The area on the wreport for the date and time of notifying the physician was left blank.
Review of Resident #163's nursing, nurse practitioner and physician progress notes, dated 10/22/22 through 10/30/22, indicated there was no reference to nursing staff informing the nurse practitioner or physician that Resident #163 had a new pressure injury on the right buttock, or any new physician orders hich identified the pressure injury.
Resident #163's Wound Physician note, dated 10/31/22, indicated he/she had an unstageable deep tissue injury on the coccyx for at least one day duration. The note indicated there was a moderate amount of serosanguinous exudate. The wound measured 3.5 x 5 x 0.3 centimeters (cm). Treatment recommendations indicated alginate calcium apply once daily for 30 days covered by a gauze border dressing.
Review of Resident #163's plan of care, start date of 11/1/22, indicated he/she was at risk for pressure ulcers related to decreased mobility, incontinence of bowel and morbid obesity. Interventions to manage this risk included the use of an air mattress, weekly skin inspection, and to report any signs of skin breakdown (sore, tender, red or broken areas).
Resident #163's physician order, dated 11/2/22, indicated:
* Wound consult
*Buttocks stage 2 (superficial). Cleanse with normal saline, pat dry, apply Solosite. Cover with coversite. Change daily and when soiled
*Offload buttocks when in and out of bed
Resident #163's nurse's note dated 11/2/22, indicated New order for Stage 2 dressing clean with normal saline; apply solosite and coversite; dressing completed, no drainage noted, no pain at site. Measurements are 1.5 x 1 and 1 x 0.5
During an interview with Nurse #3 on 11/2/22 at 11:00 A.M., she said she first noticed Resident #80's pressure injury on 10/22/22, and at that time the wound was red but not open. Nurse #3 said she telephoned the Physician and made him/her aware of the pressure injury. Nurse #3 said the Physician did not provide new orders, and that staff continued to apply barrier cream and use the air mattress to treat the pressure injury. Nurse #3 said she did not document in the medical record that she informed the Physician, or that there were no new orders. Nurse #3 said she first noticed the pressure injury had opened on 10/31/22. Nurse #3 said she then contacted the Wound Physician to examine Resident #80.
During an interview with Nurse Manager #1 on 11/2/22 at 1:00 P.M., she said it was expected that staff follow the physician's order and perform weekly skin assessments on Resident #163. Nurse Manager #1 said there was no documentation in the medical record referencing Nurse #3's 10/22/22 conversation with the Physician about Resident #163's new pressure injury.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0573
(Tag F0573)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to provide medical records upon request for 1 sampled Resident (#39), ...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to provide medical records upon request for 1 sampled Resident (#39), out of a total of 28 sampled residents.
Findings include:
Resident #39 was admitted in April, 2022 with diagnoses including atrial fibrillation and heart failure.
Review of the Minimum Data Set (MDS), dated [DATE], indicated that Resident #39 scored a 15 out of 15 on the Brief Interview for Mental Status (BIMS), which indicates the Resident is cognitively intact. Resident #39 is totally dependent on staff for bed mobility and dressing.
During an interview on 11/01/22, at 9:14 A.M., Resident #39 said that he/she had previously verbalized a request to staff to see the results of his/her blood work, and that he/she was never provided these results.
Review of Resident #39's medical record revealed a social work progress note, dated 8/26/22, indicating that the Resident had requested the results of his/her blood work.
During an interview on 11/4/22, at 8:33 A.M., the Director of Nurses (DON) said that the Resident has the right to see blood work results.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Notification of Changes
(Tag F0580)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to communicate to the physician, a concern that a reside...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to communicate to the physician, a concern that a resident's medication was ineffective, for 1 Resident (#39) out of a total sample of 12 residents.
Findings include:
Resident #39 was admitted in April, 2022 with diagnoses including heart failure.
Review of the Minimum Data Set (MDS), dated [DATE], indicated that Resident #39 scored a 15 out of
a possible total score of 15 on the Brief Interview for Mental Status (BIMS), which indicates the Resident
is cognitively intact. Further the MDS indicated Resident #39 is totally dependent on staff for bed mobility and dressing.
During an interview on 11/01/22, at 9:14 A.M., Resident #20 said that he/she has experienced eye
discomfort since admission, and that his/her eye drop medication has not been effective.
During an interview on 11/3/22, at 10:40 A.M., Nurse #7 said that Resident #20 often has complaints of
eye discomfort, including after his/her eye drops are administered. Nurse #7 said that she had not
notified a Physician or Nurse Practitioner that the Resident feels his/her eye drop medication is
ineffective.
During an interview on 11/4/22 at 8:36 A.m., the Director of Nurses (DON) said Resident #20 has been
signed up for consultant eye services, but has not yet been seen by an ophthalmologist. The DON said that
the physician or nurse practitioner should have also been notified of the Resident's concerns regarding
the effectiveness of the eye drop medication.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Safe Environment
(Tag F0584)
Could have caused harm · This affected 1 resident
Based on observation, record review and interview the facility failed to provide a clean device (wheelchair seat belt) for one Resident (#73) out of a total sample of 28 residents.
Resident #73 was ad...
Read full inspector narrative →
Based on observation, record review and interview the facility failed to provide a clean device (wheelchair seat belt) for one Resident (#73) out of a total sample of 28 residents.
Resident #73 was admitted to the facility in February of 2021.
Review of Resident #73's quarterly Minimum Data Set Assessment (MDS) with an assessment reference date of 8/25/22 indicated Resident #73 scored a 9 out of 15 on the Brief Interview for Mental Status exam indicating moderate cognitive impairment and required extensive assistance with bathing, dressing, transfers, and hygiene.
Review of Resident #73's medical record indicated the following care plan:
*Resident utilizes a self-release seat belt when up in wheelchair to help improve his/her safety and decrease his/her risk of falling out of the wheelchair, this will enable him/her to position him/herself better in the wheelchair. Resident will be asked to demonstrate his/her ability to self-release his/her seatbelt when asked 2 times a week. If unable to do so MD/NP (medical doctor/nurse practitioner) will be notified.
During the survey the following observations were made:
*On 11/1/22 at 9:01 A.M., Resident #73 was eating his/her breakfast. His/her seatbelt was soiled and dirty.
*On 11/01/22 at 10:47 A.M., Resident #73 was watching television with other residents in the hallway. His/her seatbelt was soiled and dirty.
*On 11/01/22 at 4:10 P.M., Resident #73 said the seatbelt was dirty, that staff had washed it once.
*On 11/02/22 at 11:11 A.M., Resident #73 was sitting in his/her room. His/her self- release seatbelt was soiled and dirty.
*On 11/3/22 at 9:06 A.M., Resident #73's self-released seat belt was cleaner but remained stained. Resident #73 said the nurse cleaned it this morning.
During an interview on 11/3/22 at 9:09 A.M., Nurse #6 said Resident's seatbelt was dirty and she cleaned it this morning. Nurse #6 said there was no specific plan for cleaning the seatbelt and she used her judgment.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Report Alleged Abuse
(Tag F0609)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to report to the State Agency a resident-to-resident altercation for on...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to report to the State Agency a resident-to-resident altercation for one Resident (#43) and failed to report timely to the state agency for one Resident #89, two incidents of Resident-Resident altercations, out of a total 28 sampled residents.
Findings include:
Review of the facility's policy titled Abuse Prohibition with a revision date of 10/11/22 indicated the following: The Facility will provide an environment in which the resident is free from abuse, neglect, mistreatment, misappropriation of resident property, or exploitation, including but not limited to freedom from corporal punishment, involuntary seclusion, and any physical or chemical restraint that is not required to treat the resident's medical symptoms. Facility staff will be educated on hire and annually on reporting requirements for abuse. This includes reporting alleged violations involving abuse, neglect, or mistreatment, including injuries of unknown source, and misappropriating of resident property, immediately, but not later than 2 hours after the allegations is made, the events that clause the allegation involved abuse or result in serious bodily injury.
1. Resident #43 was admitted to the facility in April 2022 and had diagnoses that included cellulitis of the chest wall.
Review of the most recent Minimum Data Set (MDS) assessment dated [DATE], revealed that on the Brief Interview for Mental Status (BIMS) exam, Resident #43 scored a 10 out of a possible 15, indicating moderately impaired cognition. The MDS further indicated Resident #43 had no behaviors.
During a record review on 11/03/22 at 8:45 A.M., a clinical progress note dated 9/24/22 indicated:
After dinner, Resident #43 was yelling at his/her roommate who was also at nurses' station, was not very clear why he/she kept saying he/she hated the roommate, tried to throw punch at him/her, writer stopped this Resident (#43) from doing that. Removed roommate temporarily to room.
Review of Healthcare Care Facility Reporting System (HCFRS) on 11/3/22 failed to indicate a resident-to-resident altercation had been reported.
During an interview with the Director of Nursing (DON) on 11/03/22 at 11:48 A.M., the clinical progress note regarding Resident #43 was reviewed with her and she said, I guess if you looked back this could have been something we reported. The DON said that she was not aware that the incident had occurred.
2. Resident #89 was admitted to the facility in July 2021 and has diagnoses that include atrial fibrillation, hypertension, and Alzheimer's dementia.
Review of the comprehensive Minimum Data Set Assessment (MDS) with an Assessment Reference Date (ARD) of 7/14/22 indicated Resident #89 scored 6 out of 15 on the Brief Interview for Mental Status, which indicated severe cognitive impairment. Further review of the MDS indicated Resident #89 was coded as requiring limited assistance from staff for transfers, dressing and hygiene and required physical assistance for bathing. Resident #89 was not coded on the MDS as exhibiting behaviors.
Review of the Health Care Facility Reporting System (HCFRS) indicated the facility reported three Resident to Resident incidents that involved Resident #89.
Review of the facility incident/investigations indicated the following:
*On 6/19/22 A resident had his/her hands in Resident #89's face. Resident #89 pushed the resident's hands away. The nurse immediately separated the residents. The resident was noted to have a 1.5-centimeter red mark on the left side of his/her neck.
The submission date on the HCFRS for the 6/19/22 incident was 6/22/22, three days after the resident-to-resident altercation occurred.
*On 4/26/22 Resident #89 at 11:00 A.M., while both resident #1 (Resident #89) and resident #2 were sitting at the nursing station, it was reported that resident #1 (Resident #89) appeared to have struck resident #2. Resident #2 sustained bruising to the left orbital area. The submission date on the HCFRS for the 4/26/22 incident was 4/28/22, two days after the resident-to-resident altercation occurred.
During an interview on 11/02/22 at 4:42 P.M., Nurse #4 said any report or allegation of abuse including resident-resident altercation needs to be reported within two hours.
During an interview on 11/02/22 at 3:32 P.M., the Director of Nursing said it was her understanding that resident-to-resident altercations were not included in the two-hour reporting timeline.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Investigate Abuse
(Tag F0610)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to investigate one resident to resident altercation for one Resident (#...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to investigate one resident to resident altercation for one Resident (#43) out of a total 28 sampled residents.
Findings include:
Review of the facility's policy titled 'Abuse Prohibition' dated as revised 10/11/22 indicated the following:
V. Investigations: Any incidents of actual or suspected abuse must have an incident report completed. In addition to the incident report, the supervisory personal are responsible to ensure the initial investigation regarding the incident occurs timely and appropriate interventions are put into place to ensure resident safety and protect the resident from additional harm.
Resident #43 was admitted to the facility in April 2022, and had diagnoses that included cellulitis of the chest wall.
Review of the most recent Minimum Data Set (MDS) assessment dated [DATE], revealed that on the Brief Interview for Mental Status (BIMS) exam, Resident #43 scored a 10 out of a possible 15, indicating moderately impaired cognition. The MDS further indicated Resident #43 had no behaviors.
During a record review on 11/03/22 at 8:45 A.M., a clinical progress note dated 9/24/22 indicated:
after dinner, Resident #43 was yelling at his/her roommate who was also at nurses station, was not very clear why he/she kept saying he/she hated the roommate, tried to throw punch at him/her, writer stopped this Resident #43 from doing that. Removed roommate temporarily to room.
During an interview with the Director of Nursing (DON) on 11/03/22 at 11:48 A.M., the clinical progress note regarding Resident #43 was reviewed with her and she said I guess if you looked back this could have been something we investigated, but that she was not aware that the incident had occurred.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0658
(Tag F0658)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure extended release (ER) medications were administe...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure extended release (ER) medications were administered in accordance with standards of practice by failing to ensure the medications were not crushed prior to administration for 2 Residents (#16 and #85) out of a total sample of 5 residents observed during medication administration.
Findings include:
Review of facility policy titled 'Medication Administration- General Guidelines' revised December 2019, indicated the following:
*Policy: Medications are administered as prescribed in accordance with good nursing principles and practices and only be persons legally authorized to do so. Personnel authorized to administer medications do so only after they have been properly oriented to the facility's medication distribution system (procurement, storage, handling and administration). The facility has sufficient staff and a medication distribution system to ensure safe administration of medications without unnecessary interruptions.
*Procedures: Tablet crushing/ capsule opening- Crushing tablets may require a physician's order, per facility policy. If it is safe to do so, medication tablets may be crushed or capsules emptied out when a resident has difficulty swallowing or is tube-fed, using the following guidelines.
-Orders to crush medications should not be applied to medications which, if crushed, present a risk to the patient. For example: Long acting or enteric- coated dosage forms should not be crushed; an alternative should be sought,
-The pharmacist should be contacted to review all medications being considered for crushing, whether a physician's order is present or not.
1. Resident #16 was admitted to the facility in April 2022 with diagnoses including hypertension and chronic obstructive pulmonary disease.
Review of Resident #16's Minimum Data Set Assessment (MDS) dated [DATE] indicated the Resident was severely cognitively impaired and scored a 2 out of 15 on the Brief Interview for Mental Status (BIMS). The MDS further indicated the Resident had no behaviors, did not reject care and required assistance with care activities.
During observation of the medication pass on 11/3/22 at 8:37 A.M., Nurse #2 said Resident #16 gets his/her medications crushed in applesauce. Nurse #2 prepared and crushed medications including the following:
-Pantoprazole Sodium (a medication used to treat GERD) 40 milligrams (mg) delayed release 1 tablet. The blister pack indicated the following instructions: Do Not Crush.
Nurse #2 administered the crushed medication to Resident #16.
Review of Resident #16's orders indicated the following:
-A physician's order dated 7/13/22 for Pantoprazole Sodium 40 mg one tablet by mouth daily- DO NOT CRUSH
During an interview on 11/03/22 at 9:51 A.M., Nurse #2 acknowledged crushing the Pantoprazole. He said he must have just missed the instructions that he was not supposed to crush it. Nurse #2 acknowledged if the order indicated do not crush, it shouldn't be crushed. Nurse #2 acknowledged that extended release medications are formulated to release medication over a longer duration and crushing a medication may change it to begin acting immediately.
2. Resident #85 was admitted to the facility in March 2022 with diagnoses including dementia, paroxysmal atrial fibrillation and hypertension.
Review of Resident #85's Minimum Data Set Assessment (MDS) dated [DATE] indicated the Resident was moderately cognitively impaired and scored an 8 out of 15 on the Brief Interview for Mental Status Exam (BIMS). The MDS further indicated the Resident had no behaviors, did not reject care and required assistance with care activities.
During observation of the medication pass on 11/3/22 at 8:51 A.M., Nurse #2 said that Resident #85 gets his/her medications crushed in applesauce. Nurse #2 prepare and crush medications including the following:
-Metoprolol Succinate (a medication used to lower blood pressure) Extended Release (ER) 25 milligrams (mg)
Nurse #2 administered the crushed medication to Resident #85.
Review of Resident #85's current physician orders indicated an order dated 3/23/22 for Metoprolol Succinate tablet extended release 25 mg once a day.
During an interview on 11/03/22 at 9:51 A.M., Nurse #2 acknowledged crushing the Metoprolol Succinate ER Nurse #2 said there was no order not to crush the extended release medication and further said he is an agency nurse and follows the orders as written. Nurse #2 acknowledged that extended release medications are formulated to release the medication over a longer time period and crushing a medication may change it to begin acting immediately. Nurse #2 said he determines if a resident gets their medications crushed with applesauce, which will be marked as c/a, or whole, which will be marked by w, by looking at the census sheet.
Review of the census sheet indicated Resident #85 takes his/her medications whole.
During an interview on 11/03/22 at 10:57 A.M., the Director of Nursing said that any medications that are extended release or delayed release should not be crushed. She said the expectation would be that the nurse would not crush any extended release meds, even if it wasn't specified in the order.
See tag F759
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
ADL Care
(Tag F0677)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview, the facility failed to ensure staff supervised and assisted with eating for o...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview, the facility failed to ensure staff supervised and assisted with eating for one Resident (#80) out of a total 28 sampled residents.
Findings include:
Resident #80 was admitted to the facility in April 2022, and had diagnoses that included dementia without behavioral disturbance and dysphagia (difficulty chewing and swallowing).
Review of the medical record indicated that on 6/2/22 the Speech Language Pathologist and Physician added a new diagnosis of aspiration precautions assist with feeding'. This order is still active.
Resident #80's Occupational Therapy Discharge summary, dated [DATE], indicated he/she required supervision or touching assistance for feeding.
Review of the most recent Minimum Data Set (MDS) assessment, dated 7/21/22, indicated Resident #80 was unable to participate in the Brief Interview for Mental Status examination and determined to have severely impaired cognition. The MDS further indicated Resident #80 was totally physically dependent on staff for eating and had no behaviors, such as resistance to care.
Resident #80's care plan, dated July 2022, indicated an activity of daily living deficit and he/she required extensive assist to dependant assist from staff for eating.
The medical record indicated that on 10/20/22 the Speech Language Pathologist and Physician added a new diagnosis of dysphagia, oropharygeal phase.
Review of the Certified Nursing Assistant documentation for August, September, October and through 11/2/22 indicated Resident #80 was totally dependent on staff for eating.
During an observation on 11/1/22 at 9:01 A.M., Resident #80 was in bed eating breakfast. No staff were present to supervise or assist.
During an observation on 11/2/22 at 8:35 A.M., Resident #80 was in bed. A staff person brought a breakfast tray to the room, woke up Resident #80, placed the breakfast directly in front of him/her, and exited the room, leaving Resident #80 alone, unsupervised and unassisted. Resident #80 attempted to feed self however he/she appeared to struggle as evidenced by food repeatedly falling off of the utensil.
During an observation on 11/2/22 at 12:39 P.M., a staff person delivered a lunch tray to Resident #80. The staff person set up the tray and exited the room, leaving Resident #80 alone, unsupervised and unassisted. At 12:44 P.M., Resident #80 was seated in a chair,with the tray directly in front of him/her, however Resident #80 made no attempts to feed self.
During an interview with the Director of Nursing (DON) on 11/3/22 at 12:29 P.M., and again on 11/9/22 at 1:45 P.M., she said it was her understanding, based on the Occupational Therapy note dated 6/14/22, that Resident #80 could safely eat alone in his/her bedroom and that the MDS, care plan and CNA entries did not reflect this change in eating status.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Quality of Care
(Tag F0684)
Could have caused harm · This affected 1 resident
Based on observation, record review and interview the facility failed to ensure quality of care for one Resident (#43) out of a total sample of 28 residents. Specifically, the facility failed to adher...
Read full inspector narrative →
Based on observation, record review and interview the facility failed to ensure quality of care for one Resident (#43) out of a total sample of 28 residents. Specifically, the facility failed to adhere to professional standards of quality of care for a change in a skin condition, when a dressing was left on Resident #43, failed to ensure orders were obtained for the care and treatment of a skin injury and that the skin injury was identified on the weekly skin observation report.
Finding include:
Review of the policy entitled 'Skin Management Program' dated as revised 10/12/22 indicated that residents will undergo a weekly body check by the licensed nurse. Certified Nursing Assistants will inspect the skin of each resident during daily care and whenever skin care is provided and report to the licensed nurse any changes to the resident's skin. Licensed nurses will respond to reports of skin problems and assess the residents' skin as soon as possible. The licensed nurse will fill out a skin incident report' and give to the director of nursing or designee. If skin breakdown is identified, the physician will be notified, and a treatment will be obtained.
Resident #43 was admitted to the facility in May 2022 and has diagnoses that include cellulitis of the chest wall, vascular dementia, atrial fibrillation, hemiplegia, and hemiparesis following a cerebrovascular disease affecting his/her non dominant left side.
Review of Resident #43's most recent Minimum Data Set Assessment (MDS) with an assessment reference date of 10/6/22 indicated Resident #43 scored 10 out of 15 on the Brief Interview of Mental Status which indicates a moderate cognitive impairment.
On 11/1/22 at approximately 10:05 A.M., Resident #43 was observed lying on his/her bed. Resident #43 had a gauze dressing around his/her left arm. Resident #43 said he/she had a cut and is on a blood thinner. A small bottle of saline was on his/her bedside table.
On 11/02/22 at 8:12 A.M., Resident #43 was resting in bed and observed with a gauze dressing around his/her left arm.
On 11/2/22 at 11:14 A.M., Resident #43 was observed resting on his/her bed. His/her left arm had approximately six inches of a gauze dressing wrapped around his/her left lower arm which was secure with tape and not dated. Resident #43 said he/she did not know how long the dressing was on his/her left arm. He/she said the nursing staff change a dressing on his/her chest. Resident #43 lifted his/her shirt, and a sternum dressing was dated 11/1/22.
On 11/2/22 at 11:42 A.M., review of the medical record failed to indicate any wound treatment or dressing to Resident #43's left lower arm.
Review of the weekly skin observation report dated 10/24/22 at 8:11 P.M., indicated alterations in skin as 'no.'
Review of the weekly skin observation report dated 11/1/22 and recorded 11/2/22 at 6:53 A.M., indicated alterations in skin, 'no.' Comments wound to chest, continue treatment.
Review of Resident #43's care plans indicated the following:
*Resident is receiving anticoagulant therapy due to A-fib dated 10/20/22 with an intervention dated 9/21/22 to monitor for bleeding gums, scleral puncture, and bruising, ETC. report to MD/NP as needed.
*Resident is at risk for pressure ulcers due to history of diabetes mellitus with neuropathy and incontinence of bowl and bladder dated 10/20/22 with an intervention dated 6/20/22 conduct a systematic skin inspection weekly.
Review of the progress notes dated from 9/8/22 through 11/1/22 failed to indicate any note addressing the skin injury on Resident #43's left arm. A note dated 10/29/22 at 3:38 P.M., indicated resident is status post fall 10/29/21. A note dated 10/29/22 at 9:13 P.M., indicated Resident #43 is status post fall 10/28/22. A note dated 10/31/22 at 8:05 P.M., indicated Resident #43 was on the floor. None of the notes indicated Resident #43 sustained an injury to his/her left arm requiring a dressing.
During an interview on 11/03/22 at 9:10 A.M., Nurse #6 said she was not aware of any dressing to Resident #43's left arm. The surveyor and Nurse #6 went to Resident #43's room and he/she was observed with a gauze dressing that was six inches in length and wrapped around Resident #43's left arm. Resident #43 said he/she bleeds a lot and when asked by Nurse #6 when the dressing was placed, he/she said he/she could not remember. Nurse #6 said Resident #43 had a fall a few days ago. Nurse #6 said a date should be on any dressing and an order should be in place for any dressing or treatments. Nurse #6 removed the gauze around Resident #43's arm which revealed a non-adherent dressing. Nurse #6 removed the non-adherent dressing which was observed to have dark drainage on it approximately 1 inch by ½ inch and was the same shape as the skin injury. Nurse #6 said clear drainage was present and that it was an abrasion. It was observed to have layers of skin missing in the area, with glistening drainage and reddened.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Accident Prevention
(Tag F0689)
Could have caused harm · This affected 1 resident
Based on record review and interview the facility failed to ensure a falls investigation was conducted for one Resident (#57), who sustained an unwitnessed fall, out of a total 28 sampled residents.
...
Read full inspector narrative →
Based on record review and interview the facility failed to ensure a falls investigation was conducted for one Resident (#57), who sustained an unwitnessed fall, out of a total 28 sampled residents.
Findings include:
The facility policy titled Fall Management Program, revised 10/13/22, indicated the following:
* A fall risk assessment will be conducted on each resident upon admission, with the quarterly MDS (Minimum Data Set) cycle, when a significant change in status occurs, annually and/or after a fall.
* If a resident falls, the nurse on duty will document a clinical assessment, physician and family notification, emergency care and/or transfer to the hospital, as applicable, in the nurses' note. The Nurse will complete the Incident/Accident Report.
* Ongoing clinical assessment for latent injury is to be conducted and documented every shift for 72 hours.
* If the resident suffers a head injury or unwitnessed fall, a neurological assessment is to be completed and neuro signs are to be documented.
Resident #57 was admitted to the facility in January 2022, and had diagnoses that included Alzheimer's disease and generalized anxiety disorder.
Review of the most recent Minimum Data Set (MDS) assessment, dated 10/20/22, revealed that on the Brief Interview for Mental Status exam, Resident #57 scored a 9 out of a possible 15, indicating moderately impaired cognition. The MDS further indicated Resident #57 had no behaviors.
On 11/03/22 at 8:47 A.M., during a review of Resident #57's medical record, the following was indicated:
* A clinical progress note, dated 11/1/22, indicated that Resident #58 had a dark purple discoloration on flank and when asked how he/she got it says that he/she fell in the bathroom;
* A clinical progress note, dated as a late entry for 10/29/22 7-3 shift, Resident #57 was noted with an old bruise on his/her back when he/she was about to receive a shower, he/she stated he/she fell a few nights ago in his/her bathroom, he/she did not tell anyone. When son visited asked resident if he/she had any fall, he/she made same statement;
* The most recent Fall Risk Assessment was completed on 9/4/22;
* Failed to indicate a clinical assessment was completed post Resident #57's report that he/she sustained a bruise due to a fall;
* Failed to indicate the physician was notified of the reported fall;
* Failed to indicate an incident/accident report was generated;
* Failed to indicate ongoing clinical assessment for latent injury was conducted;
* Failed to indicate neurological assessments were conducted once staff became aware the Resident sustained an unwitnessed fall.
During an interview with Resident #57's Certified Nursing Assistant (CNA) #1 on 11/03/22 at 9:3 A.M., she said that on approximately 10/29/22, she was showering Resident #57 and noticed Resident #57 had a bruise on his/her back. CNA #1 said that the Resident stated that he/she sustained the bruise when he/she had a recent unwitnessed fall. CNA #1 said that she immediately reported the incident to the nurse on duty.
During an interview with the Director of Nursing (DON) on 11/03/22 at 12:18 P.M., she said she remembered that Resident #57 reported that a new bruise found by staff was due to a fall, but that she did not conduct a falls investigation.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Incontinence Care
(Tag F0690)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review and interviews, the facility failed to ensure that an indwelling catheter (a tube that ente...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review and interviews, the facility failed to ensure that an indwelling catheter (a tube that enters the bladder to drain urine) bag was at the proper positioning to allow urine to be drained into the bag for 1 Resident (#75) out of a total sample of 28 residents.
Findings include:
Resident #75 was admitted to the facility in August 2020 with diagnoses that included Alzheimer's disease, Crohn's disease, and urinary tract infection.
Review of Resident #75's most recent MDS, dated [DATE] indicated that that the Resident had a Brief Interview for Mental score of 7 out of a possible 15, which indicated that he/she had moderate cognitive impairment. The MDS further indicates that he/she requires extensive assistance with transfers and toileting.
Review of the facility policy titled Catheter Care of Indwelling Urinary, dated 5/21/21 indicates the following:
*Always keep the drainage bag below the level of the resident's bladder and off of the floor. Position catheter tubing for straight drainage.
The surveyor made the following observations:
*On 11/1/22 at 1:32 P.M., Resident #75 was observed laying in bed with his/her knees in an upward position with the catheter bag strapped to his/her left knee, not hanging below the bladder level.
*On 11/2/22 at 10:41 A.M., Resident #75 was observed sleeping in his/her bed with no catheter bag hanging from the bed.
On 11/3/22 at 7:03 A.M., Resident #75 was observed sleeping in his/her bed with the catheter bag strapped to his/her left leg, not hanging below the bladder level.
Review of Resident #75's physician's orders dated 8/5/2020 indicate the following: May utilize leg bag while out of bed.
Review of Resident #75's foley catheter care plan dated 8/30/22, indicates the following:
*Change to leg bag during the day to facilitate mobility and enhance safety.
*Keep bag below level of the bladder.
During an interview on 11/3/22 at 8:58 A.M., Nurse #1 said a catheter bag can be strapped to the leg when the Resident is out of bed walking around, but it should be below the bladder location when laying in bed.
During an interview on 11/4/22 at 8:12 A.M., the Unit Manager said Resident #75's catheter bag should be hanging below the bladder level when he/she is laying in bed. During the interview, she asked an aide to change his/her catheter bag to a hanging one as he/she was laying in bed during the interview.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0692
(Tag F0692)
Could have caused harm · This affected 1 resident
Based on observation, record review and interview the facility failed to ensure a significant weight loss (9.6 pounds) was identified, assessed and interventions implemented, for one Resident (#68) an...
Read full inspector narrative →
Based on observation, record review and interview the facility failed to ensure a significant weight loss (9.6 pounds) was identified, assessed and interventions implemented, for one Resident (#68) and failed to ensure that nutritional supplements were provided in adherence to the medical plan of care for one Resident (#43) out of a total sample of 28 residents.
Findings include:
Review of the facility's policy titled 'Nutritional Management Clinical Program', not dated, indicated the following:
1. All residents will be weighed upon admission/readmission weekly times 4 weeks and then monthly or as ordered by the MD (medical doctor.)
2. Whenever possible, residents will be weighed on the same scale, at about the same time of day (morning, afternoon etc.) When wheelchair scales are used, the wight of the wheelchair and attachments and padding will be subtracted from the total weight to calculate the residents' true weight.
3. Compare the new weight to the resident's previous weight. Note the difference between weights and whether a weight loss (-), or weight gain (+). If the residents new weight differs by (3) pounds or more pounds, the resident needs to be re-weighed on the same day. Any weight loss/gain of 3 pounds or greater requires the resident to be reviewed at the weekly weight focus review and placed back on weekly weights until stabilized.
4. Determine whether the weight change is significant. An unexpected loss or gain of 5% or more within one month, and /or 10% in (6) months is significant.
5. Notify the physician and dietician of a significant weight change.
6. Any resident that has experienced a 3-pound weight change/and or significant weight loss will be followed by, the interdisciplinary weight focus group, until the team determines the resident's weight is stable.
1. Resident #68 was admitted to the facility in June 2022 with diagnoses that include Alzheimer's disease, urinary retention, atrial flutter, type 2 diabetes mellitus, depression, and weakness.
Review of the quarterly Minimum Data Set Assessment with an Assessment Reference Date of 9/8/22 indicated a staff assessment for mental status which indicated Resident #68 had severe cognitive impairment, required extensive assistance from staff for bed mobility, transfers, hygiene and required supervision for eating. Further review of the MDS indicated Resident #68 was 71 inches in height and weighed 179 pounds.
Review of Resident #68's medical record indicated a telephone order for a nutrition consult for weight loss dated 9/14/22.
Review of the Registered Dietician's progress note dated 9/14/22 indicated the consult was received verbally for weight loss. Weights were as follows:
*06/22/22 187 pounds (lbs.)
*06/28/22 179 lbs.
*07/05/22 182 lbs.
*07/19/22 182.2 lbs.
*08/02/22 179 lbs.
*08/09/22 180 lbs.
*09/06/22 179 lbs.
PO (By mouth) intake of 50-100 %, variable. Weight on 6/22/22 is likely erroneous, given patient likely did not lose 7.2 pounds in 6 days back in June. Noted weight is trending down and weight change of 3.8 lbs. in 2 months. Director of nursing aware of necessity of patient needing help with meals as of 9/14/22. Agree with Nurse Practitioner increasing Glucerna to twice a day.
Review of the care plan with the problem category of Nutritional Status, dated 6/25/22 indicated Resident #68 requires a therapeutic diet per diagnosis of diabetes. Resident is at nutritional risk due to dementia and age. Approach: Monitor weight, skin and labs as ordered. Provide supplement as ordered and monitor acceptance. Goal: Consume 50-70 percent of meals and snacks and accept supplements as offered. Resident will not lose significant unintentional weight at facility, edited date 9/22/22.
11/02/22 at 12:44 P.M., Resident #68 was observed at lunch. He/she had a lip plate and staff was present and assisting him/her to eat.
Review of Resident #68's medical record indicted the following:
*On 9/06/2022, Resident #68 weighed 179 lbs. The next recorded weight on 10/11/2022 Resident #68 weighed 169.4 pounds which is a -5.36 % weight loss, which is significant. Further review failed to indicate a re-weigh was completed the same day per facility policy. Furthermore, the medical record failed to indicate the RD was notified of the significant weight loss for Resident #68.
During an interview on 11/2/22 at 3:06 P.M., the Registered Dietician said in mid-September she was consulted by the Nurse Practitioner regarding weight loss for Resident #68. The RD said she talked with Certified Nursing Assistants and determined Resident #68 needed more assistance with meals and that Glucerna (a nutritional supplement) was increased from once a day to twice a day to assist with preventing further weight loss. The RD said she was not aware nor was made aware that Resident #68 continued losing weight resulting in a significant weight loss. The RD said she did not assess the interventions put in place on 9/14/22 to prevent further weight loss. The RD acknowledged that Resident #68's weight loss between 9/6/22-10/11/22 was significant with 9.6 lbs. weight loss and a re-weigh should have been done the same day to verify the weight loss. The RD said the weight loss did not show up on the weight variance report. The RD said residents with weight loss are followed in a weekly team risk meeting.
During an interview on 11/02/22 at 3:46 P.M., the Director of Nursing said Resident #68 is followed at the risk meeting because of the Foley urinary catheter and behaviors. The DON said residents with significant weight loss are followed in weekly risk meetings. The surveyor told the DON of Resident #68's weight loss and she said a re-weigh should have been done, the RD should be consulted, and weekly weights completed.
The significant weight loss for Resident #68 was not addressed by facility staff until 22 days after the significant weight loss occurred.
2. For Resident #43 the facility failed to ensure magic cup (a frozen nutritional supplement) was provided on the lunch and dinner meal trays.
Resident #43 was admitted to the facility in May 2022 and has diagnoses that include cellulitis of the chest wall, vascular dementia, atrial fibrillation, hemiplegia, and hemiparesis following a cerebrovascular disease affecting his/her non dominant left side.
Review of Resident #43's most recent Minimum Data Set Assessment (MDS) with an assessment reference date of 10/6/22 indicated Resident #43 scored 10 out of 15 on the Brief Interview of Mental Status which indicates a moderate cognitive impairment. Further review of the MDS indicated Resident #43 is 70 inches in height, weighs 138 pounds and has had weight loss of 5% in one month and 10% in 6 months and is not on a physician prescribed weight-loss regimen.
Review of Resident #43's care plan indicated the following:
*Problem start date 4/5/22. Category: Nutritional status. Severe protein calorie malnutrition related to chewing/swallowing difficulty need for altered texture as evidenced by significant weight loss of 39 pounds, weight loss times 3 months-improving. Approach dated 4/5/22 Supplements as ordered.
Review of Resident #43's physician's orders indicated the following:
*Magic cup daily at lunch and dinner twice a day at 12:00 P.M., and 5:00 P.M., dated 5/26/22-open ended.
On 11/2/22 at 12:45 P.M., Resident #43 was observed eating in the dining room. His/her plate had meat, gravy, potatoes, green beans, ginger ale, and dessert of vanilla pudding. There was no magic cup on the meal tray, nor did staff offer Resident #43 a magic cup.
On 11/2/22 at 5:39 P.M. Resident #43 was observed waiting for his/her dinner tray. When the tray arrived it had whole milk, chicken with rice and vegetables, a container of apples. No magic cup was on the tray, nor did staff offer Resident #43 a magic cup.
Review of the meal ticket on the tray did not indicate magic cup.
On 11/3/22 at 12:33 P.M., Resident #43 was served his/her lunch meal. No magic cup was on the tray or provided to Resident #43 by staff.
At this time during an interview Nurse #1 said the nursing staff check the trays before they are passed to make sure everything is present on the tray as required. Nurse #1 said the kitchen sends magic cup on the trays when it is ordered for a resident. Nurse #1 said Resident #43 had an order for magic cup and he/she should be getting it on his/her tray.
During an interview on 11/3/22 at 1:02 P.M., the Registered Dietician said Resident #43 had an order for magic cup for lunch and dinner. Review of the meal tracker ticket did not indicate the magic cup as ordered. The RD said the magic cup must have been removed from the ticket and said it must have been recently because she has seen the magic cup herself and nursing has said he/she had been receiving it.
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 record review, interview and observation, the facility failed to ensure the nasal cannula and tubing were dated, bagged, kept clean, and not used on a resident when unclean, for one Resident ...
Read full inspector narrative →
Based on record review, interview and observation, the facility failed to ensure the nasal cannula and tubing were dated, bagged, kept clean, and not used on a resident when unclean, for one Resident (#80) of 28 sampled residents.
Findings include:
Review of the facility's policy for Equipment Changing (undated) indicated all respiratory equipment must be changed in order to prevent nosocomial infections. The equipment should be marked with the date that it was changed. All equipment should be changed on a weekly basis as well as prn [as needed] if it becomes soiled or falls on the ground. This equipment includes but is not limited to nasal cannulas, oxygen tubing and nebulizer treatment equipment.
Resident #80 was admitted to the facility in May 2022, and had diagnoses which included chronic obstructive pulmonary disease and respiratory failure.
Resident #80's quarterly Minimum Data Set assessment, dated 7/21/22, indicated severe cognitive impairment and required extensive staff assistance for bed mobility.
During an observation on 11/1/22 at 9:01 A.M., Resident #80 was lying in bed and eating breakfast. No staff were present in the room. A nebulizer machine with attached tubing and unbagged mask were on the bedside table. The nebulizer tubing was undated. A portable oxygen concentrator machine was on the floor next to his/her bed and running at 2 liters per minute. Undated oxygen tubing and a nasal cannula, attached to the concentrator, were undated, unbagged and lying exposed on the floor.
During an observation on 11/1/22 at 10:30 A.M., Resident #80 was lying in bed, asleep. The tubing for the nebulizer machine and the oxygen concentrator were still undated and the nebulizer mask was unbagged. The nasal cannula from the oxygen concentrator was under his/her nose, and the oxygen concentrator was still running at 2 liters per minute.
During an interview with Nurse #3 on 11/1/22 at 10:35 A.M., she said staff should date nebulizer and oxygen tubing, and bag the mask and cannula when not in use. The surveyor informed Nurse #3 that Resident #80's cannula was on the floor, unbagged, and that later someone placed the dirty cannula onto Resident #80. Nurse #3 said an exposed cannula on the floor should be discarded and not be placed on Resident #80.
Nurse #3 said Resident #80 frequently removes the cannula, but he/she did not have the functional ability to pick up the nasal cannula from the floor or affix it to his/her face. Nurse #3 said she did not pick up the nasal cannula from the floor and place it on Resident #30, and did not know who did. Nurse #3 said she had not yet provided care or rounded on Resident #80 today.
During an interview with the Director of Nurses (DON) on 11/1/22 at 2:26 P.M., she said it was facility policy to date nebulizer and oxygen tubing, to bag masks and cannula when not in use, and to replace cannulas if they fall to the floor.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0698
(Tag F0698)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review the facility failed to implement a physician's order to give phosphate bind...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review the facility failed to implement a physician's order to give phosphate binders (a medication to absorb phosphate from the food you eat) at the appropriate time for 1 Resident (#32) who requires dialysis, out of a total sample of 28 residents.
Findings include:
Review of the Davita Kidney Care Professional Standards of Practice, phosphate binders help to pass excess phosphorus out of the body in the stool, reducing the amount of phosphorus that gets into the blood. Usually, phosphate binders are taken within 5 to 10 minutes before or immediately after meals and snacks.
Resident #32 was admitted to the facility on 12/2020 with diagnoses that include hemiplegia following cerebral infarction, end stage renal disease, aphasia and type 2 diabetes mellitus.
Review of Resident #32's most recent Minimum Data Set (MDS) dated [DATE] indicated that the resident had a brief interview for mental status score of 8 out of a possible 15 which indicated that he/she had moderate cognitive impairment. The MDS further indicated that Resident #32 requires total dependence with locomotion on and off the unit, with transfers and bed mobility.
Review of Resident #32's physician's orders, dated 11/8/21 indicate the following:
*Sevelamer carbonate (phosphate binder), give 3 packs, must be given with meals.
Review of Resident #32's phosphorous lab reports from the dialysis center indicate the following:
*March, 2022: 7.0 (normal range is 3.0 - 5.5)
*April, 2022: 8.9
*May, 2022: 5.7
*June, 2022: 8.6
*July, 2022: 5.9
*August, 2022: 7.4
*October, 2022: 6.4
The lab report further states that Resident #32's phosphorous is above goal and recommended to take phosphate binders as prescribed.
On 11/2/22 at 12:25 P.M., the surveyor observed the medication administration report (MAR) indicating that Resident #32 received his/her phosphate binders by Nurse #2. At 12:42 P.M., of the same day, the Resident was observed receiving his/her lunch tray, 17 minutes after consumption of the phosphate binder.
On 11/3/22 at 8:32 A.M., Resident #32 received his/her breakfast tray. At 8:51 A.M. on the same day, the MAR did not indicate the Resident received his/her phosphate binder. At 9:17 A.M., on the same day, the MAR did not indicate the Resident received his/her phosphate binder. At 10:01 A.M. on the same day, the MAR indicated that Resident #32 did receive his/her phosphate binders by Nurse #2, 89 minutes after receiving his/her breakfast tray.
During an interview on 11/3/22 at 10:52 A.M., Nurse #2 said he was not sure what phosphate binders are used for or when they should be administered.
During an interview on 11/3/22 at 10:52 A.M., Nurse #1 said phosphate binders are used to absorb phosphorous in the blood so the levels do not get too high, and they should be taken with meals, or they will not work properly. She further stated that a patient's phosphorus levels will likely be elevated if not taken with food. She continued to say that they follow the recommendations of the dialysis center and medications should be taken as prescribed by the physician.
During an interview on 11/4/22 at 8:12 A.M., Unit Manager #2 said she was unaware that phosphate binders needed to be administered within 5-10 minutes of eating.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Drug Regimen Review
(Tag F0756)
Could have caused harm · This affected 1 resident
Based on record review and interview the facility failed to ensure the recommendation from the Monthly Medication Review (MMR), conducted by the pharmacist was addressed and implemented for one Reside...
Read full inspector narrative →
Based on record review and interview the facility failed to ensure the recommendation from the Monthly Medication Review (MMR), conducted by the pharmacist was addressed and implemented for one Resident (#88) out of a total sample of 28 residents.
Findings include:
Resident #88 was admitted to the facility in October of 2020 and has diagnosis that include congestive heart failure, mild cognitive impairment, and chronic obstructive pulmonary disease.
Review of the quarterly Minimum Data Set Assessment (MDS) with an assessment reference date of 7/28/22 indicated that Resident #88 scored 14 out of 15 on the Brief Interview for Mental Status exam which indicates intact cognition and requires limited assistance with bathing, dressing and hygiene.
Review of a progress note dated 12/12/21 written by the pharmacist indicted the following: see consultant pharmacist report.
Further review of the medical record failed to have the consultant pharmacist report or any progress notes to indicate the presence of/or information from the report.
During an interview on 11/2/22 at 12:02 P.M., the Director of Nursing (DON) provided a copy of the 'Consultant Pharmacist Recommendation to Nursing Report' for recommendations created between 12/1/21 and 12/12/21. The DON said the recommendation was for nursing to have Resident #88 to rinse his/her mouth after receiving his/her Advair. The DON said it should be under special instructions in the physician's orders.
Review of the Consultant Recommendation to Nursing Report, dated 12/12/21, indicated the following:
Resident is receiving Advair. In order to help prevent the development of thrush please update the order to instruct Resident to rinse mouth after use.
Review of the physician's order indicated the following:
Advair Diskus,1 puff twice a day, special instructions 1 puff every 12 hours, start date 10/26/20-open ended. The order failed to indicate the special instructions to have Resident #88 rinse his/her mouth after use.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Medication Errors
(Tag F0758)
Could have caused harm · This affected 1 resident
Based on record review and interview the facility failed to ensure for one Resident (#88) that a gradual dose reduction (GDR) of an antipsychotic medication was documented as clinically contraindicate...
Read full inspector narrative →
Based on record review and interview the facility failed to ensure for one Resident (#88) that a gradual dose reduction (GDR) of an antipsychotic medication was documented as clinically contraindicated by the physician, out of sample of 28 residents.
Findings include:
Resident #88 was admitted to the facility in October of 2020 and has diagnosis that include congestive heart failure, mild cognitive impairment, and unspecified psychosis.
Review of the quarterly Minimum Data Set Assessment (MDS) with an assessment reference date of 7/28/22 indicated that Resident #88 scored 14 out of 15 on the Brief Interview for Mental Status exam which indicates intact cognition.
Further review of the MDS indicated that Resident #88 was administered an antipsychotic medication on a regular basis and that a GDR was not conducted and that a GDR was documented by a physician as contraindicated on 1/5/22.
Review of the physician orders dated 10/2022 indicated the following:
*An order dated 6/1/22-open ended, Seroquel (an antipsychotic medication) tablet 100 milligrams twice a day.
Review of the psychiatric nurse specialist note dated 1/5/22 indicated Resident #88's medications reviewed and to continue same medications. The note failed to indicate the GDR of the antipsychotic mediation was clinically contraindicated.
During an interview on 11/3/22 at 8:36 A.M., the Minimum Data Set Assessment Nurse said the psychiatric clinical nurse specialist reviews the psychiatric medications for residents. The MDS nurse acknowledged the 1/5/22 progress note, which was used on the MDS to indicate why a GDR is contraindicated, only indicated to continue with meds and failed to include documentation of why a GDR is contraindicated.
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 observation, record review and interview the facility failed to properly assess 1 Resident (#56) for the storage of medication in his/her bedside out of a total of 28 residents.
Findings inc...
Read full inspector narrative →
Based on observation, record review and interview the facility failed to properly assess 1 Resident (#56) for the storage of medication in his/her bedside out of a total of 28 residents.
Findings include:
Resident #56 was admitted to the facility in May 2022 and has diagnoses that include anemia, diabetes mellitus, hypertension, and coronary artery disease.
Review of the Minimum Data Set Assessment (MDS) with and assessment reference date of 8/11/22 indicated Resident #56 scored 13 out of 15 on the Brief Interview for Mental Status exam, indicating intact cognition.
On 11/1/22 at 12:20 P.M., a plastic cup filled with disc shape tablets was sitting on Resident #56's bedside table. Resident #56 said they were Rolaids. The Resident said he/she once had an order for them (Rolaids.). It was not possible to verify the contents of the plastic cup due to the discs not being in original packaging.
On 11/2/22 at 11:38 A.M., Resident #56 was observed resting on his/her bed. The plastic cup of tablets was not visible to the surveyor.
During an interview on 11/02/22 at 5:20 P.M., Resident #46 said the cup of Rolaids was in his/her drawer. He/She said the nurses know that he/she has them and just say don't take too many.
On 11/3/22 at 8:17 A.M., review of medical record failed to indicate an order for self admin of medications. The document titled 'Self Administration of Medication' was not dated and was entirely blank. Further review indicated Resident #56 did not have an order for Rolaids. There was not care plan to have medication stored bedside in Resident #56's room.
During an interview on 11/3/22 at 9:22 A.M., Nurse #9 said she did not believe Resident #56 had an order to self-administer medications. She then acknowledged that document for self-administration was blank. She said an order, and the self-administration document would need to be in place and all medications should be in original packaging. Nurse #9 said that maybe the Resident's spouse brought them in.
On 11/3/22 at 12:18 P.M., Nurse #8 said the tablets were calcium carbonate.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Comprehensive Care Plan
(Tag F0656)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. For Resident #2, the facility failed to implement the care plan for the use of an air mattress by not having the air mattress...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. For Resident #2, the facility failed to implement the care plan for the use of an air mattress by not having the air mattress at the correct setting and not using pillows to offload heels.
Resident #2 was admitted to the facility in August 2020 with diagnoses that include dementia, major depressive disorder and osteoarthritis.
Review of Resident #2's most recent Minimum Data Set (MDS) dated [DATE], indicated that Resident #2 had a Brief Interview for Mental Status score of 8 out of a possible 15, which indicated that he/she had moderate cognitive impairment. The MDS further indicated that Resident #2 required extensive assistance with bed mobility and transfers.
During the survey the surveyor observed the following observations:
*On 11/1/22 at 11:53 A.M., the air mattress was set at 250 pounds.
*On 11/3/22 at 7:02 A.M., Resident #2 was observed lying in bed with his/her heels not offloaded and the air mattress was set for 250 pounds.
*On 11/4/22 at 6:51 A.M., Resident #2 was observed lying in bed with his/her heels not offloaded and the air mattress was set at 250 pounds.
Review of Resident #2's care plan dated 6/7/21, indicated that the Resident is at risk for skin impairment related to a history of stage 2 pressure ulcer, poor skin turgor and decreased mobility. The care plan further indicated the following:
*Use pillows to offload to relieve pressure on the heels.
*Air Mattress in bed to alternate between 125-140 pounds. Check placement and function every shift.
Review of Resident #2's physician orders dated 9/3/20 indicated to check the placement and function of the air mattress every shift.
Review of Resident #2's weights indicate the following:
*10/26/22: 156 pounds, 10/25/22: 153 pounds, 10/18/22: 153 pounds, 10/17/22: 154 pounds, 10/12/22: 153 pounds, 10/7/22: 153 pounds, 10/4/22: 154 pounds.
During an interview on 11/4/22 at 7:56 A.M., Nurse #4 said that an air mattress should be set to the resident's weight, and they would follow the physician's orders for the correct settings.
During an interview on 11/4/22 at 8:12 A.M., Unit Manager #2 said that Resident #'2 air mattress was on the incorrect setting and she adjusted it to the correct one with the surveyor present. She also said the Resident's heels should be offloaded.
3) For Resident #75, the facility failed to implement a physician's order to obtain monthly weights.
Resident #75 was admitted to the facility in August 2020 with diagnoses that included Alzheimer's disease, Crohn's disease, and urinary tract infection.
Review of Resident #75's most recent MDS, dated [DATE] indicated that the resident had a Brief Interview for Mental score of 7 out of a possible 15, which indicated that he/she had moderate cognitive impairment. The MDS further indicates that he/she requires extensive assistance with transfers and toileting.
Review of the facility policy titled Weight Monitoring Policy, undated, indicated the following:
*All residents will be weighed upon admission/readmission weekly x 4 weeks and then monthly or as ordered by the MD.
Review of Resident #75's physician orders indicated an order dated 4/19/22 for the Resident to have monthly weights on the first Monday of the month.
Review of Resident #75's weight history indicated the following:
*On 8/24/22 170.5 pounds.
*On 5/11/22 168.4 pounds.
*On 5/4/22 167 pounds.
*On 4/4/22 171.1 pounds.
Resident #75's weight history fails to indicate any recorded weights for the months of June, July, September, or October since the physician's order was implemented.
During an interview on 11/3/22 at 9:07 A.M., Certified Nursing Assistant (CNA) #2 said that nursing will tell the CNA's when to weigh residents and once we weigh them, we tell nursing the resident's weights so they can input them.
During an interview on 11/3/22 at 9:12 A.M., Nurse #2 said a message will pop up on his electronic medical record to weigh a resident and he will then ask a CNA to put it on their assignment for the day and report back the weight to nursing. He further said that the unit has a new Unit Manager, and they are just starting to use a weight book to obtain resident weights. He further said that Resident #75's weights should have been done monthly if that's what the physician's orders state.
Based on observation, record review and interview the facility failed to: ensure the care plan was implemented for the use of a pressure relieving air mattresses for 2 Residents (#64 and #2); implement the use of off-loading pillows for one Resident (#2) and implement monthly orders to obtain weights for one Resident (#75), out of a total sample of 28 residents.
Findings include:
Review of the facility policy titled Alternating Pressure Air Mattress dated 11/20/21 indicated the following:
*To maintain adequate circulation, relieve pain due to pressure and aid in healing and/or prevention of pressure ulcers.
*Verify MD (Doctor) order and setting according to manufacturer guidelines.
*Check settings and function regularly, and check settings on the pump.
1. Resident #64 was admitted to the facility in July 2020, and had diagnoses that included anoxic brain injury and dementia.
Review of the most recent Minimum Data Set (MDS) assessment, dated 10/6/22, indicated Resident #64 was unable to complete the Brief Interview for Mental Status examination and was assessed by staff to have severely impaired cognition. The MDS further indicated Resident #64 had no behaviors and was totally dependent on staff for activities of daily living (ADLs), including bed mobility.
Review of Resident #64's medical record indicated:
* Resident #64's most recent weight was obtained on 11/1/22 and he/she weighed 141.4 lbs.
* Resident #64 had a care plan that he/she was at risk for pressure ulcers related to decreased mobility, incontinence and history of pressure ulcers. An intervention on the care plan was to set the air mattress at 150 lbs.
* The care plan did not indicate Resident #64 had any behaviors.
* Review of the Treatment Administration Record indicated a physician's order to check the air mattress setting on all three shifts, daily.
During an observation on 11/1/22 at 8:28 A.M., Resident #64 was observed in bed and the air mattress was set at 200 pounds (lbs).
During an observation on 11/2/22 at 8:29 A.M., Resident #64 was observed in bed and the air mattress was set at 200 lbs.
During an interview with the Director of Nursing (DON) on 11/3/22 at 1:00 P.M., she said licensed nursing staff should be checking the pressure of the air mattress to ensure it reflected Resident #64's actual weight.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Unnecessary Medications
(Tag F0759)
Could have caused harm · This affected multiple residents
Based on record review and observation, the facility failed to ensure that it was free of a medication error rate of 5 percent or greater. One of three licensed nurses made errors while administering ...
Read full inspector narrative →
Based on record review and observation, the facility failed to ensure that it was free of a medication error rate of 5 percent or greater. One of three licensed nurses made errors while administering medications on 1 of 3 units. Two medication errors were observed out of 29 opportunities for error, resulting in a medication error rate of 6.9 %.
Findings include:
Review of facility policy titled 'Medication Administration- General Guidelines' revised December 2019, indicated the following:
*Policy: Medications are administered as prescribed in accordance with good nursing principles and practices and only be persons legally authorized to do so. Personnel authorized to administer medications do so only after they have been properly oriented to the facility's medication distribution system (procurement, storage, handling and administration). The facility has sufficient staff and a medication distribution system to ensure safe administration of medications without unnecessary interruptions.
*Procedures:
-Five Rights- Right resident, right drug, right dose, right route and right time, are applied for each medication being administered.
-Tablet crushing/ capsule opening- Crushing tablets may require a physician's order, per facility policy. If it is safe to do so, medication tablets may be crushed or capsules emptied out when a resident has difficulty swallowing or is tube-fed, using the following guidelines.
-Orders to crush medications should not be applied to medications which, if crushed, present a risk to the patient. For example: Long acting or enteric- coated dosage forms should not be crushed; an alternative should be sought,
-The pharmacist should be contacted to review all medications being considered for crushing, whether a physician's order is present or not.
During observation of the medication pass on 11/3/22 at 8:37 A.M. Nurse #2 said Resident #16 gets his/her medications crushed in applesauce. Nurse #2 prepared and crushed medications including the following:
-Pantoprazole Sodium (a medication used to treat GERD) 40 milligrams (mg) delayed release 1 tablet. The blister pack indicated the following instructions: Do Not Crush.
Nurse #2 administered the medications to Resident #16.
Review of Resident #16's orders indicated the following:
-A physician's order dated 7/13/22 for Pantoprazole Sodium 40 mg one tablet by mouth daily- DO NOT CRUSH
During an interview on 11/03/22 at 9:51 A.M., Nurse #2 acknowledged crushing the Pantoprazole. He said he must have just missed the instructions that he was not supposed to crush it. Nurse #2 acknowledged if the order indicated do not crush, it shouldn't be crushed. Nurse #2 acknowledged that extended release medications are formulated to release medication over a longer duration and crushing a medication may change it to begin acting immediately.
During observation of the medication pass on 11/3/22 at 8:51 A.M., Nurse #2 said that Resident #85 gets his/her medications crushed in applesauce. Nurse #2 prepare and crush medications including the following:
-Metoprolol Succinate (a medication used to lower blood pressure) Extended Release (ER) 25 milligrams (mg)
Nurse #2 administered the crushed medications to Resident #85.
Review of Resident #85's current physician orders indicated an order dated 3/23/22 for Metoprolol Succinate tablet extended release 25 mg once a day.
During an interview on 11/03/22 at 9:51 A.M., Nurse #2 acknowledged crushing the Metoprolol Succinate ER Nurse #2 said there was no order not to crush the extended release medication and further said he is an agency nurse and follows the orders as written. Nurse #2 acknowledged that extended release medications are formulated to release the medication over a longer time period and crushing a medication may change it to begin acting immediately. Nurse #2 said he determines if a resident gets their medications crushed with applesauce, which will be marked as c/a, or whole, which will be marked by w, by looking at the census sheet.
Review of the census sheet indicated Resident #85 takes his/her medications whole.
During an interview on 11/03/22 at 10:57 A.M., the Director of Nursing said that any medications that are extended release or delayed release should not be crushed. She said the expectation would be that the nurse would not crush any extended release meds, even if it wasn't specified in the order.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected multiple residents
Based on observation, interview and policy review, the facility failed to disinfect resident care equipment between resident use on 2 of 3 resident care units.
Findings include:
Review of facility po...
Read full inspector narrative →
Based on observation, interview and policy review, the facility failed to disinfect resident care equipment between resident use on 2 of 3 resident care units.
Findings include:
Review of facility policy titled 'Disinfecting Resident Care Equipment', revised 11/3/22 indicated the following:
*Policy: To maintain infection control guidelines while utilizing resident care equipment.
*Purpose: To optimize the use of resident care equipment to minimize the risk of exposure to our staff or residents.
*Process: Vital sign machines (nurse on a stick): oral thermometers, blood pressure cuffs, stethoscopes:
-Nurse on a stick: Apply gloves, wipe down all electrical components, thermometer, Blood pressure (B/P) cuff- both inside and outside of the cuff and attached tubing, the pulse oximeter probe and the pole with a PDF or bleach wipe. Let dry for 3 minutes (or as indicated on the disinfecting solution) between use. Remove gloves, wash hands.
-Stethoscopes: Apply gloves, wipe the stethoscope with a bleach or PDF wipe, cleanse the earpiece with at least 70% isopropanol alcohol wipe and let dry 5 minutes (or as indicated on the disinfecting solution) between use. Remove gloves, wash hands.
-Pulse oximeters: Apply gloves, wipe down with PDF or bleach wipes and let dry for 3 minutes (or as indicated on the disinfecting solution) between use. Remove gloves, wash hands.
On 11/03/22 at 8:22 A.M., Nurse #3 was observed using the blood pressure cuff, her stethoscope and a pulse oximeter on a resident. Nurse #3 exited the resident's room, did not disinfect the equipment and then entered another resident's room. Nurse #3 used the potentially contaminated blood pressure cuff, stethoscope and oximeter on the second resident.
During an interview on 11/3/22 at 8:29 A.M., Nurse #3 said she should have cleaned the equipment between residents using wipes.
On 11/03/22 at 8:58 A.M., Nurse #2 was observed using the pulse oximeter on one resident. Nurse #2 exited the room, did not disinfect the equipment and then entered another resident's room. Nurse #2 used the potentially contaminated pulse oximeter on the second resident.
During an interview on 11/03/22 at 9:03 A.M., Nurse #2 said he should have disinfected the equipment between residents using a wipe.
During an interview on 11/03/22 at 11:00 A.M., the Director of Nursing said the expectation is that shared medical equipment will be cleaned between residents and it should have been done.
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 maintain proper sanitation practices related to proper glove use and the labeling and storage of food items.
Findings include...
Read full inspector narrative →
Based on observation, interview, and policy review the facility failed to maintain proper sanitation practices related to proper glove use and the labeling and storage of food items.
Findings include:
Review of the facility policy titled, Food Storage, dated 1/6/22, indicated the following:
*Food shall not be stored directly on the floor.
Review of the facility policy titled, Sanitary Dining Services Protocols, dated 12/15/21, indicated the following:
*Gloves will be changed in between tasks.
*Date and label all incoming foods
*Perishable foods are stored and discarded in a timely manner to prevent spoilage and/or growth of pathogenic organisms.
During an initial walk through of the kitchen on 11/1/22 at 7:13 A.M., the following observations were made:
*A container of cottage cheese with a best-by date of 10/25 was opened, and unlabeled.
*Two boxes containing food were stored on the floor of the walk-in freezer.
During an observation of breakfast service on 11/3/22 from 7:46 A.M. to 8:13 A.M., multiple observations were made of the dietary aid contaminating his gloved hands by touching the bottom of trays, tray lids, food carts, and the cart for storing plate lids; three times throughout service the dietary aid stepped away from the tray line and used his contaminated gloved hands to toast large amounts of bread which he then transferred with his gloved hands to the food line to be served. The dietary aid did not change his gloves or perform hand hygiene throughout breakfast service.
During an interview on 11/1/22, at 2:25 P.M., the Food Service Director said that boxes should not be stored on the floor in the freezer, boxes found stored on the floor should be discarded.
MINOR
(C)
Minor Issue - procedural, no safety impact
Deficiency F0582
(Tag F0582)
Minor procedural issue · This affected most or all residents
Based on record review and interview the facility failed to meet its obligation to inform the beneficiary of his or her potential liability for payment related to standard claim appeal rights by faili...
Read full inspector narrative →
Based on record review and interview the facility failed to meet its obligation to inform the beneficiary of his or her potential liability for payment related to standard claim appeal rights by failing to issue the advanced beneficiary notice (SNFABN) to two of two eligible residents out of three sampled residents.
Findings include:
The SNFABN provides information to residents/beneficiaries so they can decide if they wish to continue receiving the skilled services that may not be paid for by Medicare and assume financial responsibility.
Review of the of 2 sampled records of residents, who were discharged from their Medicare Part A benefits and stayed in the facility failed to have a SNF Advanced Beneficiary Notice issued.
On 11/02/22 at 9:16 A.M., the Administrator said the ABNs were not given to the two residents who stayed in the facility and said the current Social Work staff know they need to provide the correct notices.
Understanding Severity Codes (click to expand)
Life-Threatening (Immediate Jeopardy)
J - Isolated
K - Pattern
L - Widespread
Actual Harm
G - Isolated
H - Pattern
I - Widespread
Potential for Harm
D - Isolated
E - Pattern
F - Widespread
No Harm (Minor)
A - Isolated
B - Pattern
C - Widespread
Questions to Ask on Your Visit
- "Can I speak with families of current residents?"
- "What's your RN coverage like on weekends and overnight?"
Our Honest Assessment
Strengths
- • Licensed and certified facility. Meets minimum state requirements.
Concerns
- • 42 deficiencies on record, including 2 serious (caused harm) violations. Ask about corrective actions taken.
- • Grade D (48/100). Below average facility with significant concerns.
Bottom line: Trust Score of 48/100 indicates significant concerns. Thoroughly evaluate alternatives.
✓ Report will be sent to your email
About This Facility
What is Alliance Health At Rosewood's CMS Rating?
CMS assigns ALLIANCE HEALTH AT ROSEWOOD an overall rating of 3 out of 5 stars, which is considered average nationally. Within Massachusetts, this rating places the facility higher than 99% of the state's 100 nursing homes. This mid-range rating indicates the facility meets federal standards but may have areas for improvement.
How is Alliance Health At Rosewood Staffed?
CMS rates ALLIANCE HEALTH AT ROSEWOOD's staffing level at 3 out of 5 stars, which is average compared to other nursing homes. Staff turnover is 48%, compared to the Massachusetts average of 46%.
What Have Inspectors Found at Alliance Health At Rosewood?
State health inspectors documented 42 deficiencies at ALLIANCE HEALTH AT ROSEWOOD during 2022 to 2025. These included: 2 that caused actual resident harm, 39 with potential for harm, and 1 minor or isolated issues. Deficiencies causing actual harm indicate documented cases where residents experienced negative health consequences.
Who Owns and Operates Alliance Health At Rosewood?
ALLIANCE HEALTH AT ROSEWOOD is owned by a non-profit organization. Non-profit facilities reinvest revenue into operations rather than distributing to shareholders. The facility is operated by ALLIANCE HEALTH & HUMAN SERVICES, a chain that manages multiple nursing homes. With 135 certified beds and approximately 107 residents (about 79% occupancy), it is a mid-sized facility located in PEABODY, Massachusetts.
How Does Alliance Health At Rosewood Compare to Other Massachusetts Nursing Homes?
Compared to the 100 nursing homes in Massachusetts, ALLIANCE HEALTH AT ROSEWOOD's overall rating (3 stars) is above the state average of 2.9, staff turnover (48%) is near the state average of 46%, and health inspection rating (3 stars) is at the national benchmark.
What Should Families Ask When Visiting Alliance Health At Rosewood?
Based on this facility's data, families visiting should ask: "Can I visit during a mealtime to observe dining assistance and food quality?" "How do you handle medical emergencies, and what is your hospital transfer rate?" "Can I speak with family members of current residents about their experience?"
Is Alliance Health At Rosewood Safe?
Based on CMS inspection data, ALLIANCE HEALTH AT ROSEWOOD has a clean safety record: no substantiated abuse findings (meaning no confirmed cases of resident harm), no Immediate Jeopardy citations (the most serious violation level indicating risk of serious injury or death), and is not on the Special Focus Facility watch list (a federal program monitoring the lowest-performing 1% of nursing homes). The facility has a 3-star overall rating and ranks #1 of 100 nursing homes in Massachusetts. While no facility is perfect, families should still ask about staff-to-resident ratios and recent inspection results during their visit.
Do Nurses at Alliance Health At Rosewood Stick Around?
ALLIANCE HEALTH AT ROSEWOOD has a staff turnover rate of 48%, which is about average for Massachusetts nursing homes (state average: 46%). Moderate turnover is common in nursing homes, but families should still ask about staff tenure and how the facility maintains care continuity when employees leave.
Was Alliance Health At Rosewood Ever Fined?
ALLIANCE HEALTH AT ROSEWOOD has been fined $8,824 across 1 penalty action. This is below the Massachusetts average of $33,167. While any fine indicates a compliance issue, fines under $50,000 are relatively common and typically reflect isolated problems that were subsequently corrected. Families should ask what specific issues led to these fines and confirm they've been resolved.
Is Alliance Health At Rosewood on Any Federal Watch List?
ALLIANCE HEALTH AT ROSEWOOD 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.