CAPE HERITAGE REHABILITATION & HEALTH CARE CENTER
For profit - Limited Liability company
123 Beds
ATHENA HEALTHCARE SYSTEMS
Data: November 2025
Trust Grade
38/100
#207 of 338 in MA
Last Inspection: May 2025
Inspected within the last 6 months. Data reflects current conditions.
Overview
Cape Heritage Rehabilitation & Health Care Center has received a Trust Grade of F, indicating significant concerns about its care quality. Ranking #207 out of 338 facilities in Massachusetts places it in the bottom half, and #8 out of 15 in Barnstable County suggests only a few local options are better. The facility is improving, with issues decreasing from 8 in 2024 to 6 in 2025, but it still has serious concerns about resident safety and care quality. Staffing is a relative strength, with a 4-star rating and only 27% turnover, which is significantly better than the state average, and they have more RN coverage than 83% of Massachusetts facilities. However, the facility has faced serious incidents, including failing to monitor the weight loss of residents, leading to significant health risks, and not providing sufficient staff to meet nursing needs, which raises concerns about the overall quality of care.
- Trust Score
- F
- In Massachusetts
- #207/338
- Safety Record
- High Risk
- Inspections
- Getting Better
- Staff Stability ✓ Good
- 27% annual turnover. Excellent stability, 21 points below Massachusetts's 48% average. Staff who stay learn residents' needs.
- Penalties ✓ Good
- No fines on record. Clean compliance history, better than most Massachusetts facilities.
- Skilled Nurses ✓ Good
- Each resident gets 42 minutes of Registered Nurse (RN) attention daily — more than average for Massachusetts. RNs are trained to catch health problems early.
- Violations ⚠ Watch
- 56 deficiencies on record. Higher than average. Multiple issues found across inspections.
38/100
Bottom 39%
Review needed
8 → 6 violations
★★☆☆☆
2.0
Overall Rating
★★★★☆
4.0
Staff Levels
★★★☆☆
3.0
Care Quality
★★☆☆☆
2.0
Inspection Score
↔
Stable
2024: 8 issues
2025: 6 issues
The Good
-
4-Star Staffing Rating · Above-average nurse staffing levels
-
Low Staff Turnover (27%) · Staff stability means consistent care
-
Full Sprinkler Coverage · Fire safety systems throughout facility
-
No fines on record
-
Staff turnover is low (27%)
21 points below Massachusetts average of 48%
Facility shows strength in staffing levels, staff retention, fire safety.
The Bad
2-Star Overall Rating
Below Massachusetts average (2.9)
Below average - review inspection findings carefully
Chain: ATHENA HEALTHCARE SYSTEMS
Part of a multi-facility chain
Ask about local staffing decisions and management
The Ugly 56 deficiencies on record
3 actual harm
May 2025
6 deficiencies
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Safe Environment
(Tag F0584)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and observations, the facility failed to ensure it provided a clean, comfortable, and homelike environment f...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and observations, the facility failed to ensure it provided a clean, comfortable, and homelike environment for the residents residing on one unit ([NAME]) out of three units.
Findings include:
Review of the facility's policy titled Policy for Environmental Rounds, undated, indicated but was not limited to the following:
-Environmental rounds will be an integral part of daily routine and will also be performed regularly throughout the entire facility.
-Environmental survey worksheets will be retained for review to illustrate the improvement of quality of life within the facility and for review/comparison purposes within the facility over a period of time.
Review of the most recent Resident Council Minutes, dated 4/24/25, indicated it has been noted there was a lack of maintenance in the building.
On 5/15/25 at 8:40 A.M., during the initial tour of the [NAME] unit, the surveyor observed the following:
-Two keypads to the unit were loose (due to missing screws) and duct tape was visibly holding it together.
-room [ROOM NUMBER]'s bathroom light panel was missing in the bathroom with loose screws and light bulb exposed.
-room [ROOM NUMBER] had the residents' names written on medical tape with a black marker and stuck to the room number display.
-room [ROOM NUMBER] had a heating panel which was broken and had fallen off the unit.
-room [ROOM NUMBER] had multiple unpainted areas on the wall.
-Back hallway had wallpaper peeling off the walls approximately 15 inches.
-room [ROOM NUMBER] had bathroom ceiling tiles that were cracked and stained, missing molding in the bathroom, and frayed curtains.
-room [ROOM NUMBER] had water damage near the window causing paint to bubble and chip. The curtains were ripped and frayed.
-room [ROOM NUMBER] was missing a room number and had the Resident's first initial and last name taped to the wall outside of their room on a label. The Resident's wheelchair had about 4 inches of yellow foam coming out of the arm rest.
-room [ROOM NUMBER] had an air conditioner unit installed lined with duct tape and the inside had large patches of black stains and a filter that was dirty with dust and debris.
-The [NAME] dining room had peeling wallpaper with residents sitting at the table to eat their meals.
-The electrical panel was unlocked and ajar in the dining room exposing wires.
-The molding in the [NAME] dining room was missing near the refrigerator exposing a brown wall.
-The sink and countertop area in the [NAME] dining room had water damage which caused the appearance of rippling in the countertop and foam sealant was exposed, the underneath cabinets were zip tied together but the cabinets would not close all the way.
-The door near the nurses' station leading to the outside was rotting in multiple areas, exposing the outside through holes.
During an interview on 5/15/25 at 11:19 A.M., Resident #16 said nothing seems to work correctly and there are many things that are broken in their room. He/She said they have told staff about the sink being clogged for days now as well as the footboard on the bed being broken. The Resident also showed the surveyor areas of the walls that were missing molding.
During an interview on 5/15/25 at 12:00 P.M., Resident #366 said his/her name was written in marker on tape on his/her door for over a week. She said the door frames were completely rotted, and the unit was in disrepair. He/She said the bed was being held together with duct tape and the ceiling tiles were stained in the halls from water damage.
During an interview on 5/20/25 at 8:24 A.M., Resident #109 said his/her bathroom light panel has been broken since he/she was admitted which was at the beginning of April. He/She said staff were aware because they were in and out of the bathroom offering assistance.
During a tour of the [NAME] unit on 5/20/25 at 1:34 P.M., the Director of Maintenance said he expects the unit to be in good repair and reflect a homelike environment. He stated that this is not an environment he would want to live in and agreed that these items needed to be repaired. He said currently the building is using a notebook to report maintenance needs and work orders. He said he counts on staff to bring these types of things to his attention but has found the staff only seem to report issues that affect staff such as a leak or broken call light.
During an interview on 5/20/25 at 1:40 P.M., the Regional Director of Maintenance said this unit should be in better condition and he expects all the areas including dining rooms, resident rooms, and hallways to be repaired. He said he was not aware the maintenance log was currently a single bound notebook. He said he expects the maintenance log to be completed by staff with who, what, where, when, and that maintenance is indicating the progress of the work order. He said there needs to be a better system in place and staff need to know what types of maintenance issues to report.
During a tour with an interview on 5/20/25 at 2:34 P.M., the Administrator said the expectation is the unit offers a safe, clean, and homelike experience for the residents and maintenance is reviewing and fixing the items necessary. She said it is her expectation all staff are reporting these concerns and the team develops a tightened process for work orders and rounding. She said staff need to know that ripped curtains and holes in walls are not acceptable.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Quality of Care
(Tag F0684)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure a Resident with an alteration in skin integrity related to a...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure a Resident with an alteration in skin integrity related to a wound, specifically a gastrocutaneous fistula (an abnormal opening between the stomach and the skin allowing gastric contents to leak onto the skin) at an old feeding tube site, received necessary treatment and services to promote healing for one Resident (#85), out of a total sample of 23 residents. Specifically, the facility failed to transcribe and implement wound care per recommendations by the stoma clinic, complete wound care as ordered, and to notify the physician when the surrounding skin at the wound site was macerated (white and soggy skin from exposure to excessive moisture from body fluids).
Findings include:
Review of the Lippincott Manual of Nursing Practice, 11th Ed. (2019) indicated: Scope of Practice, Licensure, and Certification: The professional nurse's scope of practice is defined and outlined by the State Board of Nursing that governs practice. The National Council of State Boards of Nursing and the National League of Nursing have developed standards that guide each State Board in the development of their licensure requirements and scope of practice rules.
Review of the Massachusetts Board of Registration in Nursing Advisory Ruling on Nursing Practice, dated as revised April 11, 2018, indicated but was not limited to the following:
Nurse's Responsibility and Accountability: Licensed nurses accept, verify, transcribe, and implement orders from duly authorized prescribers that are received by a variety of methods (i.e., written, verbal/telephone, standing orders/protocols, pre-printed order sets, electronic) in emergent and non-emergent situations. Licensed nurses in a management role must ensure an infrastructure is in place, consistent with current standards of care, to minimize error.
Review of the facility's policy titled Treatments, dated April 2015, indicated but was not limited to the following:
-It is the responsibility of all nursing staff to constantly evaluate the health state of residents/patients as to the need for treatments, once treatments are ordered, they are to be carried out as prescribed.
-All treatments must be charted as ordered on the treatment sheet by indicating an initial in the appropriate slot.
-The physician should be notified if there is significant change in the area of the treatment, either positive or negative change as warranted.
Review of the facility's policy titled Consultant Services, dated April 2025, indicated but was not limited to the following:
-The consultant should document findings and recommendations on the form.
-The charge nurse will then notify the attending physician of findings, and he/she can then order the specific treatments as outlined by the consultant.
-A consultant's report or some form of documentation pertaining to the results will be retained in the clinical record.
Review of the facility's policy titled Physician's Orders-Transcription, dated April 2015, indicated but was not limited to the following:
-All written physician's orders or telephone physician's orders will be duly noted and accurately transcribed by licensed nursing staff.
-Carefully transcribe orders as written to the Medication Administration Record (MAR) and/or the Treatment Administration Record (TAR).
Resident #85 was admitted to the facility in February 2024 with diagnoses which included cerebral infarction (stroke), dysphagia (difficulty swallowing), artificial opening of digestive tract, and depression.
Review of the Minimum Data Set (MDS) assessment, dated 4/18/25, indicated Resident #85 scored 15 out of 15 on the Brief Interview for Mental Status (BIMS) indicating he/she was cognitively intact, had an open wound and was receiving dressing changes.
Review of the medical record indicated his/her Health Care Proxy (HCP) was invoked, indicating he/she was not able to make his/her own medical decisions.
Review of the Comprehensive Care Plan indicated but was not limited to the following:
FOCUS: Actual alteration in skin integrity related to chronic wound to stoma of gastrostomy tube (G-Tube) site. Chronic wound of abdomen status post gastrostomy.
GOAL: Wound will be free of infection.
INTERVENTIONS:
-Follow physician orders for skin care and treatments. (Utilize Best Practice Guidelines)
-Discuss non-compliance issues with resident/responsible party and educate about primary risk factors and prevention.
FOCUS: Behavior Problem related to reactive Depression. Refuses treatments at times, delusional, requires two care givers due to accusations, and unaware of personal limits.
GOAL: He/she will remain at reduced risk for harm to self or others with interventions in place.
INTERVENTIONS:
-Two care givers at all times.
-Explain care to resident in advance, in terms resident understands.
-Involve HCP/family as needed to discuss behaviors and reality of situations.
Review of the medical record indicated Resident #85 was followed by the Hospital Stoma Clinic.
Review of the Consults section of the medical record indicated but was not limited to the following:
-1/9/25: Appointment at Hospital Stoma Clinic
-Other Instructions:
Change pouch every three days and as needed if leaking.
Remove pouch, clean skin with warm water and pat dry.
Apply stoma powder, brush away excess. Apply stoma barrier spray and dry thoroughly.
Apply Convatec Natural SurFit urostomy pouch #401544 with Convatec 1 3/4-inch wafer #413184.
Review of the Nursing Progress notes indicated but were not limited to the following:
-1/13/25: Resident has new orders: Apply Convatec Natural [NAME]-Fit urostomy pouch #401544 with Convatec 1 3/4-inch Convex wafer #413184 with pouch/application changes.
-1/22/25: Resident returned from gastrointestinal (GI) appointment with new order. MD/NP aware. Change stoma applies (sic) to small size.
Review of the Physician's Orders including interim/telephone orders indicated but were not limited to the following:
1/13/25:
-Discontinue stoma orders.
-Change stoma pouch and appliance every three days and as needed of leaking.
-Remove pouch, clean skin with warm water, pat dry, apply stoma powder, brush away excess. Apply stoma barrier spray and dry thoroughly with pouch/appliance changes.
-Apply Convatec Natural [NAME]-Fit urostomy pouch #401544 with Convatec 1 3/4-inch Convex wafer #413184 with pouch/application changes.
1/22/25:
-Apply 1% Silver Nitrate (solution to prevent or treat infection) to G-tube site with applies (sic) changes.
-Change stoma applies (sic) to smaller size.
The physician's order written on 1/22/25 failed to indicate the size and reference number of the appliance to be used, only indicating smaller size.
Further review of the Physician's Orders including interim/telephone orders indicated:
3/1/25:
-May transfer to emergency room for 10 out of 10 Abdominal Pain.
Review of the Hospital After Visit Summary, dated 3/1/25, indicated but was not limited to the following:
-Diagnosis: Maceration of peri wound (skin around the wound) skin; Enterocutaneous fistula (abnormal connection between the skin and gastrointestinal tract, allowing stomach or intestinal contents to leak through the skin).
-Follow up Appointment on this Wednesday with Hospital Surgeon to discuss surgical correction of the area.
-In the meantime, keep the area very dry. Apply stoma powder clear once daily instead of every three days.
Review of the Physician's Orders including interim/telephone orders indicated but were not limited to the following:
3/1/25
-Order given to keep stoma area very dry.
-Apply stoma powder every day instead of every three days.
Review of the Consults section of the medical record indicated but was not limited to the following:
-3/5/25: Appointment at Hospital Stoma Clinic
-Change in Treatments: Use Convex Wafer with a 7/8-inch opening #413180 (was previously using 1 1/8-inch opening)
-Other Instructions:
-Please change pouch twice per week to prevent skin from burning.
-Empty pouch when 1/3 full.
-Cleanse skin with warm water and pat dry before applying pouch.
Review of the Nursing Progress notes indicated but were not limited to the following:
-3/1/25: Resident complained of pain and inching (sic) around stoma site. Orders given. Follow-up Appointment on 3/5/25 with general surgeon.
-3/5/25: Resident returned from trauma/stoma appointment. New order received to change wafer size to 7/8-inch, left message for medical supply to order supplies.
Review of the Physician's interim telephone orders failed to indicate an order for the 7/8-inch wafer was obtained and transcribed, failed to indicate to empty the pouch when 1/3 full, and failed to indicate pouch to be changed twice a week to prevent burning.
Review of the Physician's Progress note, dated 4/8/25, indicated but was not limited to the following:
-Fistula with leakage.
-Patient experienced consistent leakage from the tube site and developed red excoriated (irritated) skin to the surrounding area with increased pain.
-It was felt the erythema (redness) surrounding the tube site was most likely due to chemical irritation from stomach contents contacting his/her skin.
Review of the progress notes failed to indicate the physician had declined the recommendation to change the appliance to the 7/8-inch size (the smaller size would leave less skin exposed to come in contact with the leaking fluid).
Review of the ConvaTec website (https://www.convatec.com) product information page indicated but was not limited to the following:
-Product Reference #413184 has a 1 3/4-inch flange with a 1 3/8-inch stoma opening.
-Product Reference #413183 has a 1 3/4-inch flange with a 1 1/4-inch stoma opening.
-Product Reference #413182 has a 1 3/4-inch flange with a 1 1/8-inch stoma opening.
-Product Reference #413181 has a 1 3/4-inch flange with a 1-inch stoma opening.
-Product Reference #413180 has a 1 3/4-inch flange with a 7/8-inch stoma opening.
Features include:
-Durahesive® Skin Barrier provides added protection from liquid output. Durahesive® Skin Barriers will turtleneck or gently swell up and hug the stoma, better protecting the skin around your stoma.
-Remember to empty pouch when 1/3 full.
Review of the active Physician's Orders indicated but were not limited to the following:
-Change Appliance and Document the following: Stoma size, Stoma color, Stoma tissue, and PeriStoma, every 72 hours remove pouch, clean site with warm water, pat dry, apply stoma powder, brush away excess, apply stoma barrier spray and dry thoroughly**Apply Convatec Natural [NAME]-Fit Urostomy pouch #401544 with Convatec 1 3/4-inch Convex fit wafer #413184. (original order date 1/9/25; entered into new electronic medical record order system 2/20/25)
Review of the appliance the facility was actively using for Resident #85 indicated the following:
-Product Reference #413183 which has a 1 3/4-inch flange with a 1 1/4-inch stoma opening.
The facility failed to ensure the physician's order accurately matched the appliance being used.
Review of the MAR and TAR from January 2025 through May 2025 indicated but were not limited to the following:
February 2025
-2 of 10 opportunities the appliance was not signed off as being changed.
-5 of 10 opportunities the Silver Nitrate1% was not signed off as being applied.
March 2025
-5 of 10 opportunities the appliance was not signed off as being changed.
-3 of 10 opportunities the Silver Nitrate1% was not signed off as being applied.
-7 of 31 opportunities the Stoma Powder was not signed off as being applied.
The facility transitioned from paper MAR/TAR charting to electronic (eMAR/eTAR) charting on 3/26/25.
-The facility failed to transcribe the Stoma Powder daily to the eMAR/eTAR to the March 2025 orders.
-The updated appliance change orders now included a description of the stoma site.
-3/28/25 indicated the nurse documented 9 (9=see nurse's note). The correlating nurse's note indicated the appliance was intact and failed to indicate the appliance was changed per the order.
-3/31/25 indicated the appliance was changed and the appearance of the stoma was documented as M (M=macerated).
Review of the progress notes failed to indicate the facility notified the physician or the Hospital Stoma Clinic that the area was macerated on 3/31/25. Additionally, the notes failed to indicate the physician was notified the above treatments were not completed as ordered.
April 2025
-The facility failed to transcribe the Stoma Powder daily to the eMAR/eTAR.
-The appliance was signed off as being changed as ordered.
-9 of 10 times the documentation indicated the area was macerated.
Review of the progress notes failed to indicate the facility notified the physician or the Hospital Stoma Clinic the area was macerated.
May 2025
-The appliance was signed off as being changed as ordered.
-6 of 6 times the documentation indicated the area was macerated.
Review of the progress notes failed to indicate the facility notified the physician or the Hospital Stoma Clinic the area was macerated.
During an interview on 5/21/25 at 10:34 A.M., Nurse #1 said she was unsure what the current treatment to the stoma site was specifically. She said Resident #85 has been going to see the surgeon as they have been trying to get the area to close, but he/she is going to need surgery to close it, which has been scheduled for the end of this month. She said after an appointment, the nurse working reviews the referral and recommendations with the attending physician and then would write the orders and schedule follow up appointments if needed. She said the supplies in his/her room do not match the order in the computer and neither match the most recent recommendations for a 7/8-inch opening. She did not know why the orders did not match as they should.
During an interview on 5/21/25 at 10:42 A.M., Unit Manager (UM) #2 said the physician has been burning the area closed when he/she goes to the Surgeon's office and is going the end of the month to have the area surgically closed. She said the supplies in his/her room do not match the order and she did not know why. Additionally, she said when the Resident goes to the appointment, the specialist writes their recommendations on the referral and then we obtain the orders from the attending and notify central supply to order the new supplies. She said the orders in the system should match the appliance being used. She was unsure why the order for 7/8-inch opening appliance was never written as indicated. She said she was going to investigate it a little bit more as now she was unsure what appliance was supposed to be in use and would need to clarify the orders once she figures it out.
During an interview on 5/21/25 at 2:36 P.M., the Director of Nurse (DON) said all appliance orders should have the specific size and reference number as part of the order. She said the appliance the nurses apply to the resident should match the physician's order. Additionally, she said when a resident goes out for an appointment, the specialist writes recommendations on the referral. She said the nurse then calls the attending physician to obtain new orders, transcribes those orders, and should write a progress note. She said if the attending declines a recommendation, it should be noted on the referral and in the progress notes. She said the recommendations to use a smaller size appliance made sense because the area was macerated from skin being exposed. She said she called the nurse who failed to write the order on 3/5/25, today after being notified of the discrepancy, and she said the order was never changed because the resident did not want the appliance size changed. She said that is why there is a late entry note from today, in the record indicating such. She said there should have been education provided to the Resident and the HCP regarding the rationale of why the clinic wanted to use a smaller size and there was not. Additionally, the notes do not indicate the HCP was notified about the Resident not wanting to change the appliance, and the HCP should have been notified. She said the order and appliance being used should match and they do not. Additionally, she said the TAR does not indicate the treatments were done per physician's orders, because if it was not signed it was not done. The DON said if the area has remained macerated the physician and/or stoma clinic should have been notified and a progress note written, but they did not do that either.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Food Safety
(Tag F0812)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, the facility failed to follow professional standards of practice for food safety and sanitat...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, the facility failed to follow professional standards of practice for food safety and sanitation to prevent potential spread of foodborne illness to residents who are at high risk. Specifically, the facility failed to:
1. Maintain one of three kitchenettes in a clean and sanitary condition; and
2. Properly label and date food products in the main kitchen walk-in refrigerator.
Findings include:
Review of the facility's policy provided by the Administrator for food storage in the kitchen, which was untitled and not dated, indicated but was not limited to the following:
-The Dietary Department will be maintained in a clean and sanitary manner to prevent foodborne illness.
-All food items shall be labeled and dated to allow for rotation of supplies.
-Meats will be stored on the bottom shelves of the refrigerator to prevent drippings from contaminating food on lower shelves.
-All items stored in the refrigerator will be covered and labeled with contents and the date.
-All potentially hazardous foods must be discarded within three calendar days after the day prepared.
Review of the 2022 Food Code by the Food and Drug Administration (FDA), revised January 2023, indicated but was not limited to the following:
(D) A date marking system that meets the criteria stated in (A) and (B) of this section may include: (1) Using a method approved by the regulatory authority for refrigerated, ready-to-eat time/temperature control for safety food that is frequently rewrapped, such as lunch meat or a roast, or for which date marking is impractical, such as soft serve mix or milk in a dispensing machine; (2) Marking the date or day of preparation, with a procedure to discard the food on or before the last date or day by which the food must be consumed on the premises, sold, or discarded as specified under (A) of this section; (3) Marking the date or day the original container is opened in a food establishment, with a procedure to discard the food on or before the last date or day by which the food must be consumed on the premises, sold, or discarded as specified under (B) of this section; or (4) Using calendar dates, days of the week, color-coded marks, or other effective marking methods, provided that the marking system is disclosed to the REGULATORY AUTHORITY upon request.
4-602.11 (D) Equipment is used for storage of packaged or unpackaged food such as a reach-in refrigerator and the equipment is cleaned at a frequency necessary to preclude accumulation of soil residues.
4-602.13 Nonfood-contact surfaces of equipment shall be cleaned at a frequency necessary to preclude accumulation of soil residues.
6-501.12 (A) Physical facilities shall be cleaned as often as necessary to keep them clean.
1. 1. On 5/21/25 at 9:22 A.M., the surveyor made the following observations on the [NAME] unit nourishment kitchenette:
In the refrigerator:
-Clear basket of creamers which had a used disposable wipe, artificial sweetener packets, alcohol prep pad cartons, and two cartons of lactose free milk.
-On the door shelf were rolled up used napkins, multiple [NAME] Peppermint Patties unlabeled, mayonnaise packets, and a carton of milk.
-On the second shelf was a black insulated container on its side, unlabeled and stuck in a clear sticky dried liquid that had leaked out onto the back corner of the shelf.
Upper Cabinets:
-The shelves were visibly dirty with loose cup covers, random cups, and spoons.
Under the sink cabinet.:
-The sink drainpipe was leaking onto the cabinet floor, with a large black stain observed on the white cabinet floor, in addition, a white towel which was soiled with a black substance directly under the drainpipe.
During an interview on 5/21/25 at 9:35 A.M., The Food service Manager (FSM) said after viewing the [NAME] nourishment kitchenette, said it is the responsibility of the kitchen staff to keep the refrigerator, plastic containers of condiments clean and stocked, and the cabinets clean. The FSM said it's the responsibility of maintenance to clean under the sink or fix any leaking pipes.
2. On 5/13/25 at 8:10 A.M., the surveyor made the following food storage observations in the main kitchen:
Walk-in refrigerator:
-Large clear plastic container of cooked macaroni, not labeled and undated.
-An unidentified food wrapped in plastic wrap, dated 5/7 and unlabeled.
-An unsealed package of partially cooked bacon located in a box of frozen pancakes, not labeled and undated.
-Metal container of cut watermelon. not labeled and undated.
-Stored on a metal pan were multiple dishes of cut cucumbers, tomatoes, and salads, undated.
-One Chef salad containing eggs, turkey, ham, dated 5/8.
-Bowl of fresh fruit uncovered, not labeled and undated.
-Metal Container, which was covered with tinfoil, not labeled and undated. Inside the metal container was egg salad, with nine hard boiled eggs on top of the already made egg salad.
-Reusable plastic bag of raw chicken meat, not labeled and undated. The bag was stored on top of a sealed cardboard box containing raw chicken. No drip pan.
-Reusable plastic bag containing raw hamburger, not labeled and undated. The bag was stored on top of three additional rolls of sealed raw hamburger. No drip tray underneath the raw hamburger.
-Plastic container of tuna fish, dated 5/5.
-Metal container of an unidentifiable green vegetable covered with clear plastic wrap, labeled 4 puree, dated 5/10.
-Large clear plastic container of chicken salad, labeled but undated.
-Clear plastic container of melon, dated 4/28.
- Metal container of pickles, not labeled and undated.
Observation of the walk-in freezer:
-Boxes were stacked in the center of the freezer on the floor.
-The freezer was observed to have heavy frozen condensation on the ceiling, on all the boxes, inside the open boxes, thick ice buildup around the opening to the freezer, especially on the lower left floor by the door.
-Plastic container of frozen strawberries, partially covered with tinfoil.
-There were multiple boxes which were open, the internal plastic bags were open, and the food was covered with frozen condensation, including pancakes, biscuits, strawberries, pie crusts, and frozen patties.
-The frozen hamburger tubes on the lower right shelf were encased in frozen condensation.
During an interview on 5/13/25 at 8:30 A.M., the Food Service Manager said the food in the refrigerator should be labeled and dated. He said if the food is older than three days, it should be thrown out. In addition, he said the boxes and the bags should be sealed in the freezer to prevent the condensation on the food.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Garbage Disposal
(Tag F0814)
Could have caused harm · This affected most or all residents
Based on observation and staff interview, the facility failed to ensure that trash, garbage, and refuse were disposed of and properly contained within a receptable constructed with a tight-fitting lid...
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Based on observation and staff interview, the facility failed to ensure that trash, garbage, and refuse were disposed of and properly contained within a receptable constructed with a tight-fitting lid.
Findings include:
Review of the 2022 Food Code (a model for safeguarding public health and ensuring food is unadulterated and honestly presented when offered to the consumer) by the U.S. Food and Drug Administration (FDA) indicated outside receptacles must be constructed with tight-fitting lids or covers to prevent the scattering of the garbage or refuse by birds, the breeding of flies, or the entry of rodents. Proper equipment and supplies must be made available to accomplish thorough and proper cleaning of garbage storage areas and receptacles so that unsanitary conditions can be eliminated.
Review of an e-mail from the local Fire Department, dated 2/6/25, to the Department of Public Health indicated but was not limited to the following:
-Over the past year, since I have been in this position we have run into several safety concerns and issues with the facility from overflowing trash bins and trash left on the ground outside the facility, hood systems not being cleaned in the appropriate time frames, to now a possible overflowing leach field behind the building.
On 5/15/25 at 9:00 A.M., the surveyor made the following observations of the outside trash receptacles located outside of the main kitchen:
Inside the fenced in dumpster area:
- Two dumpsters in the wooden fence area: one on the left for recyclable cardboard and one on right for general refuse, both dumpsters were overflowing. Located within the fenced area on the ground were 8-10 cardboard boxes stacked, three black trash bags between the two dumpsters, an old mattress behind the refuse dumpster, four black trash bags to the right of the refuse dumpster, and five black trash bags in front of the refuse dumpster. There was miscellaneous trash scattered around the dumpster on the ground, including blue disposable gloves, small boxes, milk crates, plastic wrap, cups and other various debris.
Outside the fenced in dumpster area:
-A dolly cart with two black bags of trash and two empty cardboard boxes, uncovered.
-Three large plastic laundry carts, each overflowing with white clear trash bags, uncovered.
-One gray laundry cart overflowing with clear and black plastic trash bags, uncovered.
-One canvas, darker blue laundry cart overflowing with clear and black plastic bags, uncovered.
-There were multiple clear and black plastic trash bags which had fallen off the laundry carts onto the ground.
During an interview on 5/15/25 at 11:22 A.M., the facility's outside trash removal contractor said he is here to pick up some of the trash; he does not have room in his truck to remove all of it. He said this happens frequently, the trash was not picked up due to non-payment.
During an interview on 5/16/25 at 12:54 P.M., Dietary Staff #1 said the trash overflows frequently because it's not picked up regularly.
During an interview on 5/20/25 at 10:01 A.M., the Administrator said she was not aware the trash was not being removed or of any payment issues.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Room Equipment
(Tag F0908)
Could have caused harm · This affected most or all residents
Based on observation and interview, the facility failed to ensure mechanical equipment in the main kitchen was maintained in a safe operating condition, specifically (1) the walk-in freezer, (2) the s...
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Based on observation and interview, the facility failed to ensure mechanical equipment in the main kitchen was maintained in a safe operating condition, specifically (1) the walk-in freezer, (2) the stove hood, and (3) the ice machine.
Findings include:
Review of the 2022 Food Code by the Food and Drug Administration (FDA), revised 1/2023, indicated but was not limited to the following:
4-5 Maintenance and Operation
4-501 Equipment
4-501.11 Good Repair and Proper Adjustment.
(A) EQUIPMENT shall be maintained in a state of repair and condition that meets the requirements specified under Parts 4-1 and 4-2.
(B) EQUIPMENT components such as doors, seals, hinges, fasteners, and kick plates shall be kept intact, tight, and adjusted in accordance with manufacturer's specifications.
1. On 5/15/25 at 8:15 A.M., the surveyor observed the following in the walk-in freezer in the main kitchen:
-Freezer door unable to fully seal due to ice buildup;
-Only two plastic freezer strip curtains were intact, the rest were missing;
-Large amount of ice build-up at the base of freezer door, extending into the left side of the freezer;
-Large amount of drops of condensation frozen on the entire ceiling, the metal racks inside were covered with frozen condensation;
- Ice buildup on boxes on every shelf; and
-Frozen condensation observed inside boxes and inside numerous clear packaged food items, and three frozen hamburger tubes were encased in frozen condensation.
During an interview on 5/21/25 at 1:59 P.M., the Director of Maintenance said when he started this week, the freezer was frozen over, and he thawed it out. He said the freezer strip curtains were broken and the door was not sealing. He said he now has a call out for service.
2. Review of the Certification of Local Fire Inspection, dated 3/18/25, indicated but was not limited to the following:
-Nursing home or rest home quarterly inspection.
-Not to be in compliance with local ordinances regarding the prevention and safety. The following violations were observed:
-Hood cleaning done 2/21/24. 180 days.
On 5/15/25 at 8:15 A.M., the surveyor observed the stove hood inspection sticker, which indicated the last inspection was 2/21/24, and the next inspection was due in 180 days. Indicating the inspection was now 269 days overdue.
During an interview on 5/16/25 at 12:54 P.M., Dietary Staff #1 observed the hood sticker and said he knows the hood is overdue for cleaning and inspection.
3. Review of the Ice Cleaning and Maintenance Log, located in the maintenance office, indicated the ice machine filter was due to be changed in January 2025. The filter change was three and half months overdue.
During an interview on 5/21/25 at 2:10 P.M., Maintenance Staff #1 said he cleans the ice machine, but does not change the filter. He said they have a company for that, and it was due to be changed in January 2025, and it was not.
During an interview on 5/16/25 at 2:35 P.M., the Administrator said she was made aware the hood inspection was overdue. She said she was not aware of the condensation in the freezer or the overdue service for the ice machine.
During an interview on 5/21/25 at 9:35 A.M., the Food Service Manager (FSM) said he was not aware of the regularly scheduled maintenance of the equipment in the kitchen. He said the maintenance department handles all the service and regular maintenance of the ice machine, the freezer, and the hood.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Safe Environment
(Tag F0921)
Could have caused harm · This affected most or all residents
Based on observation and interviews, the facility failed to maintain their septic system drain field in working order and/or increase pumping of their septic tank to prevent the liquid wastewater from...
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Based on observation and interviews, the facility failed to maintain their septic system drain field in working order and/or increase pumping of their septic tank to prevent the liquid wastewater from running into their parking lot.
Findings include:
Review of website www.epa.gov/septic/how-septic-systems-work, included but was not limited to the following information from the federal government:
How a typical conventional septic system works:
1. All water runs out of your home from one main drainage pipe into a septic tank.
2. The septic tank is a buried, water-tight container usually made of concrete, fiberglass, or polyethylene. Its job is to hold the wastewater long enough to allow solids to settle down to the bottom forming sludge, while the oil and grease floats to the top as scum. Compartments and a T-shaped outlet prevent the sludge and scum from leaving the tank and traveling into the drainfield area.
3. The liquid wastewater (effluent) then exits the tank into the drainfield.
4. The drainfield is a shallow, covered, excavation made in unsaturated soil. Pretreated wastewater is discharged through piping onto porous surfaces that allow wastewater to filter through the soil. The soil accepts, treats, and disperses wastewater as it percolates through the soil, ultimately discharging to groundwater. If the drainfield is overloaded with too much liquid, it can flood, causing sewage to flow to the ground surface or create backups in toilets and sinks.
Review of an e-mail from the local Fire Department, dated 2/6/25, to the Department of Public Health indicated, but was not limited to the following:
-Over the past year, since I have been in this position we have run into several safety concerns and issues with the facility from overflowing trash bins and trash left on the ground outside the facility, hood systems not being cleaned in the appropriate time frames, to now a possible overflowing leach field behind the building.
Review of the handwritten pumping log maintained in the maintenance office indicated the septic system was last pumped on 3/27/25.
Review of the last invoice received from the septic system pumping company was dated 3/26/2025.
On 5/20/25 at 9:15 AM., the surveyor observed the lower parking lot and observed water bubbling out from the manhole cover, creating a stream of water running into a line of parked cars. The water created a strong smell of sewage.
During an interview on 5/20/25 at 9:15 A.M., Consultant #1 and Consultant #2 said they were on the premises for the first time to evaluate the septic system for the facility. Consultant #1 said they were unable to comment on the condition of the current septic system at this time, other than there is a problem. Consultant #1 said the water running from the manhole cover into the parking lot was effluent water, meaning it had gone through the septic tank and should be leaching into the ground. Consultant #1 and Consultant #2 both said more frequent pumping of the septic tank would be helpful since the water is not leaching now.
During an interview on 5/20/25 at 11:25 A.M., the Maintenance Director said he just started in the building on Monday. He said the last pumping receipt he has is from March 2025. He said the two engineers that were here today are going to the Town Hall for some investigation to see what can be done to fix the problem.
During an interview on 5/20/25 at 11:32 A.M., the Regional Maintenance Director said he was made aware of the problem one to two months ago and was here in the building a month ago. He said he was not aware of the problem in February 2025. He said his boss knew about it before him and was managing it with the previous Plant Manager by having it pumped out.
During an interview on 5/21/25 at 11:21 A.M., the Administrator said she was not aware of when the concern with the septic system started or what the previous pumping schedule was. The Administrator said she has requested the timeline from the regional maintenance director as requested by the surveyor but has not received it.
During an interview on 5/21/25 at 2:10 P.M., Maintenance Staff #1 said there has been no pumping of the septic system since March 2025. He said that this has been a problem, especially when it rains a lot, and the problem gets worse.
The facility did not provide the requested timeline of when the facility was made aware of the septic system problems or any mitigation plan at the time of survey exit.
Apr 2024
8 deficiencies
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 and interview, the facility failed to ensure resident rooms were maintained in good repair to promote a homelike environment on one of three units. Specifically, the facility fail...
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Based on observation and interview, the facility failed to ensure resident rooms were maintained in good repair to promote a homelike environment on one of three units. Specifically, the facility failed to repair areas of chipped and loose textured ceiling, also known as popcorn ceiling, in five resident rooms in one out of three units.
Findings include:
During an observation with interview on 4/8/24 at 9:30 A.M., the surveyor observed several patches of popcorn ceiling missing from Resident #12's room in the area above the bed. Resident #12 said a storm caused water to leak from the ceiling causing areas of the popcorn ceiling to peel away and fall from the ceiling. Resident #12 said a piece of the popcorn ceiling fell and hit them on the head with no injury occurring. Resident #12 said the edges of the area where the popcorn ceiling was missing were peeling. Resident #12 said the remainder of the popcorn ceiling should be chipped away and repaired. Resident #12 said the ceiling had been in that condition for about three months and did not know why the facility had not yet made the repairs. Resident #12 said the ceiling situation was an issue. Resident #12 said the peeling ceiling was a hazard and someone could get hurt.
During an observation with interview on 4/9/24 at 1:22 P.M., the surveyor observed several sizeable patches of the popcorn ceiling missing in Resident #8's room in the area above or adjacent to the Resident's bed. Resident #8 said the popcorn ceiling had been in disrepair since at least 10/31/23. Resident #8 said the remaining area adjacent to where the popcorn ceiling was missing was separating from the ceiling and the Resident wondered if any specks were going to fall down, particularly into their food.
During an observation with interview on 4/9/24 at 3:30 P.M., the surveyor observed several sizeable areas of the popcorn ceiling missing in the room where Resident #51 and Resident #56 resided. Resident #51 and Resident #56 both said the missing patches of popcorn ceiling were unsightly, making the facility look old, and they would like the ceiling to be repaired.
During an observation with interview on 4/7/24 at 9:30 A.M., the surveyor observed several areas of the popcorn ceiling missing in Resident #94's room. Resident #94 said they can see the areas of missing popcorn ceiling whenever they are in their room, and they would like the ceiling to be fixed.
During an observation with interview on 4/7/24 at 3:00 P.M., the surveyor observed several sizeable patches of popcorn ceiling missing in Resident #88's room. Resident #88 said they did not like the missing patches of ceiling and would like for the facility to repair those areas.
During an interview on 4/9/24 at 10:24 A.M., the Maintenance Director said he was aware of the loosening of the popcorn ceiling. The Maintenance Director said the maintenance department had chipped away as much of the loose popcorn ceiling as they could and were working on getting a vendor to make the repairs. The Maintenance Director said the Administrator was also aware of the ceiling situation on the unit.
During an interview on 4/10/24 at 12:47 P.M., the Administrator said he was aware of the needed repair of the popcorn ceilings in the unit and was working to get the ceiling repaired.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Report Alleged Abuse
(Tag F0609)
Could have caused harm · This affected 1 resident
Based on interviews, record review, and policy review, for one Resident (#66) of 21 sampled residents, the facility failed to ensure all alleged violations of abuse, neglect, exploitation, or mistreat...
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Based on interviews, record review, and policy review, for one Resident (#66) of 21 sampled residents, the facility failed to ensure all alleged violations of abuse, neglect, exploitation, or mistreatment were reported to the Department of Public Health's (DPH) Health Care Facility Reporting System (HCFRS-a web-based system that health care facilities must use to report incidents and allegations of abuse, neglect, and misappropriation) as required. Specifically, for Resident #66, the facility failed to report alleged abuse by a visitor within the required timeframe.
Findings include:
Review of the facility's policy titled Abuse, Neglect and Exploitation, dated 2/2023, indicated but was not limited to:
-Abuse means the willful infliction of injury, unreasonable confinement, intimidation or punishment with resulting physical harm, pain or mental anguish. Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain or mental anguish it includes verbal abuse, sexual abuse, physical abuse, and mental abuse including abuse facilitated or enabled through the use of technology.
-Alleged violation is a situation or occurrence that is observed or reported by staff, resident, relative, visitor or others but has not yet been investigated and, if verified, could be an indication of noncompliance to the Federal requirements related to mistreatment, exploitation, neglect or abuse, including injuries of unknown source, and misappropriation of resident property.
-The facility will have written procedures that include: reporting of all alleged violations to the administrator, state agency, adult Protective Services and to all other required agencies (e.g. law enforcement when applicable) within specified time frames: immediately, but not later than 2 hours after the allegation is made if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that caused the allegation do not involve abuse and do not result in serious bodily injury.
Resident #66 was admitted to the facility in July 2019 with the following diagnoses: dementia, diabetes mellitus, and post-traumatic stress disorder (PTSD).
Review of the Minimum Data Set (MDS) assessment, dated 2/13/24, indicated Resident #66 was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) score of 13 out of 15.
Review of Resident #66's progress note, dated 3/25/24, indicated Resident #66 had reported to the social worker that on 3/24/24 his/her visitor had threatened to bash his/her head in if he/she did not produce the baseball cards that the visitor was demanding.
On 4/9/24, review of the HCFRS failed to indicate that the facility had submitted a report for the alleged visitor to resident abuse that occurred on 3/24/24.
During an interview on 4/9/24 at 9:50 A.M., the Director of Social Services said when the facility was made aware of the alleged violation the police were notified and a no trespass order was obtained. The Director of Social Services said Resident #66 had been worried and scared but was satisfied with the no trespass order. The Director of Social Services said when an alleged violation occurs it is reported to the administration team immediately.
During an interview on 4/10/24 at 10:22 A.M., Unit Manager (UM) #1 said when a threat of harm was alleged the administration team was made aware so the allegation could be reported within the required timeframe.
During an interview on 4/10/24 at 10:53 A.M., the Administrator said the alleged resident to visitor violation had been reported to the police immediately and the Resident's safety was ensured. The Administrator said the alleged violation had not been reported in HCFRS.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0761
(Tag F0761)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and policy review, the facility failed to ensure staff stored all drugs and biologicals used in...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and policy review, the facility failed to ensure staff stored all drugs and biologicals used in the facility in accordance with currently accepted professional principles. Specifically, for residents on the [NAME] unit (a locked dementia unit), the facility failed to ensure psychotropic medication was secured and not accessible to residents.
Findings include:
Review of the facility's policy titled Medication Storage Room/Medication Cart Policy, dated 2/2018, indicated but was not limited to:
-Medications are stored primarily in a locked mobile medication cart which is accessible only to licensed nursing personnel.
-Storage for other medications will be limited to a locked medication room.
On 4/8/24 at 1:37 P.M., on the [NAME] unit, where 28 of 30 residents were diagnosed with Alzheimer's/ dementia, the surveyor observed:
-Nurse #1 pop one Trazodone (antidepressant) 12.5 milligram (mg) tablet into a medication cup
-Nurse #1 place the medication cup on top of the medication cart and walk down the hall to the nurses' station, leaving the medication cup on top of the medication cart outside of room [ROOM NUMBER]
-Nurse #1 standing at the nurses' station with her back to the medication cart talking to Unit Manager #2
-Four residents standing around the medication cart with one of them resting his/her hand on the cart
During an interview on 4/8/24 at 1:56 P.M., Nurse #1 said she made a mistake and should not have left the prepared medication unattended on the cart.
During an interview on 4/8/24 at 1:58 P.M., Unit Manager #2 said prepared medication should never be unattended.
During an interview on 4/10/24 at 1:20 P.M., the Administrator and the Director of Nurses (DON) said prepared medication should not be unattended and accessible to residents.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Medical Records
(Tag F0842)
Could have caused harm · This affected 1 resident
Based on records reviewed, policy review, and interviews, for one Resident (#66), out of 21 sampled residents, the facility failed to maintain an accurate medical record in accordance with accepted pr...
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Based on records reviewed, policy review, and interviews, for one Resident (#66), out of 21 sampled residents, the facility failed to maintain an accurate medical record in accordance with accepted professional standards and practices. Specifically, for Resident #66, the facility failed to ensure his/her weight was documented in the medical record as ordered by the physician.
Findings include:
Review of the facility's policy titled Weights, dated 8/2015, indicated but was not limited to:
-Weights are documented in the resident/patient's medical record and/or weight book
Resident #66 was admitted to the facility in July 2019 with the following diagnoses: dementia and diabetes.
Review of the Minimum Data Set (MDS) assessment, dated 2/13/24, indicated Resident #66 had experienced a significant weight loss and was not on a prescribed weight loss regimen.
Review of Resident #66's progress note, dated 2/9/24, indicated weights were trending down and his/her physician was made aware. The progress note indicated a new order had been obtained to weigh the Resident weekly for four weeks then monthly.
Review of Resident #66's weight summary indicated:
-2/9/24 183.3 pounds
-2/10/24 180 pounds
-2/16/24 179.2 pounds
-3/7/24 177.8 pounds
-3/11/24 178.6 pounds
Further review of Resident #66's weight summary indicated no documented weights between 2/16/24 and 3/7/24, with 20 days between recorded weights.
Review of Resident #66's February and March 2024 Treatment Administration Record (TAR) indicated he/she had been weighed as ordered on 2/24/24 and 3/2/24. The TARs did not include a numeric value to represent Resident #66's weight.
During an interview on 4/10/24 at 10:22 A.M., Unit Manager (UM) #1 said the facility did not utilize a weight book and that weights were recorded on the resident's TAR or in the electronic medical record. UM #1 and the surveyor reviewed Resident #66's February and March 2024 TAR and electronic medical record and UM #1 said the weights had not been documented.
During an interview on 4/10/24 at 1:20 P.M., the Director of Nurses (DON) said the expectation was for weights to be obtained and documented into the resident record as ordered.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected 1 resident
Based on observations, interviews, and policy review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and ...
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Based on observations, interviews, and policy review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and potential transmission of communicable diseases and infections within the facility. Specifically, the facility failed to ensure staff adhered to infection control protocols for personal protective equipment (PPE) use when providing care and services to residents requiring precautions to prevent the possible spread of germs and illnesses.
Findings include:
Review of the facility's policy titled Enhanced Barrier Precautions Policy, undated, indicated but was not limited to:
-Enhanced barrier precautions require the use of gown and gloves for certain residents during specific high-contact resident care activities in which there is an increased risk for transmission of multi-drug resistant organisms. High-contact care activities include bathing/showering, providing hygiene, dressing, transferring, linen changes, toileting, device care and wound care.
-Signage will be posted on the door or wall outside of the resident room indicating the need for enhanced barrier precautions, the required personal protective equipment (PPE), and the high-contact resident care activities that require the use of gown and gloves.
Review of the Centers for Disease Control and Prevention (CDC) Enhanced Barrier Precaution sign indicated but was not limited to:
-everyone must: clean their hands, including before entering and when leaving the room
-providers and staff must: wear gloves and a gown for the following High-Contact Resident Care Activities. Dressing, bathing/showering, transferring, changing linens, providing hygiene, changing briefs or assisting with toileting, device care or use, wound care.
Review of the Centers for Medicare & Medicaid Services (CMS) circular letter, dated 3/20/24, titled Enhanced Barrier Precautions in Nursing Homes to Prevent Spread of Multidrug-Resistant Organisms (MDROs) indicated but was not limited to:
-For residents for whom Enhanced Barrier Precautions are indicated, Enhanced Barrier Precautions is employed when performing the following high-contact resident care activities: dressing, bathing/showering, transferring, providing hygiene, changing linens, changing briefs or assisting with toileting, device care or use: central line, urinary catheter, feeding tube, tracheostomy/ventilator, and wound care: any skin opening requiring a dressing
On 4/8/24 at 1:49 P.M., the surveyor observed Certified Nursing Assistant (CNA) #2 at the foot of Resident #16's bed with one glove on and no additional PPE donned. CNA #2 was sorting linen and placing dirty linen in a bag. A CDC Enhanced Barrier Precaution sign was posted at the entrance of the room.
During an interview on 4/8/24 at 1:52 P.M., CNA #2 said she was providing care to Resident #16 and changed him/her into a hospital gown.
During an interview on 4/8/24 at 1:52 P.M., Nurse #1 said the Enhanced Barrier Precaution sign posted outside of the room was for Resident #16. Nurse #1 said the sign was for the Resident and not the staff because the Resident had a wound. The surveyor and Nurse #1 reviewed the Enhanced Barrier Precaution sign on the door and Nurse #1 said she would ask the Unit Manager to clarify the expectations.
During an interview on 4/8/24 at 1:56 P.M., Unit Manager (UM) #2 said when a resident required Enhanced Barrier Precautions staff members providing high contact care should be using PPE as indicated on the sign posted outside of the rooms. UM #2 said CNA #2 should have worn gloves and a gown while providing care to Resident #16.
On 4/9/24 at 8:46 A.M., the surveyor observed two CNAs shifting Resident #23 up in bed. The two CNAs were wearing gloves (no gown) and did not perform hand hygiene when leaving the room. A CDC Enhanced Barrier Precaution sign was posted at the entrance of the room.
On 4/10/24 at 9:00 A.M., the surveyor observed CNA #4 feeding Resident #60. CNA #4 was observed using an ungloved hand to wipe something from the Resident's face. CNA #4 was observed touching her own face with an ungloved hand and opening the Resident's yogurt with both hands. The surveyor asked CNA #4 about the precautions required for Resident #60 and she said she was not sure and needed to check with the Nurse. Nurse #3 was also unsure if precautions were indicated. Nurse #4 confirmed at the nurses' station that Resident #60 did require Enhanced Barrier Precautions. CNA #4 then donned a gown and gloves but failed to tie the gown and properly secure it. A CDC Enhanced Barrier Precaution sign was posted at the entrance of the room.
During an interview on 4/9/24 at 11:58 A.M., the Infection Control Nurse (ICN) said staff should follow the Enhanced Barrier Precautions signs as posted outside of the rooms. The ICN said everyone should perform hand hygiene prior to entering and when exiting the rooms and gowns and gloves should be worn when performing high-contact care activities.
During an interview on 4/9/24 at 11:20 A.M., the Director of Nurses (DON) said staff should wear PPE when performing high-contact care as indicated on the signs posted outside of the rooms and all staff should perform hand hygiene when entering and exiting the rooms.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0804
(Tag F0804)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, and test tray results, the facility failed to ensure each resident received food prepared by m...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, and test tray results, the facility failed to ensure each resident received food prepared by methods that conserve nutritive value, flavor, and appearance, and was palatable, attractive, and at a safe and appetizing temperature for two of two test trays.
Findings include:
During initial resident screening on 4/7/24, the survey team identified the following concerns expressed by residents about food palatability:
-Resident #8 said the food could be ice cold and could be improved.
-Resident #88 said the food was sometimes not warm enough.
-Resident #70 said the food was deplorable; the taste was not good and was usually not warm despite mentioning these concerns during previous food committee meetings.
-Resident #38 said the food was always stone cold, especially the soup. The Resident said these things had previously been discussed at Resident Council.
-Resident #45 said the food was terrible and cold all the time.
-Resident #74 said sometimes the food temperature was not right.
-Resident #53 said the food could be better, and sometimes it was cold.
-Resident #1 said the food was not that great. The Resident said the food was served warm and was bland at times.
-Resident #68 said the food was horrendous. The Resident said they sent the last five meals back to the kitchen. The Resident said they could not usually say anything good about the food, and they often ordered takeout from local restaurants.
-Resident #43 said the food was terrible, low-grade.
-Resident #47 said the food was not palatable, the flavor could use more salt and pepper.
-Resident #1A said the food was not good in terms of texture, flavor, and visually.
-Resident #55 said their family brought them food because they did not like the facility's food.
-Resident #89 said the food was bland; temperature was warm.
-Resident #20 said the mashed potatoes were watery, meat was overcooked, and hot food was served cold. The Resident said their friends bring them food.
-Resident #70 said the food had bad flavor and was usually not warm.
-Resident #33 said the food was terrible; that it was cold with no flavor.
Review of Resident Council Meeting Minutes, dated 3/21/24, indicated several resident concerns about:
-cold breakfast.
-cold soups.
Review of Resident Council Meeting Minutes, dated 2/22/24, indicated several resident concerns about receiving cold food, especially breakfast.
During Resident Council Meeting on 4/8/24 at 3:15 P.M., several residents said they had concerns with:
-cold breakfast.
-cold soup.
On 4/8/24 at 1:00 P.M., the surveyor requested a lunch test tray to the [NAME] Unit. The food truck left the kitchen at 1:16 P.M., and arrived on the unit at 1:17 P.M. The test tray was conducted with the Food Service Director (FSD) obtaining temperatures at 1:35 P.M. with the following results:
- Mixed vegetables: 124 Fahrenheit (F), cold, extremely soft, mushy texture, little flavor.
- Baked dinner roll: 127 F, cold.
- Baked lasagna: 152 F, very warm.
During an interview on 4/8/24 at 1:00 P.M., the FSD declined to taste the contents of the lunch test tray. The FSD said the mixed vegetables were overcooked.
On 4/9/24 at 8:30 A.M., the surveyor requested a breakfast test tray to the [NAME] Unit. The surveyor observed the food temperature log for breakfast that morning was not completed. The food truck left the kitchen at 8:32 A.M. and arrived on the unit at 8:33 A.M. The test tray was conducted with the FSD obtaining temperatures at 8:47 A.M. with the following result:
-Omelet 123 F, lukewarm.
-Hashbrown 123 F, lukewarm.
-Orange juice in cup, 56 F, lukewarm.
During an interview on 4/9/24 at 8:30 A.M., the FSD declined to taste the test tray. The FSD said breakfast tended to be the meal where most residents were concerned with temperature. The FSD said it was difficult to serve breakfast trays at the desired temperatures.
During an interview on 4/10/24 at 9:47 A.M., the Dietitian said test tray meal temperatures have been mixed lately, with breakfast meals more consistently difficult to hold within the desired temperature range. Specifically, the Dietitian said the milk on Tuesday's test tray warm at 60 F.
Review of Room Test Tray Evaluation forms indicated acceptable temperature ranges for food and beverage:
-Hot food items 135-160 F
-Cold food items 40-55 F
-Hot beverages 145-180 F
-Cold beverages 40-55 F
Review of completed Test Tray Evaluation sheets indicated, but were not limited to, the following:
-4/8/24 Lunch: pulled pork sandwich entrée 168 F prior to meal service, 134.2 F upon delivery; mixed vegetables 122 F upon delivery; ambrosia dessert 36 F prior to meal service, 87.6 F upon delivery; whole milk 60.6 F upon delivery. The Dietitian wrote all items were out of temperature range except for the coffee which is poured on the unit, and the vegetables were waterlogged.
-3/12/24 Lunch: chicken entrée 166 F prior to meal service, 128.5 F upon delivery; Spinach 167 F temperature prior to meal service, 128.3 F upon delivery. The Dietitian wrote the meal plate was lukewarm.
-3/19/24 Lunch: fish entrée 175 F prior to meal service, 112.3 F upon delivery; mashed potato 166 F prior to meal service, 124.7 F upon delivery; mixed vegetables 165 F prior to meal service, 106.1 F upon delivery.
-3/21/24 Dinner: hot sandwich entrée 160 F prior to meal service, 114.8 F upon delivery; French fries 164 F prior to meal service, 107.1 F upon delivery; coffee 142.4 F upon delivery; soup 125.1 F upon delivery; milk 58 F upon delivery. The Dietitian wrote the meal was tasty but unfortunately cold.
-3/27/24 Lunch: chicken picatta entrée 132.2 F upon delivery; spaghetti 122 F upon delivery; summer squash 133.3 F upon delivery; milk 60.7 F upon delivery; cottage cheese 56.2 upon delivery.
-3/28/24 Breakfast: waffle 92.3 F upon delivery; sausage links 91.8 F upon delivery; oatmeal 176 F prior to meal service, 122.9 F upon delivery; milk 35 F prior to meal service, 56.5 F upon delivery. The Dietitian wrote the meal was too cold, with residents complaining the waffle was cold and hard and difficult to cut.
-3/5/24 Breakfast: pancakes 119.1 F upon delivery; orange juice 35 F prior to service, 65 F upon delivery. The Dietitian wrote the pancakes were too cold, the plate was warm, not hot. The Dietitian also wrote the juice was too warm.
-1/26/24 Breakfast: scrambled eggs 160 F prior to service, 106.5 F upon delivery; orange juice 35 F prior to service, 60.5 F upon delivery. The administrator wrote the eggs were too cold and the orange juice was too warm.
During an interview on 4/10/24 at 12:47 P.M., the Administrator said he has experienced issues with food temperatures when he completed Room Test Tray Evaluation forms, and he was aware of residents' concerns with food temperatures.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Food Safety
(Tag F0812)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, policy review, and interview, the facility failed to follow their policy and professional standards of pra...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, policy review, and interview, the facility failed to follow their policy and professional standards of practice for food safety and sanitation to prevent the potential spread of foodborne illness to residents who are at high risk. Specifically, the facility failed to:
1. Ensure the main kitchen was maintained in a sanitary condition;
2. Ensure food items were properly labeled and dated in the main kitchen refrigerators;
3. Ensure food and drink items were properly stored, labeled, and dated in two of three kitchenettes;
4. Handle ready-to-eat food (food which does not require cooking or further preparation prior to consumption) utilizing proper hand hygiene to prevent cross-contamination (transfer of pathogens (biological contaminants) from one surface to another). In addition, to ensure the use of gloves was limited to a single use task; and
5. Utilize proper equipment cleaning and sanitation to prevent cross-contact (the inadvertent introduction of an allergen into a product that would not intentionally contain that allergen as an ingredient) during handling of ready-to-eat food.
Findings include:
1. Review of the 2022 Food Code (model for safeguarding public health and ensuring food is safe for consumption) by the U.S. Food and Drug Administration (FDA), revised 1/2023, indicated but was not limited to the following:
3-305.11 (A) Except as specified in paragraphs (B) and (C) of this section, food shall be protected from contamination by storing the food (1) in a clean, dry location.
6-501.12 (A) Physical facilities shall be cleaned as often as necessary to keep them clean.
6-501.14 (A) Intake and exhaust air ducts shall be cleaned and filters changed so they are not a source of contamination by dust, dirt, and other materials.
Review of the facility's policy titled Dietary Infection Control Policies, revised January 2011, indicated but was not limited to the following:
-The facility must store, prepare, and distribute food under sanitary conditions.
-The Dietary Department will be maintained in a clean and sanitary manner to prevent foodborne illness.
Review of the facility's policy titled Safety and Sanitation, revised February 2005, indicated but was not limited to:
-Cleaning schedule will be available for staff.
-A cleaning schedule will be posted weekly, followed by staff, and monitored by the Director of Dining Services (termed Food Service Director [FSD] in this citation).
Review of the main kitchen's Closing Check List indicated but was not limited to:
-All food items are put away, labeled, and dated. Check walk-in for compliance.
-Floor swept and mopped
On 4/7/24 at 8:03 A.M., the surveyor made the following observations concerning sanitation in the main kitchen:
-buildup of food crumbs and debris along the perimeter of the kitchen floor.
-splashes of dried food on several large bins underneath one preparation counter.
-wheeled carts holding dishwasher trays visibly dirty with crumbs and food debris.
-shelving in the dry storage room had cobwebs.
-shelving in the dry storage room had items, such as Styrofoam cups, condiment packets, sugar packets, whole and pieces of food packaging, bottle caps, and dust and debris on the floor around and underneath the shelving\.
On 4/8/24 at 11:27 A.M., the surveyor made the following observations concerning sanitation in the main kitchen:
-buildup of food crumbs and debris along the perimeter of the kitchen floor.
-debris buildup on several of the stovetop burners.
-buildup of dust in the top portion of floor-to-ceiling tubing located in or adjacent to one food preparation area, the steam table, and the three-bay sink.
-buildup of dust on all ceiling vents in the kitchen.
-pot and pan shelving in main kitchen with visible dust and rust.
-shelving in the dry storage room had cobwebs.
-shelving in the dry storage room had items, such as Styrofoam cups, condiment packets, sugar packets, whole and pieces of food packaging, bottle caps, and dust and debris on the floor around and underneath the shelving.
During an interview on 4/8/24 at 7:51 A.M., the FSD said he expected the dry storage shelving to be free of cobwebs and the kitchen floor to be clean and free of debris and food particles. The FSD said the ceiling vents and tubing should be free of dust as it could potentially contaminate work surfaces, equipment, and food.
On 4/10/24 at 2:45 P.M., the FSD provided the surveyor with records of the Closing Check List for the main kitchen. Review of Closing Check List records showed the most recent documentation was on 1/12/24, on which date staff indicated they had swept and mopped the floors.
During an interview on 4/10/24 at 9:47 A.M., the FSD said it appeared that staff were sweeping the open area of the dry storage room floor but not underneath the shelving.
2. Review of the 2022 Food Code, revised January 2023, indicated but was not limited to the following:
3-501.17 Ready-to-Eat, Time/Temperature Control for Safety Food, Date Marking. (A) Except when packaging food using a reduced oxygen packaging method as specified under § 3-502.12, and except as specified in paragraphs (E) and (F) of this section, refrigerated, ready-to-eat, time/temperature control for safety food prepared and held in a food establishment for more than 24 hours shall be clearly marked to indicate the date or day by which the food shall be consumed on the premises, sold, or discarded when held at a temperature of 41 degrees Fahrenheit (F) or less for a maximum of 7 days. The day of preparation shall be counted as Day One.
Review of the facility's policy titled Total Quality Management Program Dining Services Indicators, reviewed March 2011, indicated but was not limited to the following:
-Food is stored properly.
-Food is labeled and dated in the refrigerator and freezing and storage area.
-Open items are wrapped or in an approved container, dated and labeled.
Review of the facility's policy titled Dietary Infection Control Policies, revised January 2011, indicated but was not limited to the following:
-All items stored in the refrigerator will be covered, labeled with the contents and the date.
On 4/7/24 at 8:03 A.M., the surveyor made the following food storage observations:
A. Walk-in refrigerator in the main kitchen:
-One opened ham luncheon meat, no label or date.
-One opened bag of pre-cooked meatballs, no label or date; the packaging was not securely closed and contents were exposed to air.
-One opened container of cottage cheese, no label or date.
-Two plated side salads, wrapped, no label or date.
-One open package of cubed potatoes, no label or date.
-One open package of shredded cheese, no label or date.
B. Dry storage room off the main kitchen:
-Two bags of muffin mix, out of original box, no date.
-One opened bag containing brown powder, no label or date.
C. Outdoor walk-in freezer trailer:
-One open box of omelets, no label or date.
During an interview on 4/7/24 at 3:25 P.M., the Regional FSD said he expected any open boxes of product in the walk-in freezer to be labeled and dated.
During an interview on 4/9/24 at 7:51 A.M., the FSD said any items removed from boxes should be labeled and dated. The FSD said the two bags of muffin mix in dry storage should be dated and the opened bag of brown powder should be labeled and dated.
During an interview on 4/10/24 at 9:47 A.M., the Regional FSD said he expected any open food or drink items in the walk-in cooler to be labeled and dated with the date it was opened.
3. Review of the facility's policy titled Personal Food Policy, undated, indicated but was not limited to the following:
-Families and visitors of residents are permitted to bring food into the facility for the resident use. However, nursing home residents are at risk for serious complications from foodborne illness which may occur from unsafe food handling practices. In order to ensure the safety of our residents, food may only be brought into the facility in accordance with this policy.
-The staff person receiving the personal food shall label the container with the date it was brought into the facility (or the date of preparation, if known) and the name of the resident receiving it.
-Dietary aides are responsible for checking nourishment refrigerators daily and discarding any unused refrigerated food after three days.
-Any perishable items that are found outside of the refrigerator or unlabeled shall be discarded unless it can be verified that the food has not been out for more than two hours.
Review of the facility's policy titled Dietary Infection Control Policies, revised 1/2011, indicated but was not limited to the following:
-Foods brought into the facility by family members will be kept in appropriate storage, refrigerated if indicated, and discarded as appropriate. For example, prepared foods that require refrigeration should be discarded after 3 calendar days, whereas crackers stored in an airtight container may be kept longer.
On 4/8/24 at 8:53 A.M., the surveyor observed in the [NAME] Unit kitchenette:
-One container of iced tea, opened with no resident label or date.
-One container of thickened dairy beverage, opened, with no date. The manufacturer's label indicated to use within four days of opening.
On 4/8/24 at 4:52 P.M., the surveyor observed in the [NAME] Unit kitchenette:
-One container of iced tea, opened with no resident label or date.
-One container of thickened dairy beverage, opened, with no date. The manufacturer's label indicated to use within four days of opening.
-One plastic bag with a sandwich and bag of chips, no resident label or date.
On 4/10/24 at 7:42 A.M., the surveyor observed in the [NAME] Unit kitchenette:
-One container of iced tea, opened with no resident label or date.
-One Styrofoam cup with straw, filled with liquid, no resident label or date.
During an interview on 4/10/24 at 7:42 A.M., Certified Nursing Assistant (CNA) #4 and CNA #7 said unit staff should label all food and drink with resident name and date when it was placed in the refrigerator. CNA #4 and CNA #7 said opened food or drink should be labeled and can be in the refrigerator for three days before being thrown away. CNA #7 said unit kitchen staff were responsible for monitoring dates and expiration dates of the food in kitchenettes.
On 4/10/24 at 8:50 A.M., the surveyor observed the following in the [NAME] Unit kitchenette refrigerator:
-One pink water bottle, with no resident label or date.
-one bottle of Vitamin Water, with no resident label or date.
-one container of brown soup in Tupperware container, with no resident label or date.
On 4/10/24 at 9:12 A.M., the surveyor observed the following in the [NAME] Unit kitchenette refrigerator:
-one container of sour cream with room number, with no date; the manufacturer's expiration date was 3/25/24.
-one container of brown soup in Tupperware container, with no resident label or date.
During an interview on 4/10/24 at 12:47 P.M., the surveyor observed the following in the [NAME] Unit kitchenette refrigerator:
-one container of sour cream with room number, with no date; the manufacturer's expiration date was 3/25/24.
-one container of brown soup in Tupperware container, with no resident label or date.
During an interview on 4/10/24 at 12:47 P.M., the Regional FSD said the container of sour cream should be labeled with the resident's name and dated. The Regional FSD said the sour cream was past the expiration date.
4. Review of the 2022 Food Code, revised January 2023, indicated but was not limited to the following:
3-301.11 Preventing Contamination from Hands. (A) food employees shall wash their hands as specified under § 2-301.12. (B) Except when washing fruits and vegetables as specified under §3-302.15 or as specified in (D) and (E) of this section, food employees may not contact exposed, ready-to-eat food with their bare hands and shall use suitable utensils such as deli tissue, spatulas, tongs, single-use gloves, or dispensing equipment.
3-304.15 Gloves, Use Limitation. (A) If used, single-use gloves shall be used for only one task such as working with ready-to-eat food or with raw animal food, used for no other purpose, and discarded when damaged or soiled, or when interruptions occur in the operation.
Review of the facility's policy titled Dietary Infection Control Policies, revised January 2011, indicated but was not limited to the following:
-All foods shall be prepared according to the FDA Food Code, with special attention paid to potentially hazardous foods. These include meats, poultry, stuffing, milk, dairy products, eggs, salads, cream-filled pastries, etc., and will be handled with extreme caution throughout the preparation and storage processes.
-Handling of all food items during the preparation process will be minimized. This may be accomplished by using clean kitchen tools or by wearing clean gloves for each task.
On 4/8/24 at 11:22 A.M., the surveyor observed Dietary Staff #1 making peanut butter and jelly sandwiches with no gloves on.
On 4/8/24 at 12:26 P.M., the surveyor observed the FSD using visibly soiled oven mitts with gloved hands. The FSD returned to the tray line wearing the same gloves. The FSD was observed using the same gloves to grab handfuls of tossed salad to plate. The FSD was subsequently observed touching the tops of several resident lunch plates, buns, rolls, and tray line utensils while wearing the same gloves that handled the soiled oven mitts.
During an interview on 4/10/24 at 9:47 A.M., the Regional FSD said he expected Dietary Staff to take off gloves as soon as they leave a station, and for Dietary Staff to wash hands before entering a station. The Regional Food Service director said staff should use designated utensils for plating salad.
During an interview with the FSD and the Regional FSD on 4/10/24 at 9:47 A.M., the FSD said the oven mitts had not been laundered in about 4 months. The Regional FSD said oven mitts could be an infection control issue.
5. Review of the 2022 Food Code, revised January 2023, indicated but was not limited to the following:
3-304.11 Food Contact with Equipment and Utensils. Food shall only contact surfaces of: (A) Equipment and utensils that are cleaned as specified under Part 4-6 of this Code and sanitized as specified under Part 4-7 of this Code.
4-602.11 Equipment Food-Contact Surfaces and Utensils. (A) Equipment food-contact surfaces and utensils shall be cleaned: (5) At any time during the operation when contamination may have occurred.
4-702.11 Before Use After Cleaning. Utensils and food-contact surfaces of equipment shall be sanitized before use after cleaning.
On 4/8/24 at 12:46 P.M., the surveyor observed Dietary Staff #4 placing a peanut butter and jelly sandwich directly onto a prep table and re-using a knife to cut crust off the sandwich. Dietary Staff #4 was observed leaving the station without cleaning or sanitizing the prep table. Dietary Staff #4 left the used knife on the prep table.
On 4/8/24 at 1:12 P.M., the surveyor observed the FSD placing a tuna salad sandwich on the same area of the prep table where Dietary Staff #4 prepared the peanut butter and jelly sandwich. The FSD was observed cutting the tuna salad sandwich using the same knife that cut the peanut butter and jelly sandwich. The FSD was observed leaving the station without cleaning or sanitizing the prep table.
During an interview on 4/10/24 at 9:47 A.M., the Regional FSD said the prep table, where the peanut butter and jelly sandwich and the tuna salad sandwich were cut, should have been cleaned and sanitized after each use. The Regional FSD said Dietary Staff should have used a new knife to cut the tuna salad sandwich to prevent cross-contamination.
MINOR
(B)
Minor Issue - procedural, no safety impact
Safe Environment
(Tag F0921)
Minor procedural issue · This affected multiple residents
Based on observations and staff interviews, the facility failed to ensure a functional, safe, and clean environment. Specifically, the facility failed to ensure residents and/or staff properly dispose...
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Based on observations and staff interviews, the facility failed to ensure a functional, safe, and clean environment. Specifically, the facility failed to ensure residents and/or staff properly dispose of cigarette butts in designated smoking receptacles.
Findings include:
Review of the Centers for Medicare & Medicaid Services (CMS) circular letter, dated November 10, 2011, titled Smoking Safety in Long Term Care Facilities indicated but was not limited to the following:
-The Life Safety Code (NFPA 101, 2000 ed., 19.7.4) requires each smoking area be provided with ashtrays made of noncombustible material and safe design.
-Metal containers with self-closing covers into which ashtrays can be emptied must be readily available.
Review of the facility's policy titled Smoking, dated as revised 11/2020, indicated but was not limited to:
-It is the policy of the facility to provide a healthy and safe environment for residents, staff and visitors by limiting the use of tobacco smoking materials on its campus
-Purpose: to afford residents the privilege of smoking while maintaining a safe and clean environment within the policy of this facility, that also is respectful to the non-smoker
On 4/8/24 at 9:27 A.M. and 4:18 P.M., the surveyor observed the smoking area with a receptacle for cigarette butts but noted numerous cigarette butts on the pavement and scattered in the grass behind and around the smoking area.
On 4/9/24 at 10:15 A.M., 1:16 P.M., and 4:14 P.M., the surveyor observed the smoking area with a receptacle for cigarette butts but noted numerous cigarette butts on the pavement and scattered in the grass behind and around the smoking area.
On 4/10/24 at 7:04 A.M. and 10:09 A.M., the surveyor observed the smoking area with a receptacle for cigarette butts but noted numerous cigarette butts on the pavement and scattered in the grass behind and around the smoking area.
During an interview on 4/8/24 at 4:18 P.M., Certified Nursing Assistant (CNA) #8 said residents were not allowed to smoke without a staff member present. CNA #8 said all cigarettes should be disposed of in the receptacle.
During an interview on 4/9/24 at 10:15 A.M., CNA #3 said residents were provided four smoke breaks per day. CNA #3 said a staff member must be present with residents. CNA #3 said the cigarette butts should not be thrown on the ground and that all cigarettes should be extinguished and disposed of in the receptacle.
During an interview on 4/10/24 at 2:29 P.M., the Maintenance Director said every morning the cement in the smoking area was swept to clean up the cigarette butts. The Maintenance Director said the grassy area around the smoking area was not often raked. He said cigarettes should be disposed of in the receptacle but every morning there was a lot to sweep up.
During an interview on 4/10/24 at 1:20 P.M., the Administrator said the smoking area should be cleaned frequently and that cigarette butts should not be on the ground. The Administrator said the expectation was for cigarettes butts to be extinguished and disposed of in the receptacle.
Nov 2023
1 deficiency
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected most or all residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, document review, and policy review, the facility failed to maintain an infection control and pr...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, document review, and policy review, the facility failed to maintain an infection control and prevention program to help prevent the potential transmission of a communicable disease when the facility was experiencing an outbreak of COVID-19 infections. Specifically, the facility failed to implement outbreak testing for both staff and residents in accordance with the most current guidance and the facility policy.
Findings include:
During an interview on 11/16/23 at 7:18 A.M., the Administrator said the facility was currently in a COVID-19 outbreak with four resident cases remaining and two staff cases.
Review of the facility's policy titled COVID-19 Pandemic Resident and Staff Testing, dated as revised 5/16/23, indicated but was not limited to the following:
-An outbreak is identified as a new COVID-19 infection in any healthcare personnel (HCP) or any resident
-Upon identification of a single new case of COVID-19 infection in any staff or residents, testing should begin per current Centers for Disease Control and Prevention (CDC) or state specific guidelines.
-Facilities have the option to perform outbreak testing through two approaches, contact tracing or broad-based testing.
-If the facility has the capability of identifying close contacts of the COVID-19 individual, they could choose to conduct focused testing on known close contacts.
-If the facility does not have the expertise, resources, or ability to identify close contacts they should instead investigate the outbreak at a facility wide approach or group level (i.e., unit, floor) approach.
-Asymptomatic staff or residents identified as close contact with someone with SARS-CoV-2 infection should have a series of three viral tests for SARS-CoV-2 infection. Testing is recommended immediately, but not earlier than 24 hours after the exposure, and if negative again in 48 hours after the first negative test, and if negative again, 48 hours after the second negative test. This will typically be at day one (where the day of exposure is day zero), day three, and day five.
Review of the Department of Public Health (DPH) Memorandum titled Update to Infection Prevention and Control Considerations When Caring for Long-Term Care Residents, including Visitation Conditions, Communal Dining, and Congregate Activities, dated May 2023, indicated but was not limited to the following:
-Long-term care facilities are required to perform outbreak testing of residents and staff as soon as possible when a case is identified.
-Once a new case is identified in a facility, following outbreak testing, long-term care facilities should test exposed residents and staff at least every 48 hours on the affected unit until the facility goes seven days without a new case unless a DPH epidemiologist directs otherwise. Residents and staff who have recovered from COVID-19 in the last 30 days can be excluded from this testing.
During entrance conference on 11/16/23 at 8:37 A.M., the Director of Nurses (DON) and Administrator indicated they were provided guidance from state epidemiology that staff testing was not required during the current COVID-19 outbreak unless staff was symptomatic for COVID-19 infection; they said they would provide that guidance to the survey team.
Review of the facility's COVID-19 Line listings indicated but were not limited to the following:
- 10/18/23 Dietary Staff #1 tested positive for COVID-19 while working in the facility
- 10/23/23 Resident #1 tested positive for COVID-19 and resides on the [NAME] unit
- 10/28/23 14 additional residents, 6 on the [NAME] unit and 8 on the [NAME] unit, tested positive for COVID-19
Review of the facility's Resident Testing Logs for both the [NAME] and [NAME] units failed to indicate any outbreak testing was completed on the [NAME] unit following the identification of Resident #1 being positive with a new COVID-19 infection on 10/23/23 and outbreak testing for the residents residing on the [NAME] unit was not initiated per current guidance until 10/28/23.
During an interview on 11/16/23 at 10:49 A.M., Infection Preventionist (IP) #1 said she was not involved in the role of IP at the time the first staff member tested positive on 10/18/23 and could not speak to that. She said the facility did not initiate outbreak testing for residents on the [NAME] unit until Resident #1, who was positive for COVID-19 on 10/23/23, was at his/her day five (10/28/23). She said she does not know if contact tracing was done or if a broad-based group level outbreak strategy was used but the previous IP would probably know and be able to provide further information. She said she is aware that if a contact tracing identifying close contacts with Resident #1 was not completed, then all residents on the unit should have been tested per outbreak testing guidance. She said to the best of her knowledge she was informed by the DON that the facility did not need to test any staff during the outbreak unless they were symptomatic. She said as far as the residents being tested as of 10/28/23 they are following the guidance.
During an interview on 11/16/23 at 11:06 A.M., IP #3 said Dietary Staff #1 tested at the facility when not feeling well on 10/23/23 and was found to be positive for COVID-19. IP#3 then tested the staff that were on duty with Dietary Staff #1 that day and only tested them once as a precaution since they were considered to have had an exposure to Dietary Staff #1. He said he did not go back the 48 hour incubation period to potentially identify other staff in the kitchen who may have been exposed or complete any other contact tracing activity, choosing to test the three other staff members who were in the kitchen on 10/18/23 one time following their exposure to Dietary Staff #1. He said when Resident #1 tested positive for COVID-19 on 10/23/23 he identified that the Resident had a physical therapy session with Physical Therapist (PT) #1, who then also tested positive for COVID-19 on 10/25/23. He said there was no way to tell if Resident #1 or PT #1 was the initially infected person and so contact tracing would have been ineffective and was not completed. He said to the best of his knowledge no other staff or residents were tested, as he did not himself perform any testing on potentially exposed residents. He said he believes the unit staff tested Resident #1's roommate as a precaution for exposure. He could not explain why outbreak testing protocol was not initiated when Resident #1 tested positive for COVID-19 and no contact tracing was performed to identify close contacts. He said the facility should have initiated outbreak testing on the [NAME] unit following Resident #1 testing positive for COVID-19 on 10/23/23 but to the best of his knowledge outbreak testing was not started for residents until Resident #7 was found to be positive on the [NAME] unit on 10/28/23 and then outbreak testing was initiated on both units for the residents. He said he does not know why staff are not participating in outbreak testing, but he believed there was a directive from the DON that it was not necessary.
Review of the facility's Staff Testing Logs confirmed that the three dietary staff members on duty on 10/18/23 and exposed to Dietary staff #1, were tested on e time on 10/18/23, did not wait 24 hours following the known exposure, and did not participate in serial testing with three negative tests each 48 hours apart, in accordance with current guidance.
During an interview on 11/16/23 at 11:58 A.M., the DON said once she was made aware of Resident #1 being positive for COVID-19, the three close contact nurses who worked with the Resident that day were tested, as was the Resident's roommate. She said at that time she had not reported the case as a COVID-19 outbreak and she could not speak to what had occurred when Dietary Staff #1 tested positive for COVID-19 but would attempt to get information from the old Infection Preventionist regarding the situation and why the process was not followed. She said there have been changes in the department for the better, and although processes do not appear to have been followed initially, they are currently following all outbreak protocols. She said when Resident #7 on the [NAME] unit became symptomatic and tested positive for COVID-19 they initiated outbreak testing on both the [NAME] and [NAME] units, testing all residents initially and every 48 hours and that testing is still ongoing at this time. She said she does not have any documented guidance from her conversation with Epidemiology but left a message with two people whom she believed was epidemiology, and provided their names to the surveyor, she said those people are the ones who provided her with the guidance that staff did not need to be tested during the outbreak unless they were symptomatic.
Review of the facility's Staff Testing Logs indicated two of the three identified nurses, who were exposed to Resident #1 on 10/23/23 tested as follows:
-Nurse #1 tested negative for COVID-19 on 10/23/23 following his exposure to Resident #1, but no further testing was available or documented for this nurse after that day through 10/29/23
-Nurse #2 tested negative for COVID-19 on 10/25/23 following her exposure to Resident #1, but no further testing was available or documented for this nurse after that day through 10/29/23
-IP #3 was identified by the facility as the third nurse exposed to Resident #1 on 10/23/23, but the staff testing logs failed to indicate any testing was completed for this nurse and her name could not be found on the testing log.
During an interview on 11/16/23 at 12:07 P.M., IP #2 said she was one of the exposed nurses to Resident #1 on 10/23/23 and confirmed she tested negative one time on 10/23/23 following her exposure to the Resident.
Review of the staff testing documents following the exposure failed to indicate that serial testing was completed for the three identified nurses per current state testing guidance.
During an interview on 11/16/23 at 1:01 P.M., the Director of Public Health in the town of Sandwich said when a facility reaches out to report a cluster or with an outbreak question, they are referred to the public outreach nurse for guidance, since there are no nurses or epidemiologists that work at the Sandwich public health office. She said she recalls receiving a message from the facility and did request the public outreach nurse contact the facility and offer guidance, but she offered no guidance to the facility and did not speak with them directly.
During an interview on 11/16/23 at 1:11 P.M., the public Outreach Nurse said she contacted the facility on 10/30/23 when she was made aware of them experiencing a cluster of COVID-19 infections amongst both staff and residents in their facility. She said she informed the facility of the reporting requirements and offered to send them the current state of Massachusetts (MA) outbreak management guidance, but they told her they did not need her assistance at this time. She said she did not provide them with any guidance and did not tell them not to test their staff. She said she thinks there may have been some confusion or miscommunication because she also spoke to the facility earlier this day (11/16/23) and informed them that she is not part of MA epidemiology and that since they did not want any guidance from her, she did not provide any beyond the need to report and could not assist them with any documentation of guidance to them beyond that.
Both the Director of Public Health for the town of Sandwich and the public Outreach Nurse were the two contacts that the DON previously identified as her epidemiology contacts to the state surveyor.
During a follow up interview on 11/16/23 at 1:53 P.M., the DON said she spoke with the public Outreach Nurse today and is aware that she is not part of MA epidemiology. She said she realized there was a miscommunication and she did not contact epidemiology for guidance but would speak with the Administrator and provide any information the facility had on the guidance to not test their staff if any could be located.
During an interview on 11/16/23 at 3:17 P.M., IP #1 and IP #3 said the facility documents all resident testing in the progress notes for the individual residents and on the facility testing logs. They said they did not have any contact tracing documents or documentation to identify potential close contacts to Dietary Staff #1 or Resident #1 following their COVID-19 positive tests on 10/18/23 and 10/23/23 respectively. They said once the facility realized all potential close contacts could not be identified they should have initiated group broad-based testing for the residents on the [NAME] unit on 10/24/23 and did not. They said unit wide resident testing on the [NAME] unit did not begin until 10/28/23, when the [NAME] unit also had testing initiated unit wide for an additional COVID-19 positive resident case on that unit. They said they understood there were concerns with the facility testing policy and current guidance not being followed.
No further documents or information regarding guidance from MA Epidemiology instructing the facility to not perform staff outbreak testing, in accordance with current statewide guidance, was provided to the survey team at the time of survey exit.
Oct 2022
41 deficiencies
3 Harm
SERIOUS
(G)
Actual Harm - a resident was hurt due to facility failures
Accident Prevention
(Tag F0689)
A resident was harmed · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, record review, and policy review, the facility failed to ensure adequate supervision and deve...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, record review, and policy review, the facility failed to ensure adequate supervision and develop and implement fall interventions for one Resident (#4), out of a sample of 19 residents, resulting in a fall with major injury.
Findings include:
Review of the facility's policy titled Falls Management, last revised August 2018, included but was not limited to:
-The facility will utilize all resident/patient related information made available upon admission and ongoing to determine resident/patient at-risk for fall status. The information includes but is not limited to the following:
-Hospital admission
-Discharge summary
-Nursing admission Evaluation
-Fall Risk Evaluation
-A fall risk evaluation will be conducted on each resident/patient upon admission, with the quarterly Minimum Data Set (MDS) cycle when a significant change in status occurs, annually and following a fall.
-The interdisciplinary team will develop, initiate, and implement an appropriate individualized care plan based on the fall risk evaluation score
-A fall risk evaluation will be conducted by the nurse on duty/supervisor on any resident/patient sustaining a fall without injury
Resident #4 was admitted to the facility with diagnoses including dementia and a history of falls.
Review of the Minimum Data Set assessment, dated 9/1/22, indicated Resident #4 had severe cognitive impairment as evidenced by a score of 00 on the Brief Interview for Mental Status assessment, requires extensive assistance from staff for all activities of daily living (ADL) and had one fall with major injury since the prior assessment.
Review of Resident #4's comprehensive care plans included but was not limited to:
-Focus: Resident is at risk for fall related injury due to fall prior to admit to facility resulting in a right femur fracture, impaired mobility, weakness, osteopathic and depression (10/6/21)
-Interventions:
-educate/remind resident to request assistance prior to ambulation, footwear;
-remind resident and reinforce safety awareness, lock brakes on bed, chair, etc. before transferring, when rising from a lying position, sit on side of bed for a few minutes before transferring/standing (10/6/21)
-Goal: Resident will not sustain a fall related injury by utilizing fall precautions through next review date of 12/1/22.
Review of the medical record indicated Resident #4 had an unwitnessed fall in his/her room on 3/6/22 at 11:50 P.M. Review of a 3/7/22 Nursing Progress Note indicated the Resident was found on the floor at the bedside. The Resident was unable to say what happened due to his/her cognitive status. The Resident was given a pudding and 8 ounces of milk.
The care plan for falls was updated with the following intervention:
-Offer snack at bedtime (3/7/22)
Review of Nursing Progress Notes included, but was not limited to:
-5/1/22: Patient restless at times getting up out of bed and wandering. Redirected as need as patient has no safety awareness; patient is a high risk for fall.
-5/9/22: Resident getting up during the night, appears to be sleep walking, unsafe, hard to get to follow simple directions.
-5/10/22: Resident restless and getting out of bed multiple times without asking for help.
-5/12/22: Resident up in the middle of the night trying to get into roommate's bed. Appeared to be sleep walking.
-5/13/22: Resident up during the night, pulled off brief and johnny; found standing next to his/her bed.
-5/30/22: Resident out of bed at beginning of 11:00 P.M. to 7:00 A.M. shift. Continually standing up out of wheelchair. Resident would not stay in bed.
-6/16/22: Resident was awake most of 11:00 P.M. to 7:00 A.M. shift strolling the hallway going into every resident room during the night; very hard to redirect.
On 6/28/22, the following intervention was added to the care plan for falls:
-Invite, encourage, remind, escort to activity program consistent with resident's interests to enhance physical strengthening needs (6/28/22)
No new effective interventions were developed to address the Resident's lack of safety awareness and repeated behaviors of getting up at night.
Review of an 8/8/22 Progress Note indicated a new order written by the Nurse Practitioner (NP) to increase Trazodone (antidepressant) from 25 milligrams (mg) to 50 mg at bedtime.
Further review of Nursing Progress Notes indicated:
-8/12/22: The Resident has been awake and out of his/her room numerous times so far this shift. Started a new dose of Trazodone at bedtime with poor results. Resident wakes up and walks out of his/her room. CNA and nurse assist resident when walking, however he/she continually gets up out of chair and bed. Interventions include multiple cups of fluid, snacks, redirection with poor outcome.
-8/13/22: On 8/12/22 at approximately 11:45 P.M., Resident #4 had an unwitnessed fall and was found on the floor by the nurse while doing bed checks. The Nurse observed the Resident sitting on the floor in between the roommate's dresser and the bed with his/her back to the dresser. The Resident had a large contusion in the middle of his/her forehead and a small laceration on the bridge of his/her nose. 911 was called and the Resident was sent to emergency room for evaluation.
Review of a 8/14/22 Hospital Discharge Summary indicated Resident #4 was evaluated after having an unwitnessed fall at the facility and found to have a 1.0 X 2.9 centimeter hematoma to the forehead and a minimally displaced left nasal bone fracture.
Review of Resident #4's Physician's Orders, dated 8/15/22, indicated
-to initiate continuous 1:1 monitoring until assessed and discontinued by the Physician.
Review of the medical record indicated, on 9/6/22, Resident #4 was admitted to the hospital for treatment of a urinary tract infection and was readmitted on [DATE].
Review of the medical record indicated that all previous Physician's orders were continued except for the order for 1:1 monitoring.
There was no documentation in the medical record to indicate the Physician assessed and discontinued the order for 1:1 monitoring.
Review of the medical record indicated on 9/26/22 at 6:10 A.M., Resident #4 had an unwitnessed fall in his/her room and was found by staff face down on the floor with his/her head underneath a bureau. The Resident was sent to the hospital for evaluation.
Review of the 9/26/22 Hospital documentation indicated Resident #4 was evaluated for an unwitnessed fall with head strike and was found to have impact injury in the forehead (bruising).
During an interview on 9/30/22 at 9:35 A.M., Physician #1 said he did not discontinue the order for 1:1 monitoring and due to the Resident #4's high risk of falls, the 1:1 monitoring should have been resumed upon his/her return from the hospital to prevent further falls.
SERIOUS
(G)
Actual Harm - a resident was hurt due to facility failures
Deficiency F0692
(Tag F0692)
A resident was harmed · This affected 1 resident
Based on interviews and record review, the facility failed to monitor the nutritional status of two Residents (#43 and #42), out of a total sample of 19 residents. Specifically, the facility
1. Failed...
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Based on interviews and record review, the facility failed to monitor the nutritional status of two Residents (#43 and #42), out of a total sample of 19 residents. Specifically, the facility
1. Failed to monitor the weight loss of Resident #43, resulting in a significant weight loss; and
2. Failed to implement nutritional interventions for Resident #42.
Findings include:
1. Review of the facility's policy titled Weights, dated August 2015, indicated the following residents would be weighed weekly for four weeks:
-residents with unanticipated weight loss of more than 5% in one month
-all residents with significant weight loss are reviewed by the interdisciplinary team and interventions implemented as appropriate and are monitored weekly
-a weight loss/gain of 5 pounds or more on a resident weighing over 100 pounds, requires a reweigh for verification
Resident #43 was admitted to the facility in January 2019 with a diagnosis of Parkinson's disease.
Review of the care plans indicated Resident #43 was at risk for a nutritional decline related to Parkinson's disease with a goal, revised on 5/23/22, to have the weight stable at 165 pounds (lbs.).
Review of the medical record for Resident #43 indicated the following nutritional history:
-On 02/04/22, the Resident weighed 176.4 lbs. On 03/04/22, the Resident weighed 166.8 lbs. which was a -5.44 % loss in four weeks.
-On 02/10/22, the Resident weighed 176.4 lbs. On 05/05/22, the Resident weighed 162.0 lbs. which was a -8.16 % loss in three months.
-Nursing progress note, dated 5/25/22, indicated a recommendation from the Registered Dietitian (RD) for 8 ounces of Ensure every day
- RD progress note 6/1/22 indicated Resident continued with weight loss, supplements were added, weekly weights requested, and the Resident remained at nutritional risk
During an interview on 9/27/22 at 1:40 P.M., Unit Manager #2 said all weights for residents were located in the electronic medical record and there were no paper records of resident weights for the unit.
Review of the electronic medical record for Resident #43 indicated the Resident was weighed weekly in the month of June 2022 and weighed monthly following that. The following weights were in the medical record as of 9/30/22:
-7/5/22: 163.4 lbs.
-8/5/22: 160.8 lbs.
-9/2/22: 155.4 lbs.
During an interview on 10/4/22 at 10:13 A.M., the RD said Resident #43 should have been weighed weekly since May 2022, so the RD was able to monitor the Resident's weight closely and add interventions before the weight loss became significant. She said Resident #43 previously had a significant weight loss and had stabilized in the month of June 2022. She reviewed the electronic medical record at this time and said she had not been aware of the weight of 155.4 lbs. on 9/2/22 (one month prior). She said the Resident should have been re-weighed and the RD should have been notified by the Unit Manager.
During an interview on 10/4/22 at 11:52 A.M., the Director of Nurses said the facility was having trouble getting weekly weights on residents. She said Resident #43 should have been reweighed following a change in weight on 9/2/22.
On 10/5/22 Resident #43 weighed 149.0 lbs. On 7/5/22, the Resident weighed 163.4 lbs. which was a -9.66 % loss in three months. On 4/5/22, the Resident weighed 165.8 lbs. which was a -11.28 % loss in six months.
During an interview on 10/5/22 at 9:00 A.M., the RD said Resident #43 was now 149.0 lbs. and had a significant weight loss.
2. Resident #42 was admitted to the facility in February 2022 with medical diagnoses including dysphagia (difficulty swallowing), gastro-esophageal reflux disease without esophagitis, and type 2 diabetes mellitus.
Review of the dietary Nutritional Care Recommendation, dated 7/18/22, indicated to discontinue Glucerna and administer 4 ounces of Ensure Plus three times a day. This order requested medical review due to a weight loss of 37 lbs.
Review of the Physician's Progress Notes, dated July 2022, indicated the Resident was evaluated for weight loss. The progress notes indicated Resident was referred to be seen by nursing staff on 7/20/22 for evaluation. The progress note indicated, a new order to stop Glucerna (current) and start Ensure Plus 4 ounces three times a day.
Review of the Minimum Data Set (MDS) assessment, dated 8/15/22, indicated Resident #42 is moderately cognitively impaired as evidenced by a Brief Interview for Mental Status (BIMS) score of 12 out of 15. The MDS indicated the Resident eats independently and requires set up only. The MDS indicated the Resident's height is 60 inches and weighed 166 pounds which triggered a weight loss which was not prescribed. The weight loss was 5% or more in the last month and 10% or more in the last six months.
The threshold for significant unplanned or undesired weight loss is based on the following criteria:
a. 1 month - 5% weight loss is significant, greater than 5% is severe
b. 3 months - 7.5% weight loss is significant, greater than 7.5% is severe
c. 6 months - 10% weight loss is significant, greater than 10% is severe
Review of the Physician's Orders, dated September 2022, failed to include a physician's order to discontinue Glucerna and administer Ensure Plus 4 ounces three times daily, weekly weights for four weeks, order dated 7/20/22 for weight loss monitoring. Facility failed to obtain the weekly weight as ordered.
Review of the clinical record indicated Resident #42's weekly weight as ordered was not obtained as follows:
7/28/22; 8/11/22; and 8/13/22 out of the four weeks.
Resident weight was obtained on 8/4/22 at 2:31 P.M., the weight value equals 166.4 lbs. on a standing scale indicating 17.2 pounds less in comparison to the last weight obtained of 183.6 lbs. obtained on 5/5/22.
Further review of the clinical record indicated the facility staff did not administer the new supplement nor obtain the weekly weight for 4 weeks as ordered. In addition, the progress note did not indicate he/she refused or was unavailable to obtain weekly weights.
During an interview on 10/04/22 at 01:16 P.M., Nurse #4 said Resident #42 is receiving Glucerna 237 milliliters at 2:00 P.M. daily.
During an interview on 10/04/22 at 01:40 P.M., Unit Manager #1 said the Medication Administration Record indicated to administer Glucerna 237 milliliters at 2:00 P.M. daily to Resident #42. She said she administered Glucerna to the Resident when there are no nurses, and she is administering medications. The Unit Manager said the order for the weekly weight and the supplement were not documented in the record.
SERIOUS
(G)
Actual Harm - a resident was hurt due to facility failures
Deficiency F0725
(Tag F0725)
A resident was harmed · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews, the facility failed to ensure there was sufficient staff available to provide nursing se...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews, the facility failed to ensure there was sufficient staff available to provide nursing services and care required to meet the needs of two Residents (#43 and #40), in a total sample of 19 residents. Specifically, the facility failed
1. For Resident #43, to ensure weekly weights were obtained to monitor weight loss, resulting in significant weight loss; and
2. For Resident #40, to ensure wound care was provided as ordered.
Findings include:
1. Resident #43 was admitted to the facility in January 2019 with a diagnosis of Parkinson's disease.
Review of the care plans indicated Resident #43 was at risk for a nutritional decline related to Parkinson's disease with a goal, revised on 5/23/22, to have the weight stable at 165 pounds.
Review of the medical record for Resident #43 indicated the following nutritional history:
-On 02/04/22, the Resident weighed 176.4 pounds (lbs.). On 03/04/22, the Resident weighed 166.8 lbs. which was a -5.44 % loss in four weeks.
-On 02/10/22, the Resident weighed 176.4 lbs. On 05/05/22, the Resident weighed 162.0 pounds which was a -8.16 % loss in three months.
- Registered Dietitian (RD)'s Progress Note, dated 6/1/22, indicated the Resident continued with weight loss, supplements were added, weekly weights were requested, and the Resident remained at nutritional risk.
Review of the electronic medical record for Resident #43 indicated the Resident was weighed weekly in the month of June 2022 and weighed monthly following that. The following weights were in the medical record as of 9/30/22:
-7/5/22: 163.4 lbs.
-8/5/22: 160.8 lbs.
-9/2/22: 155.4 lbs.
During an interview on 10/4/22 at 10:13 A.M. the RD said Resident #43 should have been weighed weekly since May 2022, so the RD would be able to monitor his/her weight closely and add interventions before the weight loss became significant. She said the weekly weights were not obtained due to staffing.
During an interview on 10/4/22 at 11:52 A.M., the Director of Nurses said the facility was having trouble getting weekly weights on residents due to staffing and Resident #43 should have been reweighed following a change in weight on 9/2/22.
During an interview on 10/5/22 at 9:00 A.M., the RD said Resident #43 was now 149.0 lbs and had a significant weight loss.
2. Resident #40 was admitted to the facility in February 2022 with diabetes and a wound to the right heel and had developed multiple diabetic wounds.
Review of the September 2022 Treatment Administration Record (TAR) on 9/28/22 indicated the following treatment:
-8/1/22 Right heel: Cleanse with normal saline wash, pat dry, then apply nickel-thick Santyl ointment to wound bed, cover with ABD pad, wrap with Kerlix, change daily.
The September 2022 TAR indicated the right heel treatment was not completed on 9/2, 9/5, 9/7, 9/9, 9/13, 9/14, 9/15, 9/16, 9/17, 9/19, 9/22, and 9/23/22 (12 out of 27 days).
Review of the September 2022 Treatment Administration Record (TAR) on 9/28/22 indicated the following wound treatments:
-7/30/22 Right shin: normal saline wash, pat dry, apply skin prep to periphery, cover with adaptic gauze to wound bed, cover with ABD pad, wrap with Kerlix, change daily
-7/30/22 Right calf: normal saline wash, pat dry, apply skin prep to periphery, cover with adaptic gauze to wound bed, cover with ABD pad, wrap with Kerlix, change daily
-6/29/22 Right lower leg: apply ace bandage daily with dressing change
The September 2022 TAR indicated the right shin, calf and lower leg treatments were not completed on 9/2, 9/6, 9/7, 9/9, 9/13, 9/14, 9/15, 9/16, 9/17, 9/18, 9/19, 9/22, and 9/23/22 (13 out of 27 days)
During an interview on 9/30/22 at 2:00 P.M., Unit Manager #2 said the nurses may not have had time to complete the treatments for Resident #40. She said the nurses had to prioritize how they cared for the residents on the unit, and usually there was only one nurse on the [NAME] Unit. She said there were times when she was the only nurse on the unit and responsible for being the Unit Manager, administering medications, completing treatments, doing assessments, monitoring meals, and things were getting missed.
During an interview on 9/29/22 at 3:55 P.M. Nurse #3 said she was the only nurse on the [NAME] Unit today with 35 residents. She said usually the nurse will provide medications to all of the residents on the unit with the hope that the Unit Manager could do the treatments. She said any issues the unit had could be resolved with additional staffing.
During an interview on 10/4/22 at 11:00 A.M. Nurse #7 said she was the only nurse on the [NAME] Unit (the Unit Manager was off) with two Certified Nursing Assistants (CNAs) and the Unit Secretary was providing one to one (1:1) services to a resident. She said as the only nurse, it was a lot of work to provide care to 35 residents.
Review of the Facility assessment dated as revised on 9/19/22 indicated the average daily census on the [NAME] Unit was 35 residents.
Review of the facility nursing schedule from 9/11 through 10/5/22 indicated the following days when only one nurse was working on the [NAME] Unit on the 7:00 A.M. to 3:00 P.M. shift: 9/11, 9/14, 9/16, 9/17, 9/18, 9/19, 9/23, 9/25, 9/29, 10/1, 10/2, 10/3, 10/4, 10/5/22.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Resident Rights
(Tag F0550)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Resident #48 was admitted to the facility with diagnoses including multiple sclerosis (MS) (a disease resulting in nerve dama...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Resident #48 was admitted to the facility with diagnoses including multiple sclerosis (MS) (a disease resulting in nerve damage that disrupts the communication between the brain and the body), neurogenic bladder (lack of bladder control due to a brain, spinal cord, or nerve problem), and a urinary tract infection (UTI).
Review of the Minimum Data Set (MDS) assessment, dated 8/10/22, indicated Resident #48 had an indwelling urinary catheter (drains urine from your bladder into a bag outside your body).
Review of current Physician's Orders, dated 9/1/22 through 9/30/22, indicated an order for the following:
-suprapubic catheter to bedside drainage (place in privacy bag)
On 9/29/22 at 8:37 A.M., the surveyor observed Resident #48 lying in bed. His/her urinary catheter bag was positioned on the side of the bed in full view from the doorway exposing the urine contents. There was no privacy bag covering the catheter bag to maintain Resident #48's dignity.
On 9/29/22 at 2:41 P.M., the surveyor observed Resident #48 sitting in his/her wheelchair in his/her room. The urinary catheter bag was positioned on the side of the wheelchair in full view from the doorway exposing the urine contents. There was no privacy bag covering the catheter bag to maintain Resident #48's dignity.
During an interview on 9/29/22 at 2:41 P.M., Unit Manager #1 said a privacy bag should have been in place.
On 10/3/22 at 10:47 A.M., the surveyor observed Resident #48 sitting in his/her wheelchair at the nurses' station. The urinary catheter bag was positioned on the side of the wheelchair in full view of other residents nearby exposing the urine contents. There was no privacy bag covering the catheter bag to maintain Resident #48's dignity.
During an interview on 10/3/22 at 4:10 P.M., the Director of Nursing said the Resident's urinary catheter bag should have been placed in a privacy bag to maintain the Resident's dignity.
Based on observations and interviews, the facility failed to:
1. Promote dignity while dining for all residents in the facility by serving meals in Styrofoam containers for almost a year; and
2. Ensure the dignity of Resident (#48) by not covering a urinary catheter bag.
Findings include:
1. On 9/27/22 at 8:20 A.M., the surveyor conducted the initial tour of the facility's kitchen. The surveyor observed Styrofoam containers on the tray carts. The surveyor reviewed the dishwasher temperature logs, which indicated the dishwasher had not been functioning properly for months prior to 9/23/22. The Food Service Director said the dishwasher had been broken and was recently repaired on 9/23/22, but she continued to use Styrofoam containers after it had been repaired because of low staffing.
On 9/27/22 at 9:45 A.M. on the [NAME] Unit, Resident #147 said all his/her meals had been served in to go containers and wonders why as this feels like a constant picnic. Resident #147 said the to go containers did not keep the food hot.
On 9/27/22 at 11:50 A.M., the surveyor observed the [NAME] unit lunch meal service, and all resident meals were served in Styrofoam containers.
Review of the Resident Council Minutes, dated 8/4/22, indicated the residents said eating out of Styrofoam is getting old.
On 9/28/22 at 11:00 A.M., the surveyor held a group meeting with 17 residents. The residents said their meals were being served from Styrofoam containers for about a year because of the dish machine and there was one point they were served meals on regular dishes but not for long. The residents said they would like to resume eating meals in the main dining as this was a nice experience.
On 9/27/22 at 12:05 P.M., the surveyor observed the [NAME] unit dining room lunch meal service, and all resident meals were served in Styrofoam containers.
On 9/29/22 at 2:43 P.M., the Maintenance Director said the dishwasher was converted from a high temperature dishwasher to a chemical sanitizing dishwasher a while ago and that it could have been used.
During an interview on 9/29/22 at 5:04 P.M. at the Activity Director said the dishwasher at the facility had been broken and residents were being served meals in Styrofoam containers. She said because of this, they did not want to re-open the Main Dining room because meals in the main dining room should be served on real dishes.
During an interview on 9/30/22 at 9:00 A.M. the Activity Director said the residents were correct in saying they had been served meals in Styrofoam containers for about a year. She said there was probably about one month when residents were served meals on regular dishes and then went back to Styrofoam. She said the Styrofoam was used because of the dishwasher being broken and not enough staff in the kitchen.
During an interview on 10/5/22 at 8:20 A.M. the Food Service Director said the residents were correct, that meals have been served in Styrofoam containers for about a year, because that was how long the dishwasher was broken. She said she did not understand that the dishwasher was converted from a high temperature dishwasher to a chemical sanitizing dishwasher and that it could have been used.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0578
(Tag F0578)
Could have caused harm · This affected 1 resident
Based on interview and record review, the facility failed to ensure advanced directive decisions were made by the activated Health Care Proxy (HCP) for Resident #37, who was deemed to lack capacity to...
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Based on interview and record review, the facility failed to ensure advanced directive decisions were made by the activated Health Care Proxy (HCP) for Resident #37, who was deemed to lack capacity to make health care decisions. The total sample was 19 residents.
Findings include:
Resident #37 was admitted to the facility in June 2020 with a diagnosis of dementia.
Review of the medical record indicated Resident #37 appointed a Health Care Proxy prior to admission to the facility. A Documentation of Resident Incapacity Pursuant to Massachusetts Health Care Proxy Act M.G.L. c201D indicated Resident #37 lacked capacity to make health care decisions, invoking the Health Care Proxy as the medical decision maker as of 6/15/20, due to dementia.
A review of the Massachusetts Medical Orders for Life Sustaining Treatment (MOLST) for Resident #37 indicated advanced directive decisions of Do Not Resuscitate and Do Not Intubate was signed by the Resident on 6/15/20, the same day the physician determined the Resident was unable to make health care decisions.
During an interview on 9/28/22 at 3:15 P.M., Social Worker #1 said Resident #37 was deemed incapable of making health care decisions on 6/15/20 and the decision regarding advanced directives should have been deferred to the activated Health Care Proxy.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0583
(Tag F0583)
Could have caused harm · This affected 1 resident
Based on observation and interviews, the facility failed to ensure residents' rights to personal privacy and confidentiality was promoted and protected for one Resident (#6), from a total sample of 19...
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Based on observation and interviews, the facility failed to ensure residents' rights to personal privacy and confidentiality was promoted and protected for one Resident (#6), from a total sample of 19 residents. Specifically, facility failed to ensure Resident #6 was provided privacy during a neuropsychiatric evaluation conducted by the facility's consultant Psychiatrist in the Resident's room.
Findings include:
Resident #6 was admitted to the facility with diagnoses including dementia and depression.
On 9/28/22 at 9:42 A.M., the surveyor observed Resident #6 sitting upright in bed and the facility's consultant Psychiatrist was seated in a chair talking to Resident #6. The door to the Resident's room was opened wide, the privacy curtain was not pulled, and the Resident's roommate was sitting on his/her bed next to the clinician.
On 9/28/22 at 9:45 A.M., the surveyor and Social Worker observed the clinician speaking to Resident #6. The Social Worker said the Psychiatrist was performing a neuropsychiatric examination and should have taken the Resident to a private space to ensure the conversation was not overheard and privacy and confidentiality was maintained.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Abuse Prevention Policies
(Tag F0607)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Resident #72 was admitted to the facility in September 2021.
Review of the Minimum Data Set (MDS) assessment, dated 8/24/22, ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Resident #72 was admitted to the facility in September 2021.
Review of the Minimum Data Set (MDS) assessment, dated 8/24/22, indicated Resident #72 scored a 14 out of 15 on the Brief Interview for Mental Status (BIMS) indicating he/she was cognitively intact.
During an interview on 9/28/22 at 2:30 P.M., the family member of Resident #72 said the Resident had previously told him that the Resident had been touched in their private area. The family member said he had reported this to the Social Worker, but had never gotten a response to the investigation, so he was not sure what the outcome was.
The surveyor reviewed the abuse investigation which was provided by the Director of Nurses. Review of the Long Term Care Fax Report Form indicated the family member reported to the Social Worker on 6/27/22 that Resident #72 had been touched by a male inappropriately in the private parts on 6/24/22.
Further review of the investigation provided by the facility included a statement from two Social Workers. There were two statements from Social Worker #2 with different times for the same interviews with the family member and with Resident #72. Both statements indicated the Resident was asked if any incidents occurred that ever made him/her uncomfortable and he/she had replied, No. The statement indicated Social Worker #2 had offered Resident #72 to have only female caregivers and the Resident had replied why I like bubbly, he's very attentive and nice.
Further review of the statement from Social Worker #3 indicated Resident #72 said he/she was not touched inappropriately and was asked if staff were good to him/her. In addition, Social Worker #3 had inquired to two other residents on the unit who said they had no problems with other residents on the unit being intrusive or inappropriate. Neither statement had a date or time.
There were no other documents included with the abuse investigation.
During an interview on 9/30/22 at 9:42 A.M., the Director of Nurses (DON) said she had completed the Long Term Care Fax Report Form and had submitted the form to the Department of Public Health. She said she gathered some of the information regarding the investigation but had not been responsible for completing the investigation and assumed the Social Workers had completed the investigation. She said both Social Workers were not available for interview.
During the interview the DON said she was not sure why the statements from Social Worker #2 indicated the allegation was reported to the facility on 6/27/22 at 11:00 A.M. and another statement indicated it was at 12:19 P.M. The DON was unable to tell when Social Worker #3 conducted her interviews.
The DON and the surveyor reviewed the investigation together. The DON said there were no other staff statements (staff who provided care on 6/24/22 or through the weekend until 6/27/22 or the Unit Manager) or a statement from the roommate. She said the schedule of staff who had worked during that time had not been included and the investigation did not indicate if any male staff had worked during that time. She said she had not conducted any interviews with staff or residents and no additional information was available. The DON said she had been new to the facility at the time and had not been trained on how to complete an abuse investigation. The DON said the facility policy for abuse prohibition was not implemented.
Based on policy review, record review, and interview, the facility failed to ensure staff implemented the facility's abuse policy for two Residents (#4 and #72), out of a total sample of 19 residents. Specifically, the facility failed to ensure
1. For Resident #4, two incidents of bruises of unknown origin were thoroughly investigated and reported to the Department of Public Health (DPH) as required; and
2. For Resident #72, an allegation of sexual abuse was thoroughly investigated.
Findings include:
Review of the facility's policy Abuse Prohibition Policy, dated September 2020, included but was not limited to:
-Policy: Every [NAME] facility has the responsibility to ensure that each resident has the right to be free from abuse, mistreatment, neglect, exploitation, and misappropriation of his or her personal property;
-Procedure: Identifying events, occurrences, patterns, and trends of potential abuse for residents;
-Performing internal facility investigations of alleged violations and identification of staff members responsible for investigating incidents and the reporting of same to proper authorities;
-Protecting residents from harm during an investigation of alleged abuse;
-Reporting of all alleged violations of resident abuse to appropriate state agencies with the simultaneous development of corrective actions determined as part of the internal facility investigation to prevent further occurrences of abuse;
-Investigations: Any incidents of actual or suspected abuse must have an incident report completed. In addition to the incident report, the supervisory personnel are responsible to ensure the initial investigation regarding the incident occurs timely and appropriate interventions are put into place to ensure resident safety or protect the resident from additional harm, interview the resident further if needed and other resident witnesses, interview staff witnesses and the Director of Nurses assumes responsibility for having evidence the allegation was thoroughly investigated;
-The Administrator shall assume the overall responsibility to ensure that incident reports are accurately completed, and personnel statements are obtained timely, to ensure proper completion of the Internal Facility Investigation;
-Reporting/Documentation Requirements: All alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, the the Administrator of the facility and to other officials in accordance with State law through established procedures.
1. Resident #4 was admitted to the facility with diagnoses including Alzheimer's dementia.
Review of the Minimum Data Set (MDS) assessment, dated 6/15/22, indicated Resident #4 had both long- and short-term memory problems, severely impaired cognitive skills for daily decision making, and required extensive assistance from staff for activities of daily living.
a. Review of a Resident Incident Report, dated 10/30/21, indicated bruises to Resident #4's right and left axillary regions (arm pits) and coccyx/sacral area. The bruises were identified by a Certified Nursing Assistant (CNA) during the provision of care. The investigation included one statement from a CNA that identified the bruises. The investigation failed to include any nursing statements.
b. Review of a Situation, Background, Assessment, and Recommendation Communication (SBAR) Form, dated 5/28/22 indicated Resident #4 was found to have numerous unexplained bruising, right forearm bruising in particular, left outer thigh, and upper left side of neck between the neck and shoulder.
Review of the Health Care Facility Reporting System (a web-based system that health care facilities must use to report incidents and allegations of abuse, neglect, and misappropriation) on 9/29/22 at 3:00 P.M., failed to indicate the bruises of unknown origin to Resident #4's right and left axillary regions and coccyx/sacral area identified on 10/30/21 and the bruises of unknown origin identified on 5/28/22 were reported to DPH as required.
During an interview on 9/29/22 at 3:30 P.M., the surveyor reviewed the incident report and SBAR Communication Form with the Director of Nursing (DON). The DON said the bruises of unknown origin identified on 10/30/21 were not thoroughly investigated and not reported to DPH according to facility policy. She said for the bruising identified on 5/28/22, there was no investigation conducted at all and it was not reported to DPH as required.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Report Alleged Abuse
(Tag F0609)
Could have caused harm · This affected 1 resident
Based on policy review, record review, and interview, the facility failed to ensure staff reported bruises of unknown origin to the Department of Public Health (DPH) for one Resident (#4), out of a to...
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Based on policy review, record review, and interview, the facility failed to ensure staff reported bruises of unknown origin to the Department of Public Health (DPH) for one Resident (#4), out of a total sample of 19 residents.
Findings include:
Review of the facility's policy, Abuse Prohibition Policy (undated), included but was not limited to:
-Reporting/Documentation Requirements: All alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, the the Administrator of the facility and to other officials in accordance with State law through established procedures.
Resident #4 was admitted to the facility with diagnoses including Alzheimer's dementia.
Review of the Minimum Data Set (MDS) assessment, dated 6/15/22, indicated Resident #4 had both long- and short-term memory problems, severely impaired cognitive skills for daily decision making and required extensive assistance from staff for activities of daily living.
Review of a Resident Incident Report, dated 10/30/21, indicated bruises to Resident #4's right and left axillary regions (arm pits) and coccyx/sacral area. The bruises were identified by a Certified Nursing Assistant (CNA) during the provision of care.
Review of a Situation, Background, Assessment, and Recommendation Communication (SBAR) Form, dated 5/28/22, indicated Resident #4 was found to have numerous unexplained bruising, right forearm bruising in particular, left outer thigh, and upper left side of neck between the neck and shoulder.
Review of the Health Care Facility Reporting System (a web-based system that health care facilities must use to report incidents and allegations of abuse, neglect, and misappropriation) on 9/29/22 at 3:00 P.M., failed to indicate the bruises of unknown origin to Resident #4's right and left axillary regions and coccyx/sacral area identified on 10/30/21 and the bruises of unknown origin identified on 5/28/22 were reported to DPH as required.
During an interview on 9/29/22 at 3:30 P.M., the surveyor reviewed the incident report and SBAR Communication Form with the Director of Nursing (DON). The DON said the bruises of unknown origin identified on 10/30/21 and 5/28/22 were not reported to DPH as required.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Investigate Abuse
(Tag F0610)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Resident #72 was admitted to the facility in September 2021.
Review of the Minimum Data Set (MDS) assessment, dated 8/24/22, ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Resident #72 was admitted to the facility in September 2021.
Review of the Minimum Data Set (MDS) assessment, dated 8/24/22, indicated Resident #72 scored a 14 out of 15 on the Brief Interview for Mental Status (BIMS) indicating he/she was cognitively intact.
During an interview on 9/28/22 at 2:30 P.M., the family member of Resident #72 said the Resident had previously told him that the Resident had been touched in their private area. The family member said he had reported this to the Social Worker, but had never gotten a response to the investigation, so he was not sure what the outcome was.
Review of the Long Term Care Fax Report Form (abuse investigation) indicated the family member reported to the Social Worker on 6/27/22 that Resident #72 had been touched by a male inappropriately in the private parts on 6/24/22.
Further review of the investigation provided by the facility included a statement from two Social Workers. There were two statements from Social Worker #2 with different times for the same interviews with the family member and with Resident #72. Both statements indicated the Resident was asked if any incidents occurred that ever made him/her uncomfortable and he/she had replied, No. The statement indicated Social Worker #2 had offered Resident #72 to have only female caregivers and the Resident had replied, Why I like bubbly, he's very attentive and nice.
Further review of the statement from Social Worker #3 indicated Resident #72 said he/she was not touched inappropriately and was asked if staff were good to him/her. In addition, Social Worker #3 had inquired to two other residents on the unit who said they had no problems with other residents on the unit being intrusive or inappropriate. Neither statement had a date or time.
There were no other documents included with the abuse investigation.
During an interview on 9/30/22 at 9:42 A.M., the Director of Nurses (DON) said she had completed the Long Term Care Fax Report Form and had submitted the form to the Department of Public Health. She said she gathered some of the information regarding the investigation but had not been responsible for completing the investigation and assumed the Social Workers had completed the investigation. She said both Social Workers were not available for interview.
During the interview, the DON said she was not sure why the statements from Social Worker #2 indicated the allegation was reported to the facility on 6/27/22 at 11:00 A.M. and another statement indicated it was at 12:19 P.M. The DON was unable to tell when Social Worker #3 conducted her interviews.
The DON and the surveyor reviewed the investigation together. The DON said there were no other staff statements (staff who provided care on 6/24/22 or through the weekend until 6/27/22 or the Unit Manager) or a statement from the roommate. She said the schedule of staff who had worked during that time had not been included and the investigation did not indicate if any male staff had worked during that time. She said she had not conducted any interviews with staff or residents and no additional information was available. The DON said she had been new to the facility at the time and had not been trained on how to complete an abuse investigation.
Based on policy review, interviews, and record review, the facility failed to ensure allegations of abuse were investigated for two Residents (#4 and #72), out of a sample of 19 residents. Specifically, the facility failed:
1. For Resident #4, to investigate two incidents of bruises of unknown origin; and
2. For Resident #72, to investigate allegations of sexual abuse and report results to the representative.
Findings include:
Review of the facility's policy Abuse Prohibition Policy, dated September 2020, included but was not limited to:
-Policy: Every [NAME] facility has the responsibility to ensure that each resident has the right to be free from abuse, mistreatment, neglect, exploitation, and misappropriation of his or her personal property;
-Procedure: Identifying events, occurrences, patterns, and trends of potential abuse for residents;
-Performing internal facility investigations of alleged violations and identification of staff members responsible for investigating incidents and the reporting of same to proper authorities;
-Protecting residents from harm during an investigation of alleged abuse;
-Investigations: Any incidents of actual or suspected abuse must have an incident report completed. In addition to the incident report, the supervisory personnel are responsible to ensure the initial investigation regarding the incident occurs timely and appropriate interventions are put into place to ensure resident safety or protect the resident from additional harm, interview the resident further if needed and other resident witnesses, interview staff witnesses and the Director of Nurses assumes responsibility for having evidence the allegation was thoroughly investigated;
-The Administrator shall assume the overall responsibility to ensure that incident reports are accurately completed, and personnel statements are obtained timely, to ensure proper completion of the Internal Facility Investigation;
1. Resident #4 was admitted to the facility with diagnoses including Alzheimer's dementia.
Review of the Minimum Data Set (MDS) assessment, dated 6/15/22, indicated Resident #4 had both long- and short-term memory problems, severely impaired cognitive skills for daily decision making, and required extensive assistance from staff for activities of daily living.
a. Review of a Resident Incident Report, dated 10/30/21, indicated bruises to Resident #4's right and left axillary regions (arm pits) and coccyx/sacral area. The bruises were identified by a Certified Nursing Assistant (CNA) during the provision of care. The investigation included one statement from a CNA that identified the bruises.
The investigation failed to include statements from other CNA staff that cared for the Resident or any nursing statements.
b. Review of a Situation, Background, Assessment, and Recommendation Communication (SBAR) Form, dated 5/28/22, indicated Resident #4 was found to have numerous unexplained bruising, right forearm bruising in particular, left outer thigh, and upper left side of neck between the neck and shoulder. An incident report was not completed and there was no investigation conducted into the bruises of unknown origin.
During an interview on 9/29/22 at 3:30 P.M., the surveyor reviewed the incident report and SBAR Communication Form with the Director of Nursing (DON). The DON said the bruises of unknown origin identified on 10/30/21 were not thoroughly investigated and there was no investigation of the bruises of unknown origin identified on 5/28/22.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Transfer Notice
(Tag F0623)
Could have caused harm · This affected 1 resident
Based on record review and interview, the facility failed to ensure the Resident and/or the Resident's representative and the Ombudsman were provided a written notice of a bed hold transfer as require...
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Based on record review and interview, the facility failed to ensure the Resident and/or the Resident's representative and the Ombudsman were provided a written notice of a bed hold transfer as required for one Resident (#95), out of a total sample of 19 residents and three closed records.
Findings include:
Resident #95 was admitted to the facility in June 2022 with medical diagnoses including pain in left hip, unspecified osteoarthritis, and other chronic pain.
Review of the clinical record indicated Resident #95 was transferred to the hospital emergency department (ED) in July 2022 for further evaluation.
Review of a Nurse's Note, dated 7/2022 at 12:11 P.M., indicated Resident requesting to be transferred to the hospital for assessment and evaluation related to increase in pain and decrease in lower extremity movement. The nurse's note indicated the physician was notified, and family was made aware.
Review of the Physician's Orders, dated July 2022, including a written telephone order to transfer the Resident to the hospital for assessment and evaluation related to increase pain and lower extremities weakness.
Review of the clinical record failed to indicate required transfer notification documentation and appeal notification was provided to the Resident's/Family as required.
Review of the Clinical Record indicated, at the time of the Resident's transfer to the Hospital ED in July 2022, there was no documentation to support that he/she was provided with a Notice of Intent to Discharge or that the facility informed him/her of their intent to discharge.
During an interview on 10/5/22 at 10:31 A.M., the Minimum Data Set (MDS) Nurse #1 said the discharge transfer paperwork was not available for review, and she believed the paperwork was not completed.
Further review of the clinical record included no evidence that the notice transfer and a copy of the emergency transfer were sent to the Ombudsman's office.
During an interview on 10/5/22 at 12:09 P.M., Social Worker #1 said the Nursing Department did not inform the Social Services department when the Resident was transferred to the hospital in July 2022. She said if the Social Services Department was informed, the paperwork would have been completed. Social Worker #1 reviewed the log and said the Resident was not given a Notice of Intent to Discharge.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0625
(Tag F0625)
Could have caused harm · This affected 1 resident
Based on record review and interview, the facility failed to ensure the resident and/or the resident's representative was provided a written notice of a bed hold transfer as required for one Resident ...
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Based on record review and interview, the facility failed to ensure the resident and/or the resident's representative was provided a written notice of a bed hold transfer as required for one Resident (#95), out of a total sample of 19 residents and three closed records.
Findings include:
Resident #95 was admitted to the facility in June 2022 with medical diagnoses including pain in left hip, unspecified osteoarthritis, and other chronic pain.
Review of the clinical record indicated Resident #95 was transferred to the hospital emergency department (ED) in July 2022.
Review of a Nurse's Note, dated 7/19/22 at 12:11 P.M., indicated Resident requesting to be transferred to the hospital for assessment and evaluation related to increase in pain and decrease in lower extremity movement. The nurse's note indicated the physician was notified, and family was made aware.
Review of the Minimum Data Set (MDS) assessment, dated 7/29/22, indicated Resident #95 was discharged to the hospital. The MDS indicated return anticipated. Further review of the MDS indicated the Resident was discharged to the community whereas the Resident was transferred via ambulance to the nearest hospital.
Review of the July 2022 Physician's Orders failed to indicate an order for this transfer/discharge. The Resident's Representative was not contacted.
Further review of the medical record failed to indicate a copy of the bed-hold policy or documentation in the Nurses' Notes that a copy of the bed-hold policy was sent along with Resident #95 to the hospital as required.
During an interview on 10/5/22 at 10:31 A.M., the MDS Nurse #1 said it was a mistake, the Resident was transferred to the hospital and the facility failed to send a copy of the bed hold policy along with the Resident.
During an interview on 10/5/22 at 12:09 P.M., Social Worker #1 said the facility failed to provide a bed-hold notices/policy to the Resident/Representative. She said the Notice of Transfer and the Bed Hold policy were not done at the time of discharge.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Assessment Accuracy
(Tag F0641)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to ensure an accurate comprehensive Minimum Data Set (...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to ensure an accurate comprehensive Minimum Data Set (MDS) assessment was completed for one Resident (#94), in a total sample of 19 residents.
Findings include:
Review of the medical record for Resident #94 included a Smoking Evaluation and Safety Screen, dated 9/7/22. The evaluation indicated Resident #94 was a current smoker and would be smoking at the facility.
Review of the care plans for Resident #94 failed to include any documentation regarding smoking or a plan for smoking.
On 9/28/22 at 4:15 P.M., the surveyor observed Resident #94 smoking outside during the supervised smoking time.
Review of the MDS assessment, dated 9/14/22, indicated Resident #94 was not a smoker.
During an interview on 9/30/22 at 10:05 A.M., the MDS Coordinator said she was unaware Resident #94 was a smoker and it should have been indicated on the MDS dated [DATE].
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0657
(Tag F0657)
Could have caused harm · This affected 1 resident
Based on observation, record review, and interview, the facility failed to evaluate for effectiveness and revise the comprehensive care plan for one Resident (#40), out of a total sample of 19 residen...
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Based on observation, record review, and interview, the facility failed to evaluate for effectiveness and revise the comprehensive care plan for one Resident (#40), out of a total sample of 19 residents. Specifically, the facility failed for Resident #40, to review and revise the care plan to indicate a new pressure injury developed from the use of a catheter leg bag and to indicate interventions.
Findings include:
Review of the facility's policy titled Comprehensive Care Plans, undated, indicated the following:
-Care Plans are oriented toward preventing avoidable decline in clinical and functional levels, maintaining a specific level of functioning
-Care Plans were to be evaluated and revised as needed, but at least quarterly
Resident #40 was admitted to the facility in February 2022 with diabetes and had a suprapubic catheter.
Review of the Wound Consultant's Progress Notes indicated on 8/17/22 Resident #40 developed a pressure area to the left medial lower leg caused by the catheter leg bag. The Wound Consultant noted the pressure injury had a scant serosanguineous exudate (draining clear liquid with red blood) and the wound bed was 100% dry stable eschar/necrosis measuring 4.0 centimeters (cm) length by 2.7 cm width with an immeasurable depth. The plan for the wound was to check positioning of catheter leg bag frequently and off-load the device from the wound.
Review of the Care Plans for Resident #40 indicated the Resident was at risk for alteration in skin integrity and Resident had a suprapubic catheter.
Review of all the Care Plans for Resident #40 failed to indicate the Resident had developed a pressure injury from a catheter leg bag and what interventions were implemented.
During an interview on 9/29/22 at 3:37 P.M., Nurse #3 said she had seen the pressure area on the left lower leg of Resident #40 but was unaware the pressure area was related to the catheter leg bag and was unaware of any interventions regarding the catheter leg bag.
During an interview on 9/30/22 at 1:25 P.M., Unit Manager #2 said the pressure area to the lower left leg was on the calf and had been caused by the snaps that hold the catheter leg bag in place. She said the staff should be checking the placement of the bag every two hours to ensure no additional pressure injuries occur.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
ADL Care
(Tag F0677)
Could have caused harm · This affected 1 resident
Based on observations, interviews, and record review, the facility failed to ensure one Resident (#43) received assistance with eating. The total sample was 14 residents.
Findings include:
Resident #...
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Based on observations, interviews, and record review, the facility failed to ensure one Resident (#43) received assistance with eating. The total sample was 14 residents.
Findings include:
Resident #43 was admitted to the facility in January 2019 with a diagnosis of Parkinson's disease.
Review of the care plans for Resident #43 indicated the Resident had an ADL (activities of daily living) deficit related to Parkinson's disease and needed assistance with sequencing tasks. The interventions indicated the level of assistance may fluctuate depending on tremors and level of fatigue, staff were to provide interventions as needed for task completion when self-performance fluctuated and included Resident #43 needed continual 1 to 8 supervision during eating.
Review of an Occupational Therapy (OT) progress note, dated 11/4/22, indicated Resident #43 was able to feed self with regular utensils and a lip plate, with minimal verbal cues.
On 11/30/22 at 11:59 A.M., the surveyor observed Resident #43 eating a lunch of spaghetti and mixed vegetables as follows:
-At 12:06 P.M., the Resident was having difficulty bringing the spaghetti, on the fork, from the plate to his/her mouth. Resident #43 had tremors in his/her right hand and the spaghetti was not staying on the fork between the plate and the Resident's mouth.
-At 12:14 P.M., the Resident was bringing the fork to his/her mouth, but there was no food on the fork.
-At 12:19 P.M., the Resident picked up the dinner roll and started eating the roll, with less difficulty.
-At 12:24 P.M., the Unit Secretary spoke with the Resident who indicated they were done with the main meal and the plate was removed from the table. Resident #43 had eaten approximately 25 to 50% of the meal. The surveyor observed that Resident #43 had several strands of spaghetti on his/her lap.
During the observation from 11:59 A.M. through 12:24 P.M., the surveyor did not observe staff members offer Resident #43 assistance with eating.
On 11/30/22 at 5:40 P.M., the surveyor observed Resident #43 in the unit dining room. The Resident was seated in their wheelchair, with their eyes closed and had his/her hands on their lap. Their hands were observed to have a tremor while at rest.
The surveyor observed Resident #43 during the dinner meal eating American chop suey and broccoli as follows:
-At 5:53 P.M., the meal arrived.
-At 5:56 P.M., Certified Nursing Assistant (CNA) #5 let the Resident know the food arrived
-From 5:58 P.M. through 6:12 P.M., Resident #43 was drinking juice. He/she was observed to pick up their nosey cup (a cup with a u-shaped cut out to allow space for the nose) of juice, with visibly tremoring hands. At 6:02 P.M. the Resident tried to put the drink back down and placed it on the meal plate, on top of the food. The Resident was having difficulty moving the cup off the plate, while trying not to spill the juice on their food. At 6:10 P.M. the Resident had the cup to his/her mouth with the u-shaped cut out not in the correct position.
-At 6:00 P.M., CNA #4 sat down at the same table as Resident #43 to help another Resident with eating. CNA #4 did not look in the direction of Resident #43 and never offered assistance to Resident #43 who was struggling to drink the juice and struggling to return the cup to the table.
-From 6:12 P.M., through 6:25 P.M. Resident #43 utilized a spoon to eat their American chop suey. Resident #43 had a visible tremor in the right hand which was making it difficult for the food to stay on the spoon between the plate and their mouth. By 6:25 P.M., a half hour after the food was delivered, the Resident had eaten less than 25% of their meal.
-There were two nurses and three CNAs in the dining area. No staff members were observed to offer assistance to Resident #43.
During an interview on 11/30/22 at 6:18 P.M., CNA #5 said Resident #43 would occasionally need assistance with eating.
During an interview on 11/30/22 at 6:25 P.M., Resident #43 said their dinner was good, When I can get it in my mouth. Resident #43 said he/she had no concerns with staff assisting with eating.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Quality of Care
(Tag F0684)
Could have caused harm · This affected 1 resident
Based on observations, interviews, and record review, the facility failed to ensure wound care was provided in accordance with professional standards of practice to promote healing for one Resident (#...
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Based on observations, interviews, and record review, the facility failed to ensure wound care was provided in accordance with professional standards of practice to promote healing for one Resident (#40), in a total sample of 19 residents.
Findings include:
Resident #40 was admitted to the facility in February 2022 with diabetes and a wound to the right heel and had developed multiple diabetic wounds.
Review of the Wound Consultant's Progress Note, dated 9/14/22, indicated the diabetic wound of the right heel measured 2.0 centimeters (cm) in length by 2.2 cm in width, with no depth measured. The notes indicated the wound showed signs of slow progression toward healing with a plan to continue to off-load the wound.
Review of the September 2022 Treatment Administration Record (TAR) on 9/28/22 indicated the following treatment:
-8/1/22 Right heel: Cleanse with normal saline wash, pat dry, then apply nickel-thick Santyl ointment to wound bed, cover with ABD pad, wrap with Kerlix, change daily.
The September 2022 TAR indicated the right heel treatment was not completed on 9/2, 9/5, 9/7, 9/9, 9/13, 9/14, 9/15, 9/16, 9/17, 9/19, 9/22 and 9/23/22 (12 out of 27 days).
On 9/29/22 at 11:05 A.M., the surveyor observed Resident #4 in his/her wheelchair in the unit dining room. The Resident was wearing gray slipper socks on his/her bilateral feet with medical walking shoes (rubber soles, open toe, and Velcro straps). The strap on the shoe on the left foot said right. This shoe was observed to also have an open back, allowing for the heel to be off-loaded. The Resident's right foot was observed to be wearing a medical shoe with a back, covering the heel.
During an interview on 9/29/22 at 3:37 P.M., Nurse #3 said the shoe labeled right should be on the right foot of Resident #40, as that shoe has no back and there was a wound on the right heel.
Review of the September 2022 Treatment Administration Record (TAR) on 9/28/22 indicated the following wound treatments:
-7/30/22 Right shin: normal saline wash, pat dry, apply skin prep to periphery, cover with adaptic gauze to wound bed, cover with ABD pad, wrap with Kerlix, change daily
-7/30/22 Right calf: normal saline wash, pat dry, apply skin prep to periphery, cover with adaptic gauze to wound bed, cover with ABD pad, wrap with Kerlix, change daily
-6/29/22 Right lower leg: apply ace bandage daily with dressing change
The September 2022 TAR indicated the right shin, calf, and lower leg treatments were not completed on 9/2, 9/6, 9/7, 9/9, 9/13, 9/14, 9/15, 9/16, 9/17, 9/18, 9/19, 9/22 and 9/23/22 (13 out of 27 days).
In addition, the September 2022 TAR indicated the following order:
-7/30/22 Right foot: wrap with Kerlix starting at the toes, include the heel, end wrap at the knee, securing the right heel, calf, shin wounds together, daily. This order was only signed off as completed on 9/1/22.
During an interview on 9/30/22 at 1:25 P.M., Unit Manager #2 said there are times when she was the only nurse on the unit for 40 residents and there was not always time to do treatments as well as all of the other duties. She reviewed the TAR for Resident #40 and said she could not say if treatments to the wounds were provided on the days the TAR is blank, per the physician's order. She further said, Resident #40 did not like the ace bandage which is why the order was changed to the Kerlix from the toes to the knee and this treatment should have been provided daily as well.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Pressure Ulcer Prevention
(Tag F0686)
Could have caused harm · This affected 1 resident
Based on interview and record review, the facility failed to ensure treatments to a pressure injury were provided in accordance with professional standards of practice to promote healing for one Resid...
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Based on interview and record review, the facility failed to ensure treatments to a pressure injury were provided in accordance with professional standards of practice to promote healing for one Resident (#40), in a total sample of 19 residents.
Findings include:
Resident #40 was admitted to the facility in February 2022 with diabetes and had a suprapubic catheter.
Review of the Wound Consultant's Progress Notes indicated on 8/17/22 Resident #40 developed a pressure area to the left medial lower leg caused by the catheter leg bag. The Wound Consultant noted the pressure injury had a scant serosanguineous exudate (draining clear liquid with red blood) and the wound bed was 100% dry stable eschar/necrosis measuring 4.0 centimeters (cm) length by 2.7 cm width with an immeasurable depth. The plan for the wound was to check positioning of catheter leg bag frequently and off-load the device from the wound and the following treatment was ordered: apply protective Optifoam dressing and change daily.
Review of the September 2022 Treatment Administration Record (TAR) on 9/29/22 indicated a treatment to the left medial lower leg was to wash with normal saline, pat dry, apply skin prep to periphery and cover with an Optifoam dressing, daily. The dressing was not completed on the following days: 9/2, 9/6, 9/7, 9/9, 9/13, 9/14, 9/15, 9/16, 9/17, 9/19, 9/22, 9/23, 9/26, and 9/27/22 (14 out of 28 times).
During an interview on 9/30/22 at 1:25 P.M., Unit Manager #2 said there are times when she was the only nurse on the unit for 40 residents and there was not always time to do treatments as well as all of the other duties. She reviewed the TAR for Resident #40 and said she could not say if treatments to the pressure area were provided on the days the TAR is blank, per the physician's order.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Incontinence Care
(Tag F0690)
Could have caused harm · This affected 1 resident
Based on interviews and record reviews, the facility failed to ensure Resident #72, admitted with a catheter was assessed for the removal of the catheter as soon as possible, out of three sampled resi...
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Based on interviews and record reviews, the facility failed to ensure Resident #72, admitted with a catheter was assessed for the removal of the catheter as soon as possible, out of three sampled residents with catheters.
Findings include:
Resident #72 was admitted to the facility in September 2021 following a fall at home with pelvic and ischium fractures and a new urinary catheter.
Review of the medical record indicated Resident #72 continued to have a Foley catheter, one year after admission.
Review of the nursing Foley Catheter Evaluation, dated 9/19/21, indicated Resident #72 had a Foley catheter for less than a month related to pelvic and ischium fractures with a plan for removal.
Review of a Physician's Progress Note, dated 9/20/21, indicated Resident #72 had urinary retention, with a Foley catheter present, had previously failed a voiding trial at the hospital, and another voiding trial would be attempted.
Review of a Physician's Progress Note, dated 10/5/21, indicated Resident #72 should be referred to urology.
Review of the nursing Foley Catheter Evaluation, dated 12/10/21, indicated Resident #72 continued to have a Foley catheter with an attempted removal on 9/22/21. The progress notes indicated Resident #72 failed the voiding trial, that Resident #72 had been able to void, but then retained urine after several hours from voiding, trial failed, and catheter replaced.
Review of the nursing Foley Catheter Evaluation, dated 2/25/22, indicated Resident #72 had a catheter and did not indicate a reason for the catheter or a plan for the catheter.
Review of the nursing Foley Catheter Evaluations dated 5/20/22 and 8/18/22 were both blank and not completed by nursing.
During an interview on 9/30/22 at 10:16 A.M., Unit Manager #2 said Resident #72 had a catheter originally placed due to a pelvic fracture and according to the nursing progress notes Resident #72 had the catheter removed on 9/22/21 and had voided. There were no other nursing progress notes regarding the voiding trial. She said the nursing catheter evaluation, dated 12/10/21, indicated the trial on 9/22/21 failed because Resident #72 retained urine after several hours. She said she was not sure how this was determined as there was no documentation and the facility did not use a bladder scanner to determine if the bladder was not fully emptied. The Unit Manager said she would review the previous medical records to find documentation regarding the voiding trial.
During an interview on 9/30/22 at 2:05 P.M., Unit Manager #2 said she had reviewed the medical record and was unable to find any documentation to indicate Resident #72 failed the voiding trial at the hospital as the hospital discharge summary did not even indicate the Resident had a catheter. The Unit Manager said she was unable to locate any documentation to indicate how Resident #72 failed the voiding trial on 9/22/21. She said the physician's progress note from 10/5/21 had indicated Resident #72 should follow up with a urologist, but the follow up appointment was never made.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Tube Feeding
(Tag F0693)
Could have caused harm · This affected 1 resident
Based on observation, interview, record review, and policy review, the facility failed to provide the appropriate treatment and services to administer medications and prevent complications of an enter...
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Based on observation, interview, record review, and policy review, the facility failed to provide the appropriate treatment and services to administer medications and prevent complications of an enteral feeding tube (a method of providing nutrition and fluids directly into the stomach via a gastric tube (G-tube), which is inserted through the abdominal wall to give direct access to the stomach or upper intestines) to one Resident (#67), out of a total sample of 19 residents.
Findings include:
Review of the facility's Pharmacy policy and procedure titled Prescription Association Procedure for Enteral Tube Medication Administration, dated 2017, included but was not limited to the following:
- The facility assures the safe and effective administration of medications via enteral tubes and the routes and methods of the administration of medications are based on assessment and consultation with the physician.
- Procedure includes the Physician order which specifies the route of administration of all medications, the preparation of the medication (crushing, mixing with water), flush the tubing prior to the administration of medication and between each medication.
Resident #67 was admitted to the facility in July 2022 with diagnoses that included Cerebral Vascular Accident (CVA) and dysphagia (difficulty swallowing). The Resident had a G-tube.
During an interview on 9/28/22 at 12:30 P.M., Unit Manager #3 said Resident #67 no longer used the feeding tube for his/her nutrition.
Record review indicated the Resident was admitted with the G-tube and from 8/1/22 through 8/18/22 was able to take all his/her food and medication by mouth.
Further record review indicated the Resident was hospitalized in August 2022. Upon return to the facility, the physician's orders indicated to administer all medications through the G-tube.
Review of the Physician's Orders and the Medication Administration Record (MAR) and Treatment Administration Record (TAR) from 8/1/22 through 10/4/22, indicated the facility failed to consistently implement and obtain orders for flushing the G-tube before and after medication administration and failed to monitor the G-tube before and after administering medications.
Review of the August 2022 Physician's orders indicated the following:
- administer medications via G-tube
- Flush G-tube with 30 milliliters (ml) of water before and after medication administration
- Flush G-tube with 60 ml of water three times per day
- Flush with 100 ml of water three times per day
- Check G-tube site daily, wash with normal saline, pat dry and apply split sponge, daily and as needed.
Review of the August MAR/TAR indicated on 8/5/22, the order to flush the tube between medication administrations was discontinued and no order was obtained between 8/23/22 and 8/31/22, to administer the medications by G-tube.
- No order for the flushing of the G-tube with 60 ml of water, three times per day, was added to the MAR or TAR.
- The flushing of the G-tube of 100 ml, three times a day was started on 8/5/22 and therefore no flushing was done for five days (8/1/22 through 8/5/22).
Review of the September 2022 MAR/TAR indicated that the care and treatment of the G-tube was not documented as done for 10 treatments, flushing of the G-tube with 100 ml of water was not done 19 times and the flushing before and after the administration of medications was inaccurately documented as the Resident received some medications three to four times per day.
Review of the October 2022 MAR/TAR failed to include a physician's order for the flushes before and after the administration of medications and the care and treatment of the G-tube.
During an interview on 10/4/22 at 4:00 P.M., Unit Manager (UM) #3 said she frequently administers medications to Resident #67 and does not always document that the care of the G-tube and the flushes of the G-tube are done. UM #3 said she frequently administers Resident #67's medications orally and does not care for and flush the G-tube. UM #3 said she was aware that the Physician's order was to give the medications by G-tube, but staff did not follow the orders. The Unit Manager could not explain why the staff were not following physician's orders or providing care of the G-tube.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Respiratory Care
(Tag F0695)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Resident #71 was admitted with diagnoses including asthma, chronic obstructive pulmonary disease (COPD) (group of lung diseas...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Resident #71 was admitted with diagnoses including asthma, chronic obstructive pulmonary disease (COPD) (group of lung diseases that block airflow and make it difficult to breathe), chronic respiratory failure with hypoxia (low level of oxygen), obstructive sleep apnea (intermittent airflow blockage during sleep), congestive heart failure (chronic condition in which the heart does not pump blood as well as it should), pneumonia, chronic cough, and shortness of breath.
Review of current Physician's Orders, dated 9/1/22 through 9/30/22, indicated but was not limited to the following:
-Change and date oxygen tubing weekly on Saturday 11-7
During an observation with interview on 9/27/22 at 10:16 A.M. and 9/29/22 at 8:20 A.M., the surveyor observed Resident #71 sitting in a wheelchair in his/her room with portable oxygen in place being provided by a nasal cannula (NC) (tube that splits into two prongs that are placed in the nostrils from which oxygen flows). A second NC was observed resting on top of the Resident's bed attached to an oxygen concentrator (medical device that delivers oxygen). The tubing was not labeled with the date to indicate when it was last changed. The surveyor also observed a nebulizer (small machine that turns liquid respiratory medications into a fine mist) machine on the Resident's nightstand. The mouthpiece and tubing were resting on top of the oxygen concentrator, not contained, and exposed to potential environmental contaminants. Resident #71 said he/she used the portable oxygen while out of bed, the oxygen concentrator while in bed, and used the nebulizer on occasion for shortness of breath.
During an observation with interview on 9/29/22 at 2:06 P.M., the surveyor and Unit Manager (UM) #1 observed Resident #71's nebulizer mouthpiece and tubing resting on top of the oxygen concentrator, not contained, and exposed to potential environmental contaminants. Resident #71's NC tubing that was attached to the oxygen concentrator was not labeled with the date to indicate when it was last changed. UM #1 said the mouthpiece should have been covered with a clear plastic bag when not in use and the oxygen tubing should have been labeled to indicate when it was last changed but it was not.
During an interview on 10/3/22 at 4:05 P.M., the Director of Nursing (DON) said staff should be changing and labeling the oxygen tubing once a week and as needed. The DON further said the mouthpiece should have been attached to the nebulizer machine, so it was upright and covered in a bag.
Based on observation, record review, policy review, and interview, the facility
1. Failed to provide care and treatment in accordance with the facility policy/protocols and professional standards of practice for one Resident (#77) with a trachea/laryngeal stoma (a stoma is a surgically created hole (opening) made in the windpipe/skin in front of your neck to allow you to breathe). Specifically, the facility failed to:
a.) Obtain physician's orders to provide a person-centered care plan for care of trachea/laryngeal stoma;
b.) Implement the facility protocol to maintain a clear and patent airway; and
c.) Provide emergency bedside tracheostomy equipment needed for accidental occlusion (the blockage or closing of an opening) or mucus plugging (buildup of thick mucus); and
2. Failed to ensure proper care and storage of respiratory equipment and maintain consistent documentation of respiratory care for one Resident (#71).
Findings include:
1. Review of The National Tracheostomy Safety Project manual dated 2013 indicated but was not limited to the following:
Day-to-day management of Tracheostomies:
-Daily Checks-There should be a detailed plan of care for all patients with a tracheostomy. The plan of care should be reviewed daily and updated if there is any change.
A full assessment of the patient should include:
-Why does the patient have a tracheostomy and when was it performed.
-Sputum characteristics (Color, Volume, Consistency, Odor)
-Check stoma and clean
-Routine observations
-This assessment should be documented
Review of the facility's policy titled Tracheostomy Care, dated August 2015, indicated but was not limited to the following:
-To maintain patency of the airway, to prevent infection of the airways and the area around tracheostomy tube, and to prevent excoriation of the area around the site.
-Licensed nursing staff have the responsibility for providing maintenance trachea care for patients who have a stable pulmonary condition.
Resident #77 was admitted to the facility in August 2022 with diagnoses including laryngeal cancer with a status post-surgery and radiation with a stoma.
Review of the Minimum Data Set (MDS) assessment, dated 9/5/22, indicated a Brief Interview for Mental Status (BIMS) score of 15 out 15 (cognitively intact), required extensive assistance in his/her activities of daily living (washing, dressing, transfers and toileting), and had a trachea stoma.
During an interview on 9/27/22 at 11:30 A.M., the surveyor observed Resident #77 to have a laryngeal stoma clearly visible on the front of his/her neck. Resident #77 placed his/her fingers over the opening and said he/she has had the trachea/laryngeal stoma for 15 years. Resident #77 said on 9/26/22 he/she had trouble breathing and the staff had to call for assistance (including 911) to suction him/her to remove a mucous plug so he/she could breathe. The surveyor observed there was no equipment in the room (such as a suction machine, or products to clean the stoma) for care or treatment of the stoma.
Review of the medical record on 9/27/22, including the August, September, and October 2022 Physician's Orders, indicated there were no physician's orders, assessments, or treatment for the Resident's trachea/stoma.
Throughout the day on 9/28/22, 9/29/22, and part of the day on 9/30/22, the surveyor observed that no equipment was made available to Resident #77 to care for and treat his/her stoma.
On 9/30/22 at 3:15 P.M., the surveyor observed a suction machine under a large pile of facility linen on the Resident's bureau. The suction machine and suction catheter were across the room from the Resident. During the observation, Resident #77 could barely be heard; his/her voice was a whisper. The Resident said he/she was congested, and that the facility had just put the suction machine in the room. Subsequent observations of the suction machine from 9/30/22 through 10/4/22 revealed the machine remained covered with a large pile of facility linens and other items.
During an interview on 10/4/22 at 9:30 A.M., Resident #77 said that no one cleans or cares for his/her laryngeal stoma. Resident #77 said he/she could not do self-care and even if he/she wanted to as there was nothing to clean it with. The Resident said the area was cleaned twice a day when at home and since his/her admission [DATE]) the stoma has not been cleaned.
During an interview on 10/4/22 at 4:00 P.M., Unit Manager #3 said a plan of care or assessment had not been developed for the care of the trachea, as she thought the Resident cared for the laryngeal stoma him/herself. Unit Manager #3 was unaware the stoma had not been cared for since the Resident's admission.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0757
(Tag F0757)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure that for three Residents (#8, #90, and #67), out of a total ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure that for three Residents (#8, #90, and #67), out of a total sample of 19 residents, that each resident's drug regimen was free from unnecessary drugs. Specifically, the facility failed to monitor for potential adverse consequences related to the use of an anticoagulant (blood thinner) medication.
Findings include:
1. Review of the manufacturer's (Bristol-[NAME] Squibb) website, revised September 2016, indicated Plavix (Clopidogrel) is a P2Y12 platelet inhibitor indicated for acute coronary syndrome, recent myocardial infarction (MI), recent stroke, or established peripheral arterial disease to reduce the rate of MI and stroke.
Adverse Reactions
-Bleeding, including life-threatening and fatal bleeding, is the most reported adverse reaction
Resident #8 was admitted to the facility with diagnoses including sick sinus syndrome (heart rhythm disorder) and had a cardiac pacemaker.
Review of current Physician's Orders, dated 9/1/22 through 9/30/22, indicated the following:
-Clopidogrel (Plavix) (blood thinner which can be used to prevent stroke, heart attack, and other heart problems) tablet 75 milligrams (mg), take one tablet by mouth daily
Review of the September 2022 Medication Administration Record (MAR) indicated the following:
-Clopidogrel, administered daily from 9/1/22 through 9/29/22
Further review of the medical record failed to indicate Resident #8 was being adequately monitored for signs and symptoms of bleeding related to the use of a blood thinner.
During an interview on 10/3/22 at 2:47 P.M., Unit Manager #1 said Resident #8 was not being monitored for potential adverse consequences including signs and symptoms of bleeding but should have been.
3. Review of Bristol [NAME] Squib's website indicated that Eliquis (anticoagulant) is a prescription medicine used to reduce the risk of forming a blood clot in the legs and lungs. The website indicated to call your doctor or get medical help right away if you have any of these signs or symptoms of unexpected bleeding or bleeding that lasts a long time, such as:
-Unusual bleeding from the gums;
-Nosebleeds that happen often;
-Menstrual or vaginal bleeding that is heavier than normal;
-Bleeding that is severe or you cannot control;
-Red, pink, or brown urine;
-Red or black stools (looks like tar);
-Coughing up or vomiting blood;
-Vomit that looks like coffee grounds;
-Unexpected pain, swelling, or joint pain;
-Headaches
-Feeling dizzy or weak
Resident #90 was admitted to the facility with diagnoses including atrial fibrillation.
Review of the September 2022 Physician's Orders included but was not limited to:
-Eliquis 2.5 mg twice daily (7/7/21)
The Physician's Orders failed to include monitoring the Resident for potential side effects of anticoagulant use.
Review of July 2022 through October 2022 Medication Administration Records (MAR) indicated that Eliquis was administered as ordered by the Physician.
Further review of the medical record failed to indicate that staff monitored the Resident for signs/symptoms of potential adverse consequences of anticoagulant use as required.
During an interview on 9/30/22 at 10:15 A.M., the surveyor and Unit Manager #2 reviewed Resident #90's medical record. She said signs/symptoms of potential side effects of anticoagulant use are not monitored but should be.
3. Resident #67 was admitted to the facility in July 2022 with diagnoses that included an acute cerebella ataxia and atrial fibrillation.
Review of the current 2022 Physician's Orders included but was not limited to:
-Eliquis 5 mg twice daily (8/23/22)
Review of the plan of care dated 9/5/22 identified the risk of uncontrolled bleeding from the administration of Eliquis and implemented a plan to monitor for adverse effects from the medication.
Review of Medication Administration Records (MAR) from 8/23/22 through 10/4/22 indicated that Eliquis was administered as ordered by the Physician.
Further review of the medical record failed to indicate that staff monitored Resident #67 for signs of bleeding as required.
During an interview on 10/4/22 at 4:00 P.M., Unit Manager #3 said the medication was not being monitored.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0806
(Tag F0806)
Could have caused harm · This affected 1 resident
Based on observations and interviews, the facility failed to provide food that accommodated the preferences of 1 Resident (#94), in a total sample of 19 residents.
Findings include:
Resident #94 was a...
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Based on observations and interviews, the facility failed to provide food that accommodated the preferences of 1 Resident (#94), in a total sample of 19 residents.
Findings include:
Resident #94 was admitted to the facility in August 2022.
Review of the Minimum Data Set (MDS) assessment, dated 9/14/22, indicated Resident #94 scored a 12 out of 15 on the Brief Interview for Mental Status exam indicating the Resident was moderately cognitively impaired.
During an interview on 9/27/22 at 9:40 A.M., Resident #94 said he/she wanted fresh fruit every day for breakfast, that he/she did not like the other breakfast foods and preferred to eat fresh fruit for breakfast. He/she said the fresh fruit did not always come on the breakfast tray, sometimes he/she received canned fruit and sometimes no fruit at all.
On 9/30/22 at 7:57 A.M., the surveyor observed Resident #94 in the unit dining room having breakfast. The Resident did not have any fruit on his/her meal tray. At this time, the Resident said he/she did not get the fruit and requested fruit from a Certified Nursing Assistant (CNA). Review of the meal ticket on the tray indicated Resident #94 was to have a fresh fruit plate on the breakfast meal tray. At 8:11 A.M. a small handheld size cup (not a plate) of fruit arrived for Resident #94.
On 10/4/22 at 8:03 A.M., the surveyor observed Resident #94 eating breakfast in his/her room. At this time, the Resident said he/she did not get any fruit again this morning.
On 10/5/22 at 7:45 A.M., the surveyor observed Resident #94 to not have fruit on his/her breakfast tray.
During an interview on 10/5/22 at 8:20 A.M., the Food Service Director said she was aware of the preference for Resident #94 to have fresh fruit. She said she was unable to order fresh fruit because it was out of season. She said she did have watermelon in the fridge, but it was for a breakfast on the scheduled menu. She said she thought residents wanted strawberries and they were out of season, so she had not been providing fresh fruit. She said she had not checked with Resident #94 to determine which seasonal fresh fruit could be provided. She said if she was out of fresh fruit, she can provide canned fruit as an alternate, but had not provided any fruit to Resident #94 on 10/4/22 or 10/5/22.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Medical Records
(Tag F0842)
Could have caused harm · This affected 1 resident
2. Review of the facility's policy titled, Medical Orders for Life Sustaining Treatment MOLST (Massachusetts and Rhode Island), undated, indicated but was not limited to the following:
-The MOLST form...
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2. Review of the facility's policy titled, Medical Orders for Life Sustaining Treatment MOLST (Massachusetts and Rhode Island), undated, indicated but was not limited to the following:
-The MOLST form is a medical order form that converts an individual's wishes regarding life-sustaining treatment into Medical Orders
-It is designed to be a portable, valid and immediately actionable medical order consistent with the individual's wishes and current medical condition, which shall be honored across treatment settings
-The MOLST form is legally sufficient and recognized as a medical order
-A legally recognized health care agent/decision maker or guardian may execute, revise, or revoke the MOLST form for a resident/patient only if the resident/patient lacks decision-making capacity
Resident #67 was admitted to the facility with diagnoses including cerebral infarction, aphasia (inability to comprehend or formulate language), metabolic encephalopathy (problem in the brain caused by a chemical imbalance in the blood), and delusional disorder.
Review of the Minimum Data Set (MDS) assessment, dated 10/26/22, indicated Resident #67 had severe cognitive impairment as evidenced by a Brief Interview for Mental Status (BIMS) score of 0 out of 15.
Review of the medical record indicated a MOLST form signed and dated 8/1/22. The form contained a signature other than the Resident's and was not identified as either the health care agent or guardian as none of the circles were marked to identify the signature. The surveyor was unable to locate paperwork in the Resident's medical record to specify if the Resident had a health care agent that was invoked (determined in writing by the attending physician that the patient does not have the temporary or permanent capacity to make their own health decisions) or a legal guardian.
During an interview on 12/1/22 at 9:45 A.M., the surveyor reviewed Resident #67's medical record with Unit Manager (UM) #1 who said she was unable to locate paperwork in the medical record to identify the type of representative that signed the MOLST form. UM #1 said it should have been readily accessible in the Resident's medical record with the MOLST form but was not. She said she believed the Resident's cousin was his/her health care proxy (HCP) but she could not locate the paperwork or if the HCP had been invoked.
During an interview on 12/1/22 at 1:45 P.M., Consulting Staff #2 said she was unable to locate the paperwork in Resident #67's medical record and needed to send an outside fax to obtain the information.
During an interview on 12/1/22 at 1:50 P.M., the Social Worker said the Resident's niece was his/her legal guardian, but the guardianship paperwork was not included as part of the medical record. She said the paperwork was necessary to provide evidence of the legal authority to sign the MOLST form and should have been a part of the medical record and accessible but was not.
During an interview on 12/1/22 at 2:30 P.M., Consulting Staff #1 provided the surveyor with guardianship paperwork and said the Social Worker had located the information in the Resident's medical record.
During an interview on 12/1/22 at 2:37 P.M., the Social Worker said the paperwork was not located in the record. She said she requested it and received it from another facility.
Based on record review and staff interview, the facility failed to maintain medical records that were complete, accurate, and systemically organized within accepted professional standards of practice for two Residents (#77 and # 67), out of a total sample of 14 residents. Specifically, the facility failed to ensure:
1. For Resident #77, the documentation on the Medication Administration Record (MAR) was accurate and completed on the date specified; and
2. For Resident #67, the Decree and Order of Appointment of Guardian for an Incapacitated Person was included as part of the medical record, readily accessible, and confirmed the guardian's authority to sign the Resident's Massachusetts Medical Orders for Life-Sustaining Treatment (MOLST) form.
Findings include:
1. Resident #77 was admitted to the facility in August 2022 with diagnoses that included acute osteomyelitis of the right foot and ankle and cancer of the larynx.
Record review of the Medication Administration Record (MAR) for November 2022 indicated an entry for:
-Fax Monday labs (laboratory results) to the Infectious Disease (ID) physician.
Further review of the MAR indicated that the box on the MAR for the nurse's initials indicating that the labs had been faxed to the ID physician on 11/28/22 was blank. A copy of the MAR was made by the surveyor on 11/30/22 at 2:00 P.M.
On 12/1/22 at 8:30 A.M., the November 2022 MAR was again reviewed by the surveyor which now indicated that a nurse had initialed the entry on the MAR for 11/28/22 indicating the labs had been faxed to the ID physician's office.
During an interview on 12/1/22 at 8:31 A.M., the surveyor presented the copy made on 11/30/22 at 2:00 P.M. to the Infection Preventionist (IP), and then presented the same MAR from 12/1/22 at 8:30 A.M. The IP stated, Oh yeah, that's not good.
During an interview on 12/1/22 at 1:00 P.M., the Director of Nursing, Unit Manager #1 and Clinical Consultant #1 said that the documentation the surveyor had copied indicated that the initials were not present on 11/30/22 and on 12/1/22 the initials were now present.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
QAPI Program
(Tag F0867)
Could have caused harm · This affected 1 resident
Based on record review and interviews, the facility failed to define, implement, and maintain a comprehensive quality assurance and performance improvement (QAPI) plan to address the full range of car...
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Based on record review and interviews, the facility failed to define, implement, and maintain a comprehensive quality assurance and performance improvement (QAPI) plan to address the full range of care and services provided by the facility, including infection control practices, Quality of care, falls, and medication review.
Findings include:
Review of the facility's policy titled Quality Assurance Performance Improvement, dated April 2015, indicated the facility's QAPI program is a proactive approach to improving the quality of life, care, and services in the nursing home. The Governing Body should foster a culture where QAPI is a priority by ensuring that policies are developed to sustain QAPI despite personnel changes and staff turnover. Their responsibilities include, setting expectations around safety, quality, rights, choice, and respect by balancing safety with resident-centered rights and choice. The governing body must implement and maintain an ongoing QAPI Committee designed to monitor and evaluate the quality of resident care/services, pursue methods to improve quality care, and to identify and resolve problems, issues, concerns through:
-Designating one or more persons to be accountable for Performance Improvement (Committee Chair)
-Ensuring adequate leadership and staff training; and
-Establishing policies to sustain the program regardless of personnel changes and staff turnover.
During an interview on 10/5/22 at 2:19 P.M. with the Administrator and the Director of Nursing (DON). The DON provide the surveyor with a copy of the QAPI policy entitled Nursing Policy and Procedure Manual dated April, 2015 but did not describe the model used for the QAPI program. The DON said she had identified QAPI projects. The Administrator said he was new and was not sure of what QAPI projects were in place. The Administrator said that when he started at the facility in August 2022, no one knew where the previous QAPI plan was located; and no one knew how to identify areas for performance improvement. He said he has been working on strategies in educating the committee members and there are no current performance improvement projects currently in place. He said that QAPI was a work in progress.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Notification of Changes
(Tag F0580)
Could have caused harm · This affected multiple residents
Based on interviews and record review, the facility failed to consult with the resident's physician for four Residents (#3, #43, #40, #147 and #6), out of 19 sampled residents. Specifically, the facil...
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Based on interviews and record review, the facility failed to consult with the resident's physician for four Residents (#3, #43, #40, #147 and #6), out of 19 sampled residents. Specifically, the facility failed to notify physicians of the following:
1. A recommended antipsychotic medication for Resident #3 with delusions and hallucinations;
2. A change in weight for Resident #43 with a history of significant weight loss;
3. A recommendation to a change in wound treatments for Resident #40;
3. A new prescription from an Endocrinologist for Resident #147; and
4. A recommended antipsychotic medication, Seroquel, for Resident #6.
Findings include:
1. Resident #3 was admitted to the facility in December 2021 with a diagnosis of Parkinson's disease.
Review of the medical record indicated Resident #3 was seen by the consultant Psychiatric Nurse Practitioner (NP) on 7/21/22. The Psychiatric NP progress note indicated Resident #3 reported delusions and visual hallucinations and that he/she was bothered by the delusions and hallucinations. The Psychiatric NP made a recommendation to start Nuplazid (an antipsychotic for people with Parkinson's disease) 34 milligrams (mg) every day.
Review of the Psychiatric NP Progress Note, dated 7/21/22, indicated it was signed by the physician on 8/12/22, 22 days after it was recommended.
Review of the Nursing Progress Notes indicated on 8/12/22 the recommendation from 7/21/22 was reviewed with the physician and the physician agreed to the treatment and ordered the Nuplazid.
During an interview on 10/5/22 at 10:05 A.M., the Director of Nurses said the recommendation from the Psychiatric NP had gone to one of the fax machines in the facility and had not been brought forward for review. She said the physician had not been notified of the recommendation until 8/12/22, 22 days after the recommendation.
2. Resident #43 was admitted to the facility in January 2019 with a diagnosis of Parkinson's disease.
Review of the care plans indicated Resident #43 was at risk for a nutritional decline related to Parkinson's disease with a goal, revised on 5/23/22, to have the weight stable at 165 pounds.
Review of the medical record for Resident #43 indicated the following nutritional history:
-On 02/04/22, the Resident weighed 176.4 pounds (lbs.). On 03/04/22, the Resident weighed 166.8 lbs. which was a -5.44% loss in four weeks.
-On 02/10/22, the Resident weighed 176.4 lbs. On 05/05/22, the Resident weighed 162.0 lbs. which was a -8.16% loss in three months.
-Nursing progress note, dated 5/25/22, indicated a recommendation from the Registered Dietitian (RD) for 8 ounces of Ensure every day.
- RD's Progress Note, dated 6/1/22, indicated the Resident continued with weight loss, supplements were added, weekly weights requested, and the Resident remained at nutritional risk.
-Physician's Progress Note, dated 7/9/22, indicated Resident #43's care was transferred to a new physician and indicated there were no significant weight changes. There was no indication in the record that the new physician was aware of the previous significant weight loss.
Review of the electronic medical record for Resident #43 indicated the Resident was weighed weekly in the month of June 2022 and weighed monthly following that. The following weights were in the medical record as of 9/30/22:
-7/5/22: 163.4 lbs.
-8/5/22: 160.8 lbs.
-9/2/22: 155.4 lbs.
During an interview on 10/4/22 at 10:13 A.M., the RD said Resident #43 should have been weighed weekly since May 2022. She reviewed the electronic medical record at this time and said she had not been aware of the weight of 155.4 lbs. on 9/2/22 (one month prior). She said the Resident should have been re-weighed and the RD and the physician should have been notified to determine additional interventions.
During an interview on 10/5/22 at 9:00 A.M., the RD said Resident #43 was now 149.0 lbs. and had a significant weight loss.
3. Resident #40 was admitted to the facility in February 2022 with diabetes and had developed multiple diabetic wounds.
Review of the Wound Consultant's Progress Notes, dated 8/31/22, indicated a venous stasis cluster of wounds circumferential to the right lower leg with a plan to discontinue to the adaptic gauze dressings to the wound cluster and apply two large gentle border adhesive dressing around the circumference of the right lower leg and to change daily.
Review of the September 2022 Treatment Administration Record (TAR) on 9/28/22 indicated the following wound treatment orders:
-7/30/22 Right shin: normal saline wash, pat dry, apply skin prep to periphery, cover with adaptic gauze to wound bed, cover with ABD pad, wrap with Kerlix, change daily
-7/30/22 Right calf: normal saline wash, pat dry, apply skin prep to periphery, cover with adaptic gauze to wound bed, cover with ABD pad, wrap with Kerlix, change daily
-6/29/22 Right lower leg: apply ace bandage daily with dressing change
Review of the medical record on 9/30/22 indicated a telephone order was written on 9/28/22 to change the wound care of the right lower leg to reflect the Wound Consultant's recommendations from 8/31/22, 28 days later.
During an interview on 9/30/22 at 1:25 P.M., Unit Manager #2 said the recommendation made by the Wound Consultant on 8/31/22 had not been called in to the primary physician for review of a change in treatment until 9/28/22 when she noticed it was an incorrect treatment order while doing the monthly edits.
5. Resident #6 was admitted to the facility in November 2021 with medical diagnoses including alcohol dependence with alcohol-induced persisting dementia, major depressive disorder, and insomnia.
Review of the Minimum Data Set (MDS) assessment, dated 09/27/22, indicated Resident #6 was cognitively competent as evidenced by a Brief Interview for Mental Status score of 15 out of 15. The MDS indicated the Resident was receiving antipsychotic medications.
Review of the Psychiatric Nurse Practitioner's (NP) Progress Note, dated 7/21/22, indicated the following:
-Reason for consultation: medication management
-Problem Pertinent Review of Systems (ROS): Wishes to be dead/Denies suicidal ideas or intentions
-Clinical Assessment: Resident sitting in bed, vital signs were obtained and within the normal limits.
AIMS Exam performed: within the normal limits, no abnormalities.
Review of the Clinical Summary indicated Resident is alert and oriented x 3 and cooperative with exam. The summary indicated Resident said he/she has chronic aches. He/She said he/she has not been anxious or depressed other than that he/she really wants to go home. He/She denied suicidal ideation, he/she said he/she does not have depressive symptoms noted during exam. He/She states that he/she eats good but has trouble falling asleep and wakes up off and on.
Instructions/Recommendations/Plan: Continue to monitor patient for side effects of medication. Continue to monitor for changes in mood and behavior. Continue to encourage activity participation as tolerated.
Suggest:
1. Reduce Seroquel dosing and change dosing just to hour of sleep.
2. Addition of Prozac to better target depressive symptoms.
3. Contact [consultant Psychiatric Services provider] with worsening or persistent symptoms
4. CBC in 1-2 weeks after starting Prozac. Contact [consultant Psychiatric Services provider] with low platelet or low white blood cell (WBC) count.
Continue Remeron 22.5 Milligrams (MG) by mouth at hour of sleep (insomnia/depression)
Continue Melatonin 3 MG by mouth at hour of sleep (Insomnia)
Start Seroquel 50 MG PO at hour of sleep
Start Prozac 10 MG PO daily (Depression)
Stop Seroquel 25 MG PO TID (Reconciled at Admission)
Review of Resident #6's Nursing Progress Notes from July 2022 through October 5, 2022, failed to indicate the physician or NP were ever informed of the recommendations for changes in medications from the psychiatric NP consult dated 7/21/22.
Review of Resident #6's Physician's and NP's Progress Notes failed to indicate the psych NP recommendations were reviewed and addressed.
During an interview on 10/5/22 at 9:04 A.M., the Director of Nursing (DON) said recommendations from the Psych NP on 7/21/22 were not reviewed and addressed.
4. Resident #147 was admitted to the facility in September 2022 with diagnoses including major depressive disorder, hypothyroidism, and lymphedema.
Review of the most recent Minimum Data Set (MDS) assessment, dated 9/24/22, indicated Resident #147 scored 15 out of 15 on the Brief Interview for Mental Status (BIMS) indicating he/she was alert and oriented.
During an interview on 9/30/22 at 9:45 A.M., Resident #147 told the surveyor that he/she had an outpatient appointment with his/her Endocrinologist on 9/29/22 and had not received any information about the visit. Resident #147 said he/she did not know if anything was ordered to be changed and if the Physician was notified. Resident #147 said he/she had asked the facility staff for the documents and to make him/her aware of any changes.
On 9/30/22 at 10:15 A.M., record review failed to include the referral and/or documents for Resident #147's 9/29/22 Endocrinology appointment.
On 9/30/22 at 10:20 A.M., the surveyor asked Unit Manager (UM) #3 for the referral. UM #3 looked for the documents and located them on the counter of the nurses' station desk. UM #2 said the Endocrinologist had not documented anything on the referral form. She said she would follow-up with the Resident and the Endocrinologist.
During an interview on 10/4/22 at 11:30 A.M., Resident #147 said he/she was still unaware of the outcome of his/her appointment with the Endocrinologist on 9/29/22.
Review of the Nurse's Notes from 9/29/22 through 10/4/22 failed to indicate the physician was notified of any recommendations made by the Endocrinologist.
Further record review indicated on 10/2/22 a telephone order was obtained from the Physician to increase the Resident's Topriamate (an anticonvulsive medication) from 25 milligrams (mg), twice a day to 100 mg, twice daily. The telephone order indicated the increase in the medication had come from the Endocrinologist.
During an interview on 10/4/22 at 3:45 P.M., UM #3 said the facility Social Worker would be calling the Resident's Endocrinologist and would have them fax over the documents from Resident #147's appointment on 9/29/22. The surveyor asked about the telephone order written on 10/2/22. UM #3 said a prescription for the medication changed had been sent to the facility on 9/29/22. She said the delay in notifying the Physician for the change in the Resident's medication dose was because no one had seen the prescription until 10/2/22.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Comprehensive Care Plan
(Tag F0656)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and policy review, the facility failed to ensure that individualized, comprehens...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and policy review, the facility failed to ensure that individualized, comprehensive care plans were developed and consistently implemented for seven Residents (#8, #38, #48, #6, #94, #77, and #147), out of 19 sampled residents. Specifically, the facility failed:
1. For Resident #8, to develop a care plan for the use of a blood thinning medication;
2. For Resident #38, to implement care plan interventions for falls;
3. For Resident #48, to implement care plan interventions for an indwelling urinary catheter;
4. For Resident #6, to develop a comprehensive care plan for psychotropic medication use that identified target behaviors, non-pharmacological interventions, and measurable goals of treatment;
5. For Resident #94, to develop a care plan for smoking;
6. For Resident #77, to assess or develop a plan of care for the treatment of his/her laryngeal stoma (hole (opening) made in the skin in front of your neck to allow you to breath), and
7. For Resident #147, to implement an individualized care plan that was consistent with the Resident's preferences and goals for nutrition.
Findings include:
Review of the facility's policy titled Comprehensive Care Plans, dated August 2015, indicated but was not limited to the following:
-Care plans are oriented toward preventing avoidable decline in clinical and functional levels, maintaining a specific level of functioning and reflect resident preferences and right to refuse certain services or treatment
-Care plans are a combination of data concerning the resident that is obtained from the physician, clinical records, evaluations done professionally and other disciplines, the resident and/or family goals for treatment, acute/chronic events, and behaviors and/or illness
-Based on the above, the Interdisciplinary Team develops a comprehensive care plan for each resident that includes measurable objectives and timelines to accommodate preferences, special medical, nursing and psychosocial needs identified
-The care plan is evaluated and revised as needed, but at least quarterly
1. Resident #8 was admitted to the facility with diagnoses including sick sinus syndrome (heart rhythm disorder) and had a cardiac pacemaker.
Review of the current Physician's Orders, dated 9/1/22 through 9/30/22, indicated the following:
-Clopidogrel (Plavix) (blood thinner which can be used to prevent stroke, heart attack, and other heart problems) tablet 75 milligrams, take one tablet by mouth daily (3/4/20)
Further review of Resident #8's medical record failed to indicate an interdisciplinary care plan had been developed for the use of a blood thinner that included measurable objectives, timeframes, and interventions.
During an interview on 10/3/22 at 2:47 P.M., Unit Manger (UM) #1 said there should have been a care plan developed and implemented for the Resident's Clopidogrel use but there was not.
2. Resident #38 was admitted to the facility with diagnoses including morbid obesity, muscle weakness, abnormalities of gait and mobility, abnormal posture, osteoarthritis, chronic pain syndrome, left femur fracture, and right foot fracture.
Review of the Minimum Data Set (MDS) assessment, dated 10/3/22, indicated Resident #38 was an extensive assist with bed mobility, toileting, and personal hygiene, and had a fall prior to re-admission.
Review of the Fall Risk Assessment, dated 9/15/22, indicated Resident #38 was at risk for falls.
Review of the medical record indicated an interdisciplinary care plan for falls, initiated 9/19/22, that included but was not limited to the following:
Focus:
-Resident is at risk for falls related to injury due to fall prior to readmit to facility, obesity, muscle weakness, impaired mobility, osteoarthritis, and chronic pain
Goal:
-Resident will not sustain a fall related injury by utilizing fall precautions through next review
Interventions:
-Call light within reach
During an observation with interview on 9/29/22 at 8:11 A.M. and 2:05 P.M., the surveyor and UM #1 observed Resident #38 lying in bed. The call bell was tied to the upper siderail and was hanging down towards the floor. Resident #38 said he/she did not know where the call bell was. Once identified, Resident #38 was unable to demonstrate his/her ability to reach it. Resident #38 told UM #1 he/she preferred to have the call bell placed on the overbed table or on his/her chest where he/she could reach it. UM #1 said the call bell should have been within the Resident's reach and easily accessible but was not.
3. Review of the facility's policy titled Urinary Catheter Care, undated, indicated but was not limited to the following:
-Always keep the drainage bag below the level of the resident's bladder
Resident #48 was admitted to the facility with diagnoses including multiple sclerosis (MS) (a disease resulting in nerve damage that disrupts the communication between the brain and the body), neurogenic bladder (lack of bladder control due to a brain, spinal cord, or nerve problem), and urinary tract infection (UTI).
Review of the Minimum Data Set (MDS) assessment, dated 8/10/22, indicated Resident #48 had an indwelling urinary catheter (drains urine from your bladder into a bag outside your body).
Review of the current Physician's Orders, dated 9/1/22 through 9/30/22, indicated an order for the following:
-suprapubic catheter to bedside drainage (place in privacy bag)
Review of the medical record indicated an interdisciplinary care plan for a suprapubic (surgically created connection between the urinary bladder and the skin to drain urine) catheter, initiated 8/19/21, that included but was not limited to the following:
Focus:
-Resident is at risk of developing a UTI/complications due to catheter use related to neurogenic bladder
Interventions:
-Keep drainage bag below level of bladder
On 9/29/22 at 2:41 P.M., the surveyor observed Resident #48 sitting in his/her wheelchair in his/her room. Resident #48's urinary catheter bag was hanging from the right armrest of the wheelchair, above the level of the bladder.
During an interview on 9/29/22 at 2:41 P.M., UM #1 said the catheter should have been positioned below the level of the bladder to help prevent infection.
On 10/3/22 at 10:47 A.M., the surveyor observed Resident #48 sitting in his/her wheelchair at the nurses' station. Resident #48's urinary catheter bag was hanging from the left armrest of the wheelchair, above the level of the bladder.
During an interview on 10/3/22 at 4:10 P.M., the Director of Nursing (DON) said the Resident's urinary catheter bag should have been positioned below the level of the bladder to help prevent an infection or any complications.
5. Review of the medical record for Resident #94 included a Smoking Evaluation and Safety Screen, dated 9/7/22. The evaluation indicated Resident #94 was a current smoker and would be smoking at the facility.
Review of the care plans for Resident #94 failed to include any documentation regarding smoking or a plan for smoking.
On 9/28/22 at 4:15 P.M., the surveyor observed Resident #94 smoking outside during the supervised smoking time.
Review of the Minimum Data Set (MDS) assessment, dated 9/14/22, indicated Resident #94 was not a smoker.
During an interview on 9/30/22 at 10:05 A.M., the MDS Coordinator said she was unaware Resident #94 was a smoker and it should have been indicated on the MDS dated [DATE]. She said the MDS process would have initiated a care plan with interventions based on the Resident's smoking evaluation.
4. Resident #6 was admitted to the facility with medical diagnoses including major depressive disorder.
Review of the Resident's medications included but were not limited to:
-Mirtazapine (used to treat depression) 45 milligram (mg) tablet, give one half tablet (22.5 mg) by mouth at bedtime;
-Quetiapine (used to treat depression) 50 mg tablet at bedtime;
-Quetiapine 25 mg daily at 9:00 A.M.
Review of Resident #6's Comprehensive Care Plans included but was not limited to:
-Focus: Psychotropic drug use related to diagnoses of antidepressants, antipsychotics medications-
Goals: Resident will be free from signs and symptoms of adverse effects of psychotropic drug use
-Interventions:
-Administer psych medications as prescribed by the physician
-AIMS/Discuss review every six months and as needed
-Consult psych services as needed
-Documentation of Mood/Behavioral issues every shift
-Educate resident/family/Guardian/HCP on potential risks benefits psychotropic drug use
-labs as ordered
-Monitor for effectiveness of psychotropic drugs
-Observe for any signs and symptoms of drug related adverse effect
-Pharmacy medication monitoring as needed
-Report to physician any negative consequences associated with use of drug
-Review with (interdisciplinary team) IDT for gradual dose reduction (GDR) as indicated
Further review of the care plan failed to identify Resident specific targeted signs and symptoms of depression, any non-pharmacological approaches in addition to antidepressant therapy, and measurable goals to meet the Resident's needs.
During an interview on 10/3/22 at 10:30 A.M., Nurse #4 said the care plan was not individualized.
During an interview on 10/5/22 at 9:15 A.M., the Director of Nursing said the Resident's care plan was not individualized.
6. Resident #77 was admitted to the facility in August 2022 with diagnoses that included laryngeal cancer with a status post- surgery and radiation with a stoma.
Review of the 9/5/22 Minimum Data Set (MDS) assessment indicated Resident #77 had a Brief Interview for Mental Status (BIMS) score of 15 out of 15 (cognitively intact), required extensive assistance in his/her activities of daily living (washing, dressing, transfers and toileting), and had a trachea stoma.
During observation and interview on 9/27/22 at 11:30 A.M., Resident #77 was in bed and had a laryngeal stoma clearly visible on the front of his/her neck. Resident #77 placed his/her fingers over the opening and said he/she has had the trachea/laryngeal stoma for 15 years. The surveyor observed there was no equipment in the room (such as a suction machine, or products to clean the stoma) for care or treatment of the stoma.
Review of the medical record on 9/27/22 failed to indicate the facility staff had assessed or developed a care plan for the care and treatment of a laryngeal stoma.
During an interview on 10/4/22 at 9:30 A.M., Resident #77 said that no one cleans or cares for his/her laryngeal stoma. Resident #77 said he/she could not do self-care and even if he/she there was nothing to clean it with. The Resident said the area was cleaned twice a day when at home and since his/her admission [DATE]) the stoma has not been cleaned.
During an interview on 10/4/22 at 4:00 P.M., Unit Manager #3 (UM #3) said a plan of care had not been developed, as she thought the Resident cared for the laryngeal stoma him/herself. The UM was unaware the stoma had not been cared for since the Resident's admission.
7. Resident #147 was admitted to the facility in September 2022.
During an interview on 9/27/22 at 10:00 A.M., Resident #147 said he/she wanted to develop a healthy and nutritional plan of care. Resident #147 said no one at the facility had met with him/her to develop the plan.
Record review on 9/28/22 indicated a nutritional care plan had been developed by the dietitian for Resident #147 and identified the Resident as morbidly obese. The goal was for Resident #147 to lose 5 to 15 pounds each quarter.
During an interview on 9/30/22 at 8:44 A.M., Resident #147 said he/she had gone to an appointment on 9/29/22 to discuss potential surgery for a hernia and eventual bypass surgery for his/her weight. Resident #147 said he/she was not sure of the outcome of the appointment. Resident #147 said weight loss was not his/her interest, but to learn how to eat better and to get physically stronger was the goal. Resident #147 said he/she had not met with the facility's dietitian.
During a follow-up interview on 10/04/22 at 12:06 P.M., the Resident said he/she had not met with the dietitian to talk about the care plan the dietitian developed for weight loss.
During an interview on 10/05/22 at 8:43 A.M., the Dietitian said she had not met with the Resident to complete Resident #147's nutrition assessment. The Dietitian said that it was her clinical judgement that Resident #147 should lose weight and was here for short term care not long-term care. The Dietitian said she did not have to follow the guidance of an individualized plan of care that was based on a resident's preference, choices, and goals if the residents were not long-term care. The Dietitian said she focused on the medical condition because they are here for that reason and said the plan of care is not valid until she meets with a resident.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0658
(Tag F0658)
Could have caused harm · This affected multiple residents
4. Review of the facility's policy titled Pacemaker Checks, undated, indicated but was not limited to the following:
-Identify the type and identification number of pacemaker resident/patient has on a...
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4. Review of the facility's policy titled Pacemaker Checks, undated, indicated but was not limited to the following:
-Identify the type and identification number of pacemaker resident/patient has on admission and note same in medical record
-Schedule pacemaker checks as ordered by the physician
-Nurse calls the appropriate pacemaker laboratory
-Document in the medical record
-For other types of pacemakers, refer to the testing laboratory for directions or follow the physician's order
Designed to operate for 3 to 20 years, a permanent pacemaker is a self-contained device that provides electrical stimulation to the myocardium. The surgeon implants the pacemaker in a pocket beneath the patient's skin. Permanent pacemakers function in the demand mode, allowing the patient's heart to beat on its own but preventing it from falling below the preset rate. Pacing electrodes can be placed in the atria, the ventricles, or both chambers.
Check Ups
-Be sure to schedule a follow-up visit, and keep regular checkup appointments with your practitioner
-If your practitioner monitors your pacemaker status remotely by wireless telemetry, keep your transmission schedule and instructions handy
Lippincott Nursing Procedures, 8th Edition, 2019
Resident #8 was admitted to the facility with diagnoses including sick sinus syndrome (heart rhythm disorder) and had a cardiac pacemaker.
Review of Physician's Progress Note, dated 6/28/22, indicated Resident #8 had a permanent pacemaker.
Further review of the medical record failed to indicate physician's orders, an interdisciplinary care plan, or a cardiology note for the management and frequency of telephonic/office pacemaker monitoring and battery life. The medical record also failed to indicate appointment dates for a cardiology follow up to ensure the device was working properly and the settings were correct for the Resident.
During an interview on 10/3/22 at 2:37 P.M., Unit Manager (UM) #1 said Resident #8 did not have a permanent pacemaker but would call the attending physician to clarify.
During an interview on 10/3/22 at 3:50 P.M., UM #1 said she spoke to the attending physician who said Resident #8 did have a cardiac pacemaker but did not know what type and the Resident was not being monitored but should have been.
During an interview on 10/3/22 at 4:15 P.M., the Director of Nursing (DON) said Resident #8 was re-admitted in 2020 and was not certain how long the Resident's cardiac pacemaker had not been monitored. The DON said there should have been orders in the medical record to identify the type of pacemaker, the type of monitoring required, and cardiology consults once or twice a year but there was not.
Based on observation, interview, record review, and policy review, the facility failed to ensure Residents were provided care in accordance with professional standards of practice for four Residents (#4, #90, #6, and #8), from a total sample of 19 residents.
Specifically, the facility failed
1. For Resident #4, to ensure physician's orders for a bowel protocol was implemented which resulted in the Resident not having a bowel movement for seven days;
2. For Resident #90, to ensure the physician's order for an air mattress was implemented and accurately documented;
3. For Resident #6, to ensure a physician's order was transcribed as per the acceptable professional standards of clinical practice; and
4. For Resident #8, to ensure the Resident's pacemaker was monitored and evaluated as per the facility policy and standards of practice.
Findings include:
1. Resident #4 was admitted to the facility with diagnoses including dementia.
Review of the 6/15/22 Minimum Data Set (MDS) assessment indicated Resident #4 has severely impaired cognitive skills for daily decision making, requires assistance of two or more staff for toileting, and is frequently incontinent of bowel.
Review of August and September 2022 Physician's Orders included but was not limited to:
-Milk of Magnesia 30 milliliters (ml) as needed if no bowel movement for 3 days, administer on 3:00 P.M. to 11:00 P.M. shift (11/19/21)
Review of the medical record indicated Resident #4 had a bowel movement on 8/24/22 during the 7:00 A.M. to 3:00 P.M. shift. The Resident's next bowel movement was recorded on 9/1/22 during the 7:00 A.M. to 3:00 P.M. shift. (seven days).
Review of the August 2022 Medication Administration Record (MAR) failed to indicate Milk of Magnesia was administered at any time between 8/25/22 and 8/30/22 during which time Resident #4 was documented as not having a bowel movement for three days.
Review of a 9/1/22 Nursing Progress Note indicated that Resident #4's last bowel movement was recorded on 8/24/22 (7 days earlier) and was administered Milk of Magnesia.
During an interview on 9/30/22 at 10:20 A.M., the surveyor and Unit Manager #1 reviewed Resident #4's medical record. The Unit Manager confirmed that staff did not administer Milk of Magnesia according to physician's orders which resulted in Resident #4 not having a bowel movement for seven days.
2. Review of the facility's policy titled Air Mattress Overlay (April 2015) included but was not limited to:
-An air mattress overlay is used to prevent skin breakdown in accordance with a Physician's Order
-Procedure: verify Physician's order, evaluate air mattress functions and proper inflation every shift
Resident #90 was admitted to the facility with diagnoses including dementia.
On 9/27/22 at 11:17 P.M., the surveyor observed an air mattress on Resident #90's bed that was on and set to 400 pounds (lbs.). A sticker adhered to the unit indicated the unit to be set between 80-160 lbs.
On 9/28/22 at 9:42 A.M., the surveyor observed Resident #90 lying in bed awake. The air mattress was on and set to 400 lbs.
On 9/29/22 at 9:10 A.M., the surveyor observed Resident #90 lying in bed asleep. The air mattress was on and set to 400 lbs.
On 9/30/22 at 8:25 A.M., the surveyor observed Resident #90 sitting upright in bed eating breakfast. The air mattress was on and set to 400 lbs.
Review of the September 2022 Physician's Orders indicated an order for an air mattress with bolster overlay, check function and setting (80-160 lbs.) every shift.
Review of the September 2022 Treatment Administration Record (TAR) indicated staff signed off that Resident #90's air mattress was set according to physician's orders on the days and times of the surveyor's observations when it was not.
During an interview on 9/30/22 at 1:15 P.M., the surveyor and Unit Manager #1 observed Resident #90 sitting upright in bed. The air mattress was on and set to 400 lbs. The Unit Manager said the air mattress should be set between 80 - 160 lbs. according to physician's orders and documented accurately on the TAR.
3. Resident #6 was admitted to the facility in November 2021 with medical diagnoses including alcohol dependence with alcohol-induced persisting dementia, major depressive disorder, and insomnia.
Review of the clinical record included a Physician's telephone order (T.O.), dated 8/12/22, which indicated the following:
-Discontinue current Seroquel order; Start Seroquel 25 Milligrams (MG) by mouth daily at 9:00 A.M.
-Give Seroquel 12.5 MG by mouth daily at 1:00 P.M. for two weeks, then discontinue the 1:00 P.M. dose; Start Seroquel 50 MG PO daily at hour of sleep.
- Start Prozac 10 MG daily
-Draw CBC Lab in two weeks after Prozac begins
The T.O. was addressed and signed as noted (8/12/22) by Nurse #12 (not present during the survey).
Review of the clinical record failed to include the new order dated 8/12/22.
Review of the September 2022 Physician's Orders failed to include the order to administer Seroquel 25 MG at 9:00 A.M. and 50 MG at hour of sleep from 9/1/22 to 9/14/22.
Review of the Medication Administration Record, dated 9/14/22 to 9/30/22, indicated Resident #6 started to receive the new ordered medication on 9/14/22.
During an interview on 10/5/22 at 09:35 A.M., Nurse #3 said she could not explain why the physician's order to change the dose of Seroquel was not transcribed and administered.
During an interview on 10/5/22 at 10:09 A.M., the Director of Nursing said nursing staff failed to transcribe and administer the medication as ordered.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0694
(Tag F0694)
Could have caused harm · This affected multiple residents
Based on observation, interview, and record review, the facility failed to ensure staff provided care for a Peripherally Inserted Central Catheter (PICC- a long catheter inserted through a peripheral ...
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Based on observation, interview, and record review, the facility failed to ensure staff provided care for a Peripherally Inserted Central Catheter (PICC- a long catheter inserted through a peripheral vein then into a larger vein to administer intravenous (IV) treatments over a long period of time).
Specifically, the facility failed to ensure staff
(a) administered flushes,
(b) changed the dressing,
(c) measured the external catheter length, and
(d) monitored the IV site for one Resident (#77), out of a total sample of 19 residents.
Findings include:
Review of the Pharmacy's policy, followed by the facility, for PICC Catheter flushing and care, undated, indicated:
-Flushing is performed to ensure and maintain cannula patency;
-A physician's order is required to flush a PICC;
-Document date and time of flushing, flushing agents, and amounts, on the Infusion Medication Administration Record (IMAR); and
-Document and date the care on the Infusion Therapy Flowsheet (ITF).
Resident #77 was admitted to the facility in August 2022 with diagnoses including wound infection that required IV antibiotic (delivered through the PICC).
Review of the Physician's Infusion Therapy Orders, dated 8/31/22, indicated Resident #77 was to be administered Ertapenem (antibiotic) 1 gram (gm) Intravenous (IV), daily for 25 days and Vancomycin (antibiotic) 1 gm daily. The PICC line had two lumens (a multi-lumen catheter is a single catheter with more than one internal channel (called a lumen). A different IV infusion/medication can be connected to each lumen and the fluid will infuse at the IV site). The care ordered for the PICC line included the following:
-Pre-Flush each lumen with 10 milliliters (ml) of normal saline (NS),
-Post-Flush each lumen with 10 ml of NS followed by 5 ml of Heparin (anticoagulant) and at least every 12 hours if infusion is not continuous,
-Document total catheter length and external length,
-Document baseline arm circumference and as needed,
-Document external catheter length prior to medication administration, weekly with dressing and change and as needed,
-Flush all lumen as per prescribed protocol and as needed,
-Change needleless connectors weekly and as needed,
-Site assessment before and after medication administration and at least every shift (three times per day).
Review of the September and October IMAR and ITF indicated the facility had not followed the Physician's prescribed flushes and Catheter care as follows:
September 2022 - on 9/7/22 and 9/21/22 the Ertapenem (antibiotic) was not administered and on 9/7/22 and 9/16/22 the Vancomycin was not administered
-No pre-flush or post flushes were done as ordered, with the exception on 9/28/22, 9/29/22, and 9/3/22.
-No needleless connectors were changed, and the weekly dressing change appeared to not be done as ordered on two of the four times scheduled.
-The external catheter length documented prior to medication administration was not done 34 out of 60 times
-The site assessment before and after medication administration and at least every shift (three times per day) was not done as ordered 39 out 90 times.
October 1, 2022 - October 4, 2022:
-No pre-flush or post flush were done as ordered on all days,
-The weekly dressing change scheduled for 10/4/11 was not done as ordered,
-The external catheter length documented prior to medication administration was not done and documented 5 out of 7 times
-The site assessment before and after medication administration and at least every shift (three times per day) was not done on 10/1/22, 10/3/22, and 10/4/22 as (7 out 12 times).
During an interview on 10/4/22 at 4:15 P.M., Unit Manager #3 (UM #3) said there was no documentation to support that the IV flushes and care had been done as ordered. She said she could not say if it was or was not being done by the nursing staff. However, UM #3 said that the facility no longer flushed each lumen post medication administration with 10 ml of NS followed by 5 ml of Heparin and at least every 12 hours if infusion is not continuous. She said the facility only flushed with NS. However, UM #3 agreed that the Physician's order included the Heparin.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Pharmacy Services
(Tag F0755)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and policy review, the facility failed to ensure that emergency drug kits were re-ordered when ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and policy review, the facility failed to ensure that emergency drug kits were re-ordered when medications were dispensed from the emergency kits in two out of three medication rooms observed.
Findings include:
Review of the facility's policy titled Emergency Boxes (EBox), undated, indicated but was not limited to the following:
Contents and quantities of each EBox are determined by the facility's Medical Director/Director of Nursing
- Each EBox will be locked with a tamper resistant lock indicating if the box has been opened.
- Each box that is opened needs to be returned to the pharmacy for replenishment.
- Each box contains a label with the soonest to expire medication clearly displayed on the outside of the box.
- Boxes should be reviewed monthly and returned to the pharmacy to be replaced.
- Antibiotic PO EBox
- Emergency Ebox
- Super Ebox
- Injectable Med Ebox
- IV Ebox
- Insulin Ebox
- Anaphylaxis/Glucagon/SPS Ebox
A laminated instruction of each EBox is provided by the pharmacy. They should be posted and visible to the staff in the same area as the Eboxes are kept.
EBox Usage Form:
- Nurse to use the usage form provided by the pharmacy
- Form can be used to bill the patient for the medications
- Pharmacy to replace Ebox upon receipt of the faxed form
1. On 09/28/22 at 04:28 P.M., the surveyor reviewed the [NAME] Unit medication storage room with Nurse #9 and observed the following open E-Kits:
a.) Review of the Super Kit # S1040 (e-kit) indicated the following were removed and not replaced by the pharmacy:
- Furosemide (used to treat fluid retention) 20 Milligrams tablets; five with two removed
- Metoprolol (used to treat high blood pressure) 25 MG tablets; four with three removed
- Protonix (used to treat gastroesophageal reflux disorder) 40 MG; four with one removed
- Trazodone (used to treat depression) 50 MG tablets; eight with three removed
- Albuterol inhaler (used to treat or prevent bronchospasm; one with one removed
- Sertraline (used to treat depression) 25 MG tablets; six with two removed
- Lisinopril (used to treat blood pressure) 5 MG tablets; four with one removed
- Nifedipine XL 30 MG tablets (used to treat blood pressure) 30 MG tablets; four with two removed
- Atenolol 25 MG tablets (used to treat high blood pressure and chest pain); six with one removed
The Super Kit Usage Report was not completed to ensure that the kit was replenished or replaced.
b.) Review of the Warfarin Kit #C1117 emergency (e-kit) indicated the following were removed and not replaced by the pharmacy:
- Warfarin (used to prevent blood clot) 1 MG tablets; ten with one removed
- Warfarin 5 MG tablets; ten with one removed
The Warfarin Kit Usage Report was not completed to ensure that the kit was replenished or replaced.
c.) Review of the Antibiotic Kit # AB1052 emergency (e-Kit) indicated the following were removed and not replaced by the pharmacy:
- Augmentin (used to treat infections) 875/125 MG tablets; four with one removed
- Zithromax (used to treat certain bacterial infections) 250 MG tablets; six with two removed
- Keflex (used to treat infection caused by bacteria) 250 MG capsules; six with one removed
The Antibiotic Kit Usage Report was not completed to ensure that the kit was replenished or replaced.
During an interview on 9/28/22 at 4:40 P.M., Nurse #9 said the pharmacy was not notified about the open kits on the Unit. Nurse #9 said whoever opened the kit should have filled out the form inside of the kits and faxed them to the pharmacy. She said upon receiving the faxed slips the pharmacy would have replenished or replaced the open kits.
2. On 09/28/22 at 04:45 P.M., the surveyor reviewed the [NAME] Unit medication storage room with Nurse #6 and observed the following open E-Kit:
Review of the Super Kit #S1011 emergency kit (e-kit) indicated the following were removed and not replaced by the pharmacy:
- Lasix (to treat fluid retention) 20 MG tablets; five with two used
- Risperdal (to treat depression) 1 MG tablets; four with two removed
- Albuterol Inhaler (breathing Inhaler) 1 each with one removed
- Olanzapine (antidepressant) 2.5 MG tablets; six with four removed
- Lisinopril (to treat blood pressure) 5 MG tablets; four with four removed
- Zofran (nausea) 4 MG tablets; six with one removed
The Super Kit Usage Report was not completed to ensure that the kit was replenished or replaced.
During an interview on 9/28/22 at 5:10 P.M., Nurse #6 said she was new to the facility. Nurse #6 added whoever opened the kit should have filled out the form inside of the kits and faxed them to the pharmacy. She said upon receiving the faxed slips the pharmacy would have replaced the open kits.
During an interview on 10/3/22 at 10:10 A.M., the Director of Nurses said she did not know all these kits were opened, she said whoever opened a kit should have filled out the form inside of the kit and faxed it to the pharmacy.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Medication Errors
(Tag F0758)
Could have caused harm · This affected multiple residents
Based on record review, policy review, and staff interviews, the facility failed to ensure that for six Residents (#38, #48, #4, #90, #40, and #19), out of a total sample of 19 residents, that each Re...
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Based on record review, policy review, and staff interviews, the facility failed to ensure that for six Residents (#38, #48, #4, #90, #40, and #19), out of a total sample of 19 residents, that each Resident's drug regimen was free of unnecessary drugs. Specifically, the facility failed to ensure that an appropriate diagnosis was identified, targeted behaviors/signs and symptoms were monitored to evaluate the effectiveness of psychotropic medication, and/or potential side effects were identified and monitored to promote or maintain the Residents' highest practicable mental, physical, and psychosocial well-being, per the facility policy.
Findings include:
Review of the facility's policy titled Psychotropic Medication Management, undated, indicated but was not limited to the following:
-Each resident's drug regimen will be free from unnecessary drugs
-Administration of psychoactive medications will focus on the individual needs of the resident, and will be prescribed only when necessary and clinically indicated to treat specific conditions and symptoms as diagnosed and documented
-Psychoactive medication management will include implementation of behavioral interventions, gradual dose reductions attempts, and adequate monitoring that complies with Federal and State guidelines
-Ensure that supportive diagnosis and target behaviors are documented and clearly identify the use of the medication is necessary
-Monitor target behaviors daily for Antipsychotics, Antidepressants, and Anxiolytics using a behavioral monitoring tool
-Monitor the resident's response to the medication and for any potential adverse consequences of the medication
-Care plan the psychoactive medication use with supportive diagnoses, goals of therapy, target behaviors and pharmacological and non-pharmacological approaches including behavioral interventions
-Review the care plan with IDT quarterly, annually, and as needed and revise as necessary
1. Resident #38 was admitted to the facility with diagnoses including bipolar disorder (episodes of mood swings ranging from depressive lows to manic highs), major depressive disorder, and mild cognitive impairment.
Review of the Minimum Data Set (MDS) assessment, dated 9/21/22, indicated Resident #38 exhibited mood symptoms such as little interest or pleasure in doing things, feeling down, depressed, or hopeless, trouble falling or staying asleep, feeling tired or having little energy, and trouble concentrating.
Review of the current Physician's Orders, dated 9/1/22 through 9/30/22, indicated the following:
-Bupropion (antidepressant) 100 milligrams (mg) by mouth daily for 30 days then re-evaluate
-Risperidone (antipsychotic) 1 mg by mouth nightly
Further review of the medical record failed to indicate an order to monitor targeted behaviors and signs/symptoms for the use of the antidepressant and antipsychotic medications as required, or nursing staff documentation.
During an interview on 9/29/22 at 8:08 A.M., Resident #38 said he/she felt depressed.
During an interview on 9/29/22 at 8:52 A.M., Unit Manager (UM) #1 said there was not an order to monitor for side effects or behaviors related to the medications and a behavioral monitoring sheet for Resident #38 had not been initiated since his/her readmission, but it should have been. UM #1 said Resident #38 was exhibiting behaviors including anxiety and was fearful at times when staff were providing care.
2. Resident #48 was admitted to the facility with diagnoses including major depressive disorder and altered mental status.
Review of current Physician's Orders, dated 9/1/22 through 9/30/22, indicated the following:
-Fluoxetine (Selective Serotonin Reuptake Inhibitor (SSRI) that treats depression, obsessive-compulsive disorder, bulimia nervosa, and panic disorder) capsule 40 mg, one capsule by mouth daily (2/15/22)
-Divalproex (anticonvulsant that is also used for certain psychiatric conditions) tablet 250 mg, one tablet by mouth at bedtime, take with 1000 mg for total dose 1250 mg (8/4/22)
-Divalproex 500 mg tablet, take two tablets (1000 mg) by mouth at bedtime (take with 250 mg for total dose equal to 1250 mg) (8/4/22)
-Divalproex 500mg tablet, take one tablet by mouth daily in the morning
-Gabapentin (anticonvulsant and nerve pain medication) capsule 100 mg, take one capsule by mouth three times a day (2/15/22)
The physician's orders failed to include monitoring of targeted behaviors and signs/symptoms for the use of psychotropic medications as required.
Review of the August and September Behavioral/Intervention Monthly Flow Records failed to indicate that staff consistently monitored side effects and targeted behaviors for the use of psychotropic medications as required and did not reflect Resident #48 exhibited any side effects or behaviors; documented as all zeros.
Review of Psychotherapy Progress Notes, dated 8/18/22, indicated Resident #48 admitted to feeling depressed secondary to his/her current situation.
On 9/29/22 at 12:00 P.M., the surveyor observed Resident #48 lying in bed. Resident #48 had difficulty opening his/her eyes to speak to the surveyor and did not engage. Resident #48 told the surveyor he/she just wanted to sleep.
During an interview on 9/29/22 at 2:36 P.M., the surveyor reviewed the August and September 2022 monthly flow records with UM #1 who said they were incomplete and had all zeros indicating Resident #48 did not exhibit any side effects, mood, or behaviors but said the Resident had a depressed affect and spent a lot of time in his/her room. UM #1 further said Resident #48's appetite was not great and his/her mood was better in the afternoon.
During an interview on 10/3/22 at 2:25 P.M., UM #1 said the Resident had behaviors and medication changes, so she did not understand why only zeros were documented.
During an interview on 10/3/22 at 4:08 P.M., the Director of Nursing (DON) said if the Resident had exhibited mood/behaviors or side effects they should have been documented on the Behavioral/Intervention Monthly Flow Records. The DON said documentation should be consistent daily for each shift.
5. Resident #40 was admitted to the facility in February 2022 with a diagnosis of agitation.
Review of the medical record for Resident #40 indicated a Physician's Interim Order written 8/24/22 to continue Trazodone (antianxiety medication) 25 mg as needed, twice per day for 30 days.
Review of the paper medical record included a most recent Physician's Progress Note, dated 8/17/22, one week before the physician's order.
Review of the medical record indicated a Physician's Interim Order written 9/27/22 to continue Trazodone 25 mg as needed, twice per day for 30 days.
During an interview on 9/30/22 at 2:00 P.M., Unit Manager #2 said the process for psychotropic medications ordered on an as needed basis was for the interdisciplinary team to review the medication and then the physician would renew the order. She said the rational for renewing the as needed order would be in the physician progress notes.
Review of all Physician's Progress Notes after 8/17/22 (dated 9/7/22, 9/8/22, and 9/14/22) indicated that none of the Physician's Progress Notes addressed the use of Trazodone on an as needed basis and did not include a rational for the continued use of an as needed psychotropic medication.
3. Resident #4 was admitted to the facility with diagnoses including Alzheimer's dementia, psychotic disorder, major depression, and anxiety.
Review of the September 2022 Physician's Orders indicated the following psychotropic medications:
-Risperidone (antipsychotic) 0.5 mg twice a day (9/1/22)
-Trazodone (antidepressant) 25 mg twice a day (9/1/22)
-Remeron (antidepressant) 15 mg one time a day at bedtime (9/1/22)
The Physician's orders failed to identify resident specific, targeted behaviors for the use of the psychotropic medication, and failed to include monitoring of signs/symptoms of potential adverse consequences for the use of antipsychotic and antidepressant medication as required.
Further review of the medical record failed to indicate that staff monitored signs/symptoms of potential adverse consequences for the use of psychotropic medication as required.
4. Resident #90 was admitted to the facility with diagnoses including dementia, psychotic disorder, and anxiety.
Review of the September 2022 Physician's Orders indicted the following psychotropic medications:
-Trazodone 50 mg at bedtime (12/6/21)
-Trazodone 37.5 mg twice daily (12/6/21)
The Physician's orders failed to identify resident specific, targeted behaviors for the use of the psychotropic medication, and failed to include monitoring of signs/symptoms of potential adverse consequences for the use of psychotropic medication as required.
During an interview on 9/30/22 at 10:15 A.M., the surveyor reviewed Residents #4 and #90's medical record with Unit Manager #2. She said the physician's orders did not identify targeted behaviors for their use, and facility staff do not monitor for side effects of psychotropic medications.
6. Resident #19 was admitted to the facility in June 2022 with diagnoses including depression and anxiety.
Record review on 9/28/22 indicated that Resident #19 received psychotropic medication daily.
Review of the October 2022 Physician's Orders included but was not limited to:
-Trazodone (antidepressant) 150 mg daily
-Cymbalta (antidepressant) 60 mg daily
The Physician's orders failed to include monitoring of potential side effects of the medication as required.
Review of the medical record failed to indicate that potential side effects for the use of Trazodone and Cymbalta were monitored.
During an interview on 10/5/22 at 10:30 A.M., Unit Manager #3 said the facility was not monitoring for potential side effects of the psychoactive medications.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0761
(Tag F0761)
Could have caused harm · This affected multiple residents
Based on observation, interview, document review, and policy review, the facility failed to ensure all medications used in the facility were safely stored in accordance with currently accepted profess...
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Based on observation, interview, document review, and policy review, the facility failed to ensure all medications used in the facility were safely stored in accordance with currently accepted professional principles. Specifically, the facility failed to maintain a temperature log for one out of one medication refrigerators to preserve the integrity of the vaccines stored.
Findings include:
Review of the facility's policy titled Medication Storage in the Facility, dated 2017, indicated but was not limited to the following:
-Medications requiring refrigeration are kept in a refrigerator at temperatures between 2 degrees Celsius (C) (36 degrees Fahrenheit (F)) and 8 degrees C (46 degrees F) with a thermometer to allow temperature monitoring
-The facility should maintain a temperature log in the storage area to record temperatures
-The facility should check the refrigerator or freezer in which vaccines are stored, at least two times a day, per Centers for Disease Control and Prevention (CDC) guidelines
On 10/5/22 at 8:22 A.M., the surveyor reviewed the vaccine medication refrigerator located in the Infection Preventionist's office with the Director of Nursing (DON). Stored inside were nine boxes (10 pre-filled syringes each) of Afluria Quadrivalent influenza vaccine and six boxes (10 pre-filled syringes each) of Fluzone High Dose Quadrivalent influenza vaccine. The Vaccine Refrigerator Temperature Log was not maintained after 9/26/22 where, for two days, temperatures were only checked once a day and, for seven days, temperatures were not checked at all.
During an interview on 10/5/22 at 8:23 A.M., the DON said the Infection Preventionist was responsible for checking temperatures twice a day, but he had been out. The DON said there was no process to ensure temperatures were being checked in his absence and could not be sure of the integrity of the vaccines stored if proper temperatures could not be verified.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0887
(Tag F0887)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, policy review, and interview, the facility failed to ensure all residents were offered the COVID-19 vacc...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, policy review, and interview, the facility failed to ensure all residents were offered the COVID-19 vaccine unless immunization was medically contraindicated, or the resident had already been immunized for 38 of 92 residents currently residing in house.
Findings include:
Review of the facility's policy titled COVID-19 Resident Vaccination Policy, revised 3/16/22, indicated but was not limited to the following:
-It is the policy of this facility to minimize the risk of acquiring, transmitting, or experiencing complications from COVID-19 (SARS-CoV-2) by offering our residents immunization to COVID-19
-It is the policy of this facility, in collaboration with the medical director, to have an immunization program against COVID-19 disease in accordance with national standards of practice
-COVID-19 vaccinations and boosters will be offered as per Centers for Disease Control and Prevention (CDC) and/or U.S. Food and Drug Administration (FDA) guidelines unless such immunization is medically contraindicated, the resident has already been immunized during this time period, or resident/responsible party refuses to receive the vaccine
-COVID-19 vaccine may also be administered in the facility by the Vaccine Coordinator or designee
Review of Centers for Disease Control and Prevention (CDC) guidance titled Stay Up to Date with your Covid-19 Vaccines Including Boosters, updated September 2022, indicated but was not limited to the following:
When are you up to date (UTD)?
-You are up to date with your COVID-19 vaccines if you have completed a COVID-19 vaccine primary series and received the most recent booster recommended for you by CDC.
On 9/28/22 the surveyor cross referenced the resident COVID-19 Immunization report provided by the Infection Preventionist (IP) and the facility Immunization Report provided by the Director of Nursing (DON) which indicated, of the 92 residents residing in house, 43 residents were currently not up to date with their COVID-19 immunizations. Of the 43 residents, five residents had refused.
During an interview on 9/28/22 at 2:15 P.M., the DON said the IP was out, so she was filling in for him. She said the IP started in October 2021 and was not sure how much training he had. The DON said the facility did not have an effective immunization program against COVID-19 disease as the vaccines that they did have were expired and the booster vaccination percentage rate for residents was very low.
During an interview on 9/29/22 at 4:15 P.M., the surveyor reviewed the COVID-19 Immunization reports with the DON. The DON said she was not sure what the definition of UTD meant and was not sure what residents were not UTD in the facility, particularly on the [NAME] Unit which was the affected unit during the current COVID-19 outbreak. She said the facility had a COVID-19 vaccination clinic in August, but it was only offered to some of the residents on the [NAME] unit and was the only one she knew of that had been conducted this year.
During an interview on 10/3/22 at 4:57 P.M., the DON said the latest guidance said any resident who had not received either the Moderna or Pfizer-BioNTech bivalent boosters were considered not UTD. She said she spoke to the IP who said he could not speak to why so many residents were not UTD with their COVID-19 vaccines prior to the newly released 9/8/22 CDC guidance and told the DON he was on a medication cart almost daily. The IP said he did not know of any other dates this year that the vaccine was offered to residents besides in August.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0888
(Tag F0888)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, document review, and policy review, the facility failed to
1) Develop a COVID-19 vaccination p...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, document review, and policy review, the facility failed to
1) Develop a COVID-19 vaccination policy for staff that included all the required components that were current and based on national standards;
2) Ensure additional precautions, intended to mitigate the transmission and spread of COVID-19, were implemented for all staff who were not fully vaccinated for COVID-19; and
3) Track and document the COVID-19 vaccination status for two of eight staff members sampled.
Findings include:
Review of the facility's policy titled COVID-19 Employee Vaccination Policy, revised April 2022, indicated but was not limited to the following:
-The facility will require and maintain for each individual staff member proof of vaccination status or the individual's declination statement and maintain a central system to track the vaccination status of all personnel. Individual proof of current vaccination may include, but is not limited to, copy of CDC Vaccination Card, copy of vaccination from their electronic health record, or copy of Immunization Information System (MIIS) Vaccination record
Review of the facility's policy titled COVID-19 Employee Exemption Policy, dated April 2022, indicated but was not limited to the following:
-Staff members who have a medical or religious exemption must not provide direct care for residents who are confirmed or suspected to be infected with COVID-19, are immunocompromised or are not fully vaccinated
-Staff members who are not up to date with vaccinations must adhere to the CMS requirements applicable to infection control and must adhere to all testing requirements as determined by CMS or their specific Department of Health guidance
-Staff members who have a medical or religious exemption will be required to quarantine per CDC guidance after a close contact or exposure to someone with COVID-19
1. During an interview on 9/28/22 at 2:15 P.M., the Director of Nursing (DON) said the Infection Preventionist (IP) was out, so she was filling in. She said the IP was responsible for the staff vaccination effort.
Review of the Centers for Medicare and Medicaid Services (CMS) Memorandum titled, Guidance for the Interim Final Rule - Medicare and Medicaid Programs; Omnibus COVID-19 Health Care Staff Vaccination, Long Term Care and Skilled Nursing Facility Attachment A, revised January 2022, indicated, but was not limited to the following:
-The facility must develop and implement policies and procedures to ensure that all staff are fully vaccinated for COVID-19
-Regardless of clinical responsibility or resident contact, the policies and procedures must apply to facility employees, licensed practitioners, students, trainees, volunteers, and individuals who provide any care, treatment, or other services for the facility and/or its residents under contract or by other arrangement
-The policies and procedures must include, at a minimum, the following components:
viii. A process for ensuring that all documentation, which confirm recognized clinical contraindications to COVID-19 vaccines, and which supports staff requests for medical exemptions from vaccination, has been signed and dated by a licensed practitioner and for further ensuring that such documentation contains:
a. All information specifying which of the authorized COVID-19 vaccines are clinically contraindicated for the staff member to receive and the recognized clinical reasons for the contraindication: and
b. A statement by the authenticating practitioner recommending that the staff member be exempted from the facility's COVID-19 vaccination requirements for staff based on the recognized clinical contraindications
ix. A process for ensuring the tracking and secure documentation of the vaccination status of staff for whom COVID-19 vaccination must be temporarily delayed
x. Contingency plan for staff who are not fully vaccinated for COVID-19
Review of the facility's COVID-19 vaccination policies and procedures failed to include all the required components per the January 2022 CMS QSO memorandum including sections viii, ix, and x.
During an interview on 10/3/22 at 5:54 P.M., the DON said the COVID-19 health care staff vaccination policies and procedures should be updated annually and as needed for all new guidance. She said she was not aware of all the elements that were supposed to be included in the facility's staff vaccination policy.
2. Review of the COVID-19 Staff Vaccination Status for Providers matrix provided to the surveyor by the DON on 9/29/22 indicated that, of 145 total staff members, three were granted medical exemptions and 12 were granted non-medical exemptions.
During an interview on 9/28/22 at 2:15 P.M., the DON said unvaccinated staff had to wear an N95 facemask and test more often, but it may have changed and would need to review the guidance and get back to the surveyor.
During an observation with interview on 9/29/22 at 8:27 A.M., the surveyor observed Staff #2 in a resident care area wearing a surgical facemask. Staff #2 said he/she had an exemption but said no one had discussed with him/her additional precautions to be implemented and did not do anything differently than anyone else.
During an observation with interview on 9/29/22 at 8:52 A.M. and 10/3/22 at 9:57 A.M., the surveyor observed Staff #3 working on a nursing unit wearing a surgical facemask. Staff #3 said he/she was assigned to a medication cart and was assigned to three residents that day who were unvaccinated as well as residents who were not up to date with their COVID-19 vaccinations (did not complete a COVID-19 vaccine primary series and/or received the most recent booster recommended by CDC). Staff #3 said he/she had an exemption but would have to provide direct care to the residents if needed. Staff #3 said he/she was not advised of any additional precautions to take other than not being assigned to COVID-19 positive residents.
During an observation with interview on 10/3/22 at 12:24 P.M., the surveyor observed Staff #4 working on a nursing unit wearing a surgical facemask. Staff #4 said he/she floated to all three units and was assigned to care for all types of residents including those who were unvaccinated, potentially immunocompromised, or not up to date. Staff #4 said he/she had worked on the [NAME] Unit which was the affected unit during the facility's current COVID-19 outbreak and was not advised of any additional precautions to take because of his/her granted exemption.
During an observation with interview on 10/3/22 at 12:29 P.M., the surveyor observed Staff #5 working on a nursing unit wearing a surgical facemask. Staff #5 said he/she floated to all three units and was assigned to care for all types of residents including those who were unvaccinated, potentially immunocompromised, or not up to date. Staff #5 said he/she had worked on the [NAME] Unit which was the affected unit during the facility's current COVID-19 outbreak and was not advised of any additional precautions to take because of his/her granted exemption.
During an observation with interview on 10/3/22 at 12:39 P.M., the surveyor observed Staff #6 working on a nursing unit wearing a surgical facemask. Staff #6 said he/she did not like providing direct care to residents who were unvaccinated but sometimes had to. Staff #6 said he/she was not advised of any additional precautions to take because of his/her granted exemption.
During an interview on 10/3/22 at 4:47 P.M., the DON said additional precautions only included not working in rooms with residents who were COVID-19 positive but said maybe that should also include residents who were not up to date with their COVID-19 vaccines. The DON was not sure if unvaccinated staff were being tested more frequently and said there was no clear plan to implement additional precautions.
3. Review of the staff COVID-19 Immunization log provided to the surveyor by the DON on 9/29/22 indicated the following:
Staff #7
-completed COVID-19 primary vaccination series on 5/21/21
-no booster doses documented as being given
During an interview on 10/3/21 at 5:21 P.M., the DON was unable to provide the surveyor with documentation of screening, eligibility, or education for Staff #7 to receive the COVID-19 vaccine. The DON said she did not have proof of vaccination status on file for Staff #7 to determine where the vaccines were administered or if the staff member had received any booster doses.
Staff #8
-contracted staff
-no vaccination data
During an interview on 10/3/22 at 5:32 P.M., the DON said she was not familiar with the contracted staff member and did not have proof of vaccination status on file. The surveyor reviewed the 9/27/22 COVID-19 testing log with the DON which indicated Staff #8 was listed as contract staff and worked on 9/27/22. The DON said she should have had the documentation per facility policy but did not.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0919
(Tag F0919)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, the facility failed to maintain a functioning call light system on 1 of 3 Resident units.
Fi...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, the facility failed to maintain a functioning call light system on 1 of 3 Resident units.
Findings include:
On 9/30/22 beginning at 8:50 A.M., on the [NAME] Unit, the surveyor observed several call lights to be lit up above the doors of residents' rooms, and several staff members were observed to not be responding to the call lights.
On 9/30/22 at 9:20 A.M., the surveyor arrived at the nurses' station and observed that the call bell system was disconnected. The surveyor observed multiple call lights lit and staff were observed to not be responding to the call lights. The surveyor connected the call bell system and could hear the audible alert; the alert could be heard at the nursing desk and throughout the unit hallways.
On 9/30/22 at 9:35 A.M., Nurse #10 said the call bell system does not work and could not remember when she last heard the call bell working on the unit. Nurse #10 said if the receiver of the system is engaged, the sound cannot be stopped and continually sounds. Nurse #10 and a Certified Nursing Assistant (CNA) said the staff try to keep an eye on the call lights above the Resident's doors and answer them accordingly. The Nurse said sometimes the Maintenance Director can get it working properly but it never lasts. The Nurse did not know of any interventions put in place when the system was and is not functioning properly.
During an interview on 9/30/22 at 9:50 A.M., the Maintenance Director said there was nothing he could do about the call light system. He said room [ROOM NUMBER] triggered the system to malfunction and shutting the light off in the room did not stop the constant alert sound at the nurses' station. He said he would contact a vendor to look at it but did not know when they would be available to repair the system.
During an interview on 9/30/22 at 10:10 A.M., Unit Manager #3 said she would get the Resident in room [ROOM NUMBER] a call bell.
On 9/30/22 at 10:10 A.M., the surveyor observed the following residents' rooms' call lights were not visible from the nurses' station: Rooms 200, 201, 202, 203, 216, 218, 219, 221 and 223. The residents in these rooms were not offered a call bell until surveyor intervention on 9/30/22 at 4:30 P.M.
Review of the [NAME] Unit Maintenance Log indicated from 6/17/22 through 9/28/22, a request to fix the call lights was written into the logbook.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0726
(Tag F0726)
Could have caused harm · This affected most or all residents
Based on interview, review of employee education files, and document review, the facility failed to ensure nursing staff received the appropriate competencies and skill sets for 5 out of 5 licensed nu...
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Based on interview, review of employee education files, and document review, the facility failed to ensure nursing staff received the appropriate competencies and skill sets for 5 out of 5 licensed nurses.
Findings include:
Review of the Facility Assessment Tool indicated the following:
-the facility will actively secure resources to ensure that employees are properly trained and have competency
-licensed nurse competencies include: medication administration, IV (intravenous care), tracheostomy care/suctioning, colostomy care, feeding tubes, wound care, etc.
Review of the Resident Census and Condition (from CMS-672) provided by the facility on 9/27/22 indicated the following:
-8 residents with indwelling or external catheter
-5 residents with pressure ulcers
-1 resident with IV therapy
-1 resident with ostomy care
-1 resident with tube feeding
Review of the Competency Schedule, provided by the Staff Development Coordinator on 10/4/22 indicated the following competencies, including but not limited to, should be conducted annually for licensed staff:
-cardiovascular assessment
-choking and abdominal thrust
-clean dressing change
-equipment use: infusion pump, feeding pump
-IV dressing change
-syringe safety
-tracheostomy care
-suctioning
-Foley catheter insertion
During an interview on 10/4/22 at 4:00 P.M., the surveyor reviewed the trachea /stoma care of Resident #77 with Unit Manager #3. The Unit Manager said that she did not provide care for the Resident's trachea because she thought the Resident took care of it him/herself. She said she had not trained at the facility for the Resident's trachea care needs and would have to go talk with the Resident to find out how to care for it.
Review of the following licensed nursing employee education files indicated:
1. Nurse #2 was hired in September 2022; there were no competencies included in her education folder.
2. Unit Manager #1 was hired in 2015. Unit Manager #1 had taken an IV education course in September 2022, there were no other yearly competencies in the employee education folder.
3. Unit Manager #3 was hired in March 2022; there were no competencies included in the education folder.
4. Nurse #8 was hired in August 2022; there were no competencies included in her education folder.
5. Nurse #3 had last completed competencies in 2018.
During an interview on 10/4/22 at 3:30 P.M., the Staff Development Coordinator said Unit Manager #1 and Nurse #3 should have completed annual competencies and she was not sure when the last time competencies were completed at the facility. She further said the competencies for Unit Manager #3 should have been located in her employee education folder, from when she was hired in March 2022. She said Nurse #2 and Nurse #8 had both come off of orientation in September 2022 and their preceptor was responsible for ensuring competencies were completed. She said she had no record if other newly hired licensed nurses had completed competencies with their preceptors.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0802
(Tag F0802)
Could have caused harm · This affected most or all residents
Based on observations and interviews, the facility failed to provide sufficient support personnel to carry out the functions of the food and nutrition services safely and effectively in the kitchen.
F...
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Based on observations and interviews, the facility failed to provide sufficient support personnel to carry out the functions of the food and nutrition services safely and effectively in the kitchen.
Findings include:
On 9/27/22 at 8:45 A.M. the surveyor observed the Food Service Director (FSD) doing dishes. During an interview at the time of the observation, the FSD said she had one cook, a diet aide and herself to feed and prepare food for the 90 plus residents. The FSD said the kitchen was short staffed.
On 9/27/22 at 8:45 A.M., the surveyor observed Styrofoam containers in the meal trucks. The FSD said the kitchen had been serving meals in the Styrofoam containers because of dishwasher problems, but more because of short staffing. She said short staffing also prevented the kitchen staff from opening the dining room for Resident dining.
During an interview on 9/27/22 at 9:25 A.M., Resident #147 complained that all his/her meals were served in to go containers. Resident #147 said the food was cold and he/she felt that it was a constant picnic.
On 9/27/22 during the noon meal, the surveyors observed that all resident meals were served in Styrofoam containers on 3 of 3 resident units.
Review of the Resident Council minutes for the past three months, Residents reported concerns about eating out of Styrofoam is getting old and food not being hot. Other concerns were not receiving a menu or correct meals and cold food. The minutes indicated the Residents had requested to go back to using the dining room and wanting to start a Food Committee.
On 9/28/22 at 11:00 A.M., the surveyor held a group meeting with 17 residents in attendance. The residents said that food service (palatability and temperature of the foods) from the kitchen was a problem.
Review of the kitchen staffing for the week ending 10/1/22 indicated the FSD worked 7 days a week and four of the shifts began at either 5:00 A.M. or 6:00 A.M. and ended at 7:30 P.M. The schedule indicated there was one cook scheduled every day except on one day when no cook was scheduled from 5:00 A.M. - 1:00 P.M. The schedule indicated that the facility had several consistent dishwashers at night, but diet aides were limited to sometimes one or two per day. The FSD said there are frequent call outs, and she usually has to cook and serve the meals.
Review of the Facility Assessment, updated 9/19/22, indicated the facility had 1 Dietitian, 1 FSD and 10 food and nutrition service staff. The Assessment indicated the turnover in the kitchen/other is 9.2% and to other disciplines License staff at 2.8 - 3/5% yearly. The Facility Assessment did not indicate a plan to ensure the kitchen staff met the threshold outlined in the assessment.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0804
(Tag F0804)
Could have caused harm · This affected most or all residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and observations, facility failed to ensure that food was palatable and served at an appetizing temperature....
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and observations, facility failed to ensure that food was palatable and served at an appetizing temperature.
Findings include:
On 9/27/22 at 9:45 A.M., Resident #147 said his/her meals were served in a Styrofoam container and the food was often served late, was cold, and was not always palatable.
Review of the Resident Council minutes for August and September 2022 indicated Resident concerns about food temperatures and palatability of foods. The Resident Council requested a Food Committee.
On 9/28/22 at 11:00 A. M., the surveyor held a Group Meeting with 17 residents in attendance. The residents reported concerns of having their meals served in Styrofoam containers, cold food, terrible coffee, and the meats were not recognizable. The Residents said that they had requested a Food Committee and that it was supposed to start.
During an interview on 9/27/22 at 8:45 A.M., the Food Supervisor (FS) said she was unaware of any food complaints. The FS said she did not have a Food Committee and received no reported concerns from the Resident Council meetings. She said she uses hot plates to keep food hot and has been using Styrofoam containers due to dishwasher issues and low staffing.
On 9/29/22 at 10:20 A.M., the FS said again she was unaware of any food complaints about temperature and palatability. The FS said she only takes temperatures of the food at the point of service and does not follow through with the meal delivery to make sure the temperatures are palatable at the point of service. The FS said she would occasionally put a plate on the kitchen table and at the end of service take a temperature of the food. The FS was unable to state when she had last done this and if it was while using the Styrofoam containers.
A test tray was conducted on 10/4/22 for the lunch time meal on the [NAME] Unit with the following results:
At 11:42 A.M., the first meal truck arrived on the [NAME] Unit.
At 11:56 A.M. the second meal truck arrived on the [NAME] Unit.
At 12:05 P.M. staff members started passing trays from the first meal truck.
At 12:35 P.M. tray pass was incomplete for first meal truck and the staff had not started passing the trays from the second meal truck.
At 12:35 P.M. temperatures of food on a test tray from the first food truck were recorded by the surveyor and Unit Manager (UM) #3, and validated the residents' food concerns:
- Noodles 95 degrees Fahrenheit (F) - tasted cold and flavorless
- Brussel sprouts 102 degrees F - tasted slightly warm
- Swedish meatballs 101 degrees F - tasted slightly warm and very salty
- Milk 42 degrees F - warm
- Coffee 139 degrees F - warm with a bitter flavor
During an interview on 10/4/22 at 12:35 P.M., UM #3 said she agreed that the food temperatures were not appetizing, and the food palatability was not great. UM #3 said the trays were not passed out in a timely fashion due to the number of staff available and this resulted in cold food. The Administrator arrived during the test and was informed of the temperature results.
During an interview on 10/5/22 at 8:20 A.M., the FS said she was unaware the test tray indicated the meals were not served at appetizing temperatures. She said she was unaware there was a problem.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0865
(Tag F0865)
Could have caused harm · This affected most or all residents
Based on policy review and interview, the facility failed to develop a Quality Assurance and Performance Improvement (QAPI) plan that described their approach to improving the quality of life, care, a...
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Based on policy review and interview, the facility failed to develop a Quality Assurance and Performance Improvement (QAPI) plan that described their approach to improving the quality of life, care, and services delivered to residents in the facility.
Findings include:
A review of the facility's QAPI policy, dated 4/2015, indicated the facility's QAPI plan serves to accomplish the following:
-Address all systems of care management practices.
-Always assure clinical care, quality of life and resident choice.
-Ensure safety and high quality with all clinical interventions.
-Emphasize autonomy and choice in daily life for residents/agents.
-Utilize the best available evidence to define and measure goals.
-Have a written QAPI Plan adhering to these principles.
-Develop a culture that involves leadership seeking from facility staff, and their families and/or representatives.
-Assure adequate resources exist to conduct QAPI efforts.
-Designate one or more persons to be accountable for QAPI.
-Developing leadership and facility-wide training on QAPI, ensuring staff time, equipment and technical training as needed.
-Foster a culture where QAPI is a priority by ensuring that policies are developed to sustain QAPI despite changes in personal and turnover.
-Setting expectations around safety, quality, rights, choice, and respect by balancing safety with resident-centered rights and choice.
-Ensure staff accountability.
-Create an atmosphere where staff is comfortable identifying and reporting quality problems as well as opportunities for improvement.
-Identify and solve problems using a team-centered approach that includes input from all departments and stakeholders (resident, families, physicians, staff, Ombudsman, and regulatory agencies) involved; and
-Enhance interdepartmental communication and teamwork by having leaders participate in cross-department Performance Improvement Project activities when analyzing problems, identifying solutions, and assessing outcomes.
During an interview on 10/5/22 at 2:19 P.M. with the Administrator and the Director of Nursing (DON), the DON said since she started at the facility in June 2022 and had attended one QAPI meeting with the former Administrator on 7/29/22. Although the DON had attended a meeting, she was unable to determine which policy and procedures were in place for the QAPI process.
The Administrator said he was new to the facility, and he had not attended a QAPI meeting since starting in August 2022. The Administrator was not able to locate previous QAPI meeting minutes and prospective QAPI plans for surveyor review.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected most or all residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, document review, and policy review, the facility failed to establish and maintain an infectio...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, document review, and policy review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment to help prevent the development and potential transmission of communicable diseases and infections. Specifically, the facility failed to:
1. Ensure infection control policies and procedures were reviewed at least annually;
2. Document staff with signs/symptoms (e.g., fever) of COVID-19 according to their surveillance plan;
3. Implement return to work criteria for healthcare personnel (HCP) with SARS-CoV-2 infection;
4. Implement appropriate use of personal protective equipment (PPE);
5. Post proper signage for residents on transmission-based precautions (TBP) to ensure staff were aware of precaution needs;
6. Ensure adequate drainage from a washing machine while in operation in the laundry room; and
7. Ensure staff performed proper handwashing and the proper cleaning of glucometer equipment after use.
Findings include:
1. Review of the facility's policy titled Infection Prevention Program, revised January 2020, indicated but was not limited to the following:
-The Infection Control Program will be monitored on a regular basis
-Infection control policies will be reviewed annually and signed off by the Medical Director
-Maintain the monthly infection to record each resident infection
-Analyze trends and clusters of infection, and any increase in the rate of infection in a timely manner
-Prevent and control outbreaks and cross contamination using transmission-based precautions in addition to standard precautions
During an interview on 9/29/22 at 3:34 P.M., the surveyor reviewed infection control policies and procedures with Consulting Staff #2 who said she not sure when they were last reviewed. Consulting Staff #2 said there should have been a document that was dated and signed by the Administrator, Director of Nursing (DON), and the Medical Director which would have indicated when the last annual review of its Infection Prevention Control Program (IPCP) was but there was not.
During an interview on 10/3/22 at 5:54 P.M., the DON said there was no documentation of the last annual review but said there should have been. The DON said, We have not had the meetings; we should.
2. During an entrance interview on 9/27/22 at 9:01 A.M., the Administrator said the facility was experiencing a COVID-19 outbreak after a staff member had tested positive on 9/18/22 and said the [NAME] unit was an affected unit requiring enhanced precautions.
During an interview on 9/28/22 at 3:31 P.M., the surveyor reviewed the staff COVID-19 Positive Cases document provided by the Infection Preventionist (IP) on 9/27/22 with the DON who said she was filling in for the IP and said the current outbreak began on 9/2/22 and was as follows:
Staff #9 - COVID-19 positive on 9/2/22 (symptomatic)
Staff #10 - COVID-19 positive on 9/10/22 (unsure if symptomatic)
Staff #11 - COVID-19 positive on 9/11/22 (unsure if symptomatic
Staff #12 - COVID-19 positive on 9/11/22 (unsure if symptomatic)
Staff #13 - COVID-19 positive on 9/14/22 (symptomatic)
Staff #14 - COVID-19 positive on 9/18/22 (asymptomatic)
Staff #15 - COVID-19 positive on 9/28/22 (symptomatic)
Throughout survey, 9/27/22 to 10/5/22, the surveyor requested COVID-19 documentation of residents and staff with signs/symptoms (e.g., fever) of COVID-19 according to their surveillance plan. The facility was unable to provide the requested documentation to identify the number of residents or staff that had a fever, respiratory signs/symptoms, or other signs/symptoms related to COVID-19.
During an interview on 10/3/22 at 4:54 P.M., the DON said she could not locate the resident and staff COVID-19 line listings but said they should have been done.
3. Review of the Centers for Disease Control and Prevention (CDC) guidance titled Interim Guidance for Managing Healthcare Personnel (HCP) with SARS-CoV-2 Infection or Exposure to SARS-CoV-2, updated September 2022, indicated but was not limited to the following:
Return to work criteria for HCP with SARS-CoV-2 infection
HCP with mild to moderate illness who are not moderately to severely immunocompromised could return to work after the following criteria have been met:
-At least 7 days have passed since symptoms first appeared if a negative viral test is obtained within 48 hours prior to returning to work (or 10 days if testing is not performed or if a positive test at day 5-7), and
-At least 24 hours have passed since last fever without the use of fever-reducing medications, and
-Symptoms (e.g., cough, shortness of breath) have improved.
*Either a NAAT (molecular) or antigen test may be used. If using an antigen test, HCP should have a negative test obtained on day 5 and again 48 hours later
HCP who were asymptomatic throughout their infection and are not moderately to severely immunocompromised could return to work after the following criteria have been met:
-At least 7 days have passed since the date of their first positive viral test if a negative viral test* is obtained within 48 hours prior to returning to work (or 10 days if testing is not performed or if a positive test at day 5-7).
*Either a NAAT (molecular) or antigen test may be used. If using an antigen test, HCP should have a negative test obtained on day 5 and again 48 hours later
Test-based strategy
HCP who are symptomatic could return to work after the following criteria are met:
-Resolution of fever without the use of fever-reducing medications, and
-Improvement in symptoms (e.g., cough, shortness of breath), and
-Results are negative from at least two consecutive respiratory specimens collected 48 hours apart (total of two negative specimens) tested using an antigen test or NAAT.
HCP who are not symptomatic could return to work after the following criteria are met:
-Results are negative from at least two consecutive respiratory specimens collected 48 hours apart (total of two negative specimens) tested using an antigen test or NAAT.
Review of the staff COVID-19 Positive cases document provided by the IP on 9/27/22 indicated Staff #9 tested positive for COVID-19 on 9/2/22. Review of Staff #9's work punch card indicated he/she worked on 9/5/22, three days after testing positive for COVID-19. Staff #9 also worked on 9/6/22, 9/7/22, and 9/12/22. Review of the BinaxNOW Testing Logs failed to indicate documentation of a COVID-19 negative test prior to or after returning to work.
During an interview on 9/28/22 at 3:31 P.M., the DON said facility documentation indicated Staff #9 tested positive for COVID-19 on 9/2/22 and worked three days later. The DON said she did not have documentation of a negative test result for Staff #9 and said Staff #9 did not follow facility policy for work exclusion. The DON said he/she should have provided a negative test on day 5 with symptoms resolved prior to returning to work to help prevent the potential transmission of COVID-19.
Review of the staff COVID-19 Positive cases document provided by the IP on 9/27/22 indicated Staff #13 tested positive for COVID-19 on 9/14/22. Review of Staff #13's work punch card indicated he/she returned to work on 9/20/22, six days later. Review of the BinaxNOW Testing Logs failed to indicate documentation of a COVID-19 negative test prior to returning to work.
During an interview on 10/3/22 at 4:42 P.M., the DON was unable to provide documentation of a negative COVID-19 test prior to Staff #13 returning to work. The DON said Staff #13 may have tested at home but could not be sure and said there should have been documentation of a negative test result prior to Staff #13 returning to work.
4. Review of Centers for Disease Control and Prevention (CDC) guidance titled, Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic, updated September 2022, indicated but was not limited to the following:
Implement Source Control Measures
-Source control refers to use of respirators or well-fitting facemasks or cloth masks to cover a person's mouth and nose to prevent spread of respiratory secretions when they are breathing, talking, sneezing, or coughing.
-Source control options for healthcare personnel include a well-fitting facemask.
During an observation with interview on 9/27/22 at 2:08 P.M., the surveyor observed Staff #18 standing at the [NAME] Unit nurses' station with her face mask below her chin sucking on a lollipop. Residents and other staff members were located nearby. Staff #18 said she should not have done that.
During an interview on 10/3/22 at 5:54 A.M., the DON said Staff #18 should have been wearing a facemask covering her mouth and nose and not eating in a clinical area.
5. During an interview on 9/28/22 at 2:15 P.M., the DON said the facility followed the most updated Centers for Disease Control and Prevention (CDC), Centers for Medicare and Medicaid Services (CMS), and the Massachusetts Department of Public Health (DPH) guidance in regard to testing protocols and infection control.
Review of the Department of Public Health (DPH) Memorandum, dated June 2022, indicated but was not limited to the following:
Resident Type:
-Residents who are not up to date with COVID-19 vaccine or recovered from COVID-9 in the last 90 days when there are resident, or staff cases identified within the last 14 days on their affected unit
Recommended Sign for Resident Room:
-Enhanced personal protective equipment (PPE) sign
Review of the facility's policy titled COVID-19 New Facility Outbreak for MA, revised March 2022, indicated but was not limited to the following:
-Continue to wear PPE for all high contact care for residents that are not up to date with COVID vaccines or not recovered in the last 90 days on units with COVID cases in the last 14 days (please use MA Enhanced Barrier Precautions sign)
During an entrance interview on 9/27/22 at 9:01 A.M., the Administrator said the facility was currently experiencing a COVID-19 outbreak and said the [NAME] unit was identified as an affected unit requiring enhanced PPE precautions.
During an interview on 9/28/22 at 3:31 P.M., the DON said the [NAME] Unit was identified as an affected unit on 9/10/22 after a staff member who had worked on the unit tested positive for COVID-19. The DON said the facility had not gone 14 days yet without a new staff positive case. No residents had tested positive.
During a tour of the [NAME] Unit on 9/27/22 and 9/28/22 at 10:25 A.M., the surveyor did not observe proper signage posted for residents not up to date with their COVID-19 vaccinations on the [NAME] Unit to specify the PPE required and ensure staff were aware of the need for precautions.
During an interview on 9/28/22 at 4:46 P.M., Consulting Staff #3 said they were working on a list of residents who were not up to date on the [NAME] Unit to post enhanced PPE precaution signs. Consulting Staff #3 said the signs should have been posted as soon as the unit was identified as an affected unit on 9/10/22 but were not.
During an interview on 9/29/22 at 4:15 P.M., the DON said she was uncertain of the current guidance and definition of up to date and would have to get back to the surveyor.
During an interview on 10/3/22 at 4:57 P.M., the DON said [NAME] residents who had not had the new bivalent COVID-19 booster should have had enhanced PPE signs posted as soon as the unit was identified as an affected unit. The DON said she did not believe they knew to do that. The DON said staff should have been wearing a N95 face mask, goggles, gloves, and gown for high contact care of residents who were not up to date.
6. During an observation with interview on 10/3/22 at 1:33 P.M., the surveyor reviewed the laundry room with Laundry Personnel #1. While the washer was in operation, the surveyor observed a large amount of water coming up from the floor drain flooding a large perimeter of the laundry room floor then get pulled back down into the drain. Four clean rolling clothing racks were observed in the immediate area. Laundry Personnel #1 said the washer was not working properly and called Maintenance Staff #1. Maintenance Staff #1 entered the laundry area and said the washer was emptying faster than what could flow out into the drain, and it had been happening for a couple of months now. He said he did not know what the plan was to fix it but said he had not discussed it with anyone.
During an interview on 10/3/22 at 3:11 P.M., the surveyor brought the concern forward to the Administrator who said he was not made aware and would need to have the drain serviced.7. The Center for Disease Control (CDC) recommended practices for preventing bloodborne pathogen transmission during blood glucose monitoring, included, but was not limited to:
- Fingerstick devices should never be used for more than one person
- Whenever possible, blood glucose meters should not be shared. If they must be shared, the device should be cleaned and disinfected after every use, per manufacturer's instructions. If the manufacturer does not specify how the device should be cleaned and disinfected, then it should not be shared.
a. On 09/28/22 at 4:13 P.M., the surveyor observed Nurse #9 came out of a resident's room after obtaining a blood sugar on Resident #197. Nurse #9 removed her gloves, touched the dirty glucometer with bare hands, did not clean it after use, and placed it in the little tray that contained alcohol pad and lancets, on top of the medication cart.
During an interview on 9/28/22 at 4:25 P.M., Nurse #9 said she failed to clean the glucometer.
b. On 09/28/22 at 4:59 P.M., the surveyor observed Nurse #4 obtaining a blood sugar on Resident #197, Nurse #4 removed her gloves touched the dirty glucometer with bare hands, did not clean it, and stored it in the case that contained alcohol pads and lancets. Nurse #4 did not sanitize or wash her hands.
During an interview on 9/28/22 at 5:15 P.M., Nurse #4 said she did not realize what she did. Nurse #4 said she failed to clean the glucometer after using it.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Antibiotic Stewardship
(Tag F0881)
Could have caused harm · This affected most or all residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, policy review, and interview, the facility failed to develop an antibiotic stewardship program that prom...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, policy review, and interview, the facility failed to develop an antibiotic stewardship program that promoted appropriate use of antibiotics and included a system to monitor antibiotic use. Specifically, the facility failed:
1. To adequately track infections to review for trends and review antibiotic therapy usage to provide feedback, and
2. For Resident #40, to ensure the criteria for the initiation of antibiotics, per the facility's policy and infection control requirements, was followed.
Findings include:
Review of the facility's policy titled Antibiotic Stewardship, undated, indicated but was not limited to the following:
It is the policy of this facility to treat only symptomatic infections meeting criteria, and to promote antibiotic stewardship to reduce inappropriate antimicrobial use, improve patient care outcomes and reduce possible consequences of antimicrobial use.
-The facility will establish an antimicrobial stewardship team (AMS) dedicated to improving antimicrobial use
-All infections will be tracked by the Infection Preventionist (IP) or designee and reviewed for trends
-Recommendations to improve antibiotic therapy usage will be reviewed by the facility and shared with MS/APRN
-Audits will be done randomly to ensure antibiotic orders are complete and are reassessed
-The AMS team will review antibiotic therapy usage and provide feedback at the quarterly medical staff meeting
When symptoms of infection are documented, the following measures will be implemented:
-notify MD/APRN and responsible party
-symptoms will be reviewed with the MD/APRN and further testing will be obtained as ordered
-if a urine culture is ordered antibiotic therapy will not be initiated until after the culture results have been obtained unless otherwise ordered
-test results will be reviewed with the MD/APRN
-All orders will include dose, duration, and indication for the antibiotic
-the duration of the antibiotic therapy will be defined and/or regularly reviewed by the prescriber
Harms from antibiotic overuse are significant for the frail and older adults receiving care in nursing homes. These harms include risk of serious diarrheal infections from Clostridium difficile, increased adverse drug events and drug interactions, and colonization and/or infections with antibiotic resistive organisms. They also can lead to an increase in the development of antibiotic resistance within the facility and burden of excess cost to the resistant, the facility and community (CDC-Core Elements of Antibiotic Stewardship for Nursing Homes).
Review of the facility's policy titled Infection Prevention Program, revised January 2020, indicated but was not limited to the following:
-Promote antibiotic stewardship and ensure residents receive the right antibiotic, at the right dose, at the right time, and for the right duration
-Maintain the monthly infection reports by unit to record each resident infection
1. During an interview on 9/28/22 at 2:15 P.M., the Director of Nursing (DON) said the Infection Preventionist (IP) was out so she was filling in. She said the IP was responsible for tracking all infections to review trends. The DON further said to determine if an antibiotic is indicated or if adjustments need to be made, the facility protocol is to review clinical signs and symptoms and lab reports.
Review of the September 2022 Monthly Resident Infection Reports failed to indicate complete documentation including the site of infection, signs and symptoms, date of onset, type of infection, or chest Xray/culture results and date (if applicable) for six out of six residents on the [NAME] Unit and for seven out of seven residents residing on the [NAME] Unit. The surveyor was unable to locate 2022 Antibiotic Usage Audit Tools.
During an interview on 10/3/22 at 5:54 P.M, the surveyor reviewed the monthly reports with the DON who said the expectation was to complete the line listing documentation with all the required data to determine trends, clusters, similar symptoms, and appropriate use of antibiotics and by the standard of what an infection was. She said this expectation was not met. She said although the facility has an antimicrobial stewardship team consisting of herself, the IP, Assistant Director of Nursing (ADON), and staff development, they have never had a meeting that she knew of to review antibiotic therapy usage and provide feedback. She said random audits should have been done to ensure orders were complete and the prescribed antibiotics were necessary.
2. Resident #40 was admitted to the facility in February 2022 with a diagnosis of urinary retention and had a urinary catheter.
Review of the Nursing Progress Notes indicated on 9/3/22 Resident #40 had increased behaviors and a urinary dip test was positive for a possible infection. The positive dip was called in to the physician who ordered a urine culture and sensitivity, which would indicate which antibiotic should be administered. On 9/3/22, the physician ordered Macrobid 100 mg (milligrams) twice per day for five days and noted to re-evaluate when the results came in.
Review of the nursing progress notes, and telephone orders indicated on 9/6/22 the urine culture and sensitivity results were obtained, and the antibiotic was changed to Keflex 500 mg twice per day for seven days.
During an interview on 10/3/22 at 4:54 P.M., the DON said antibiotics should not be started prior to obtaining culture results and, if so, then the physician should be questioned regarding the rationale.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0885
(Tag F0885)
Could have caused harm · This affected most or all residents
Based on interview, policy review, and record reviews, the facility failed to ensure resident representatives/families were notified of each new COVID-19 positive staff member or resident case by 5:00...
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Based on interview, policy review, and record reviews, the facility failed to ensure resident representatives/families were notified of each new COVID-19 positive staff member or resident case by 5:00 P.M. the following day.
Findings include:
Review of the facility's policy titled COVID-19 New Facility Outbreak for MA, revised 3/23/22, indicated but was not limited to the following:
-Legal representatives, families, residents, and staff should be notified by 5 pm the following day after a new positive case (staff or resident) with documentation of notification
Review of Centers for Disease Control and Prevention (CDC) guidance titled Interim Infection Prevention and Control Recommendations to Prevent SARS-CoV-2 Spread in Nursing Homes, updated February 2022, indicated but was not limited to the following:
-Notify residents and families promptly about identification of SARS-CoV-2 in the facility and maintain ongoing frequent communication with residents and families with updates on the situation and facility actions
During an interview on 9/27/22 at 9:01 A.M., the Infection Preventionist (IP) said there was a current outbreak of COVID-19 at the facility after a Certified Nursing Assistant (CNA) had tested positive.
Review of the facility cases indicated the following:
9/2/22 - 1 staff member (CNA) tested positive for COVID-19
9/10/22 - 1 staff member (Nurse) tested positive for COVID-19
9/11/22 - 1 staff member (Nurse) tested positive for COVID-19
9/11/22 - 1 staff member (Dietary Aide) tested positive for COVID-19
9/14/22 - 1 staff member (Nurse) tested positive for COVID-19
9/18/22 - 1 staff member (CNA) tested positive for COVID-19
9/28/22 - 1 staff member (Nurse) tested positive for COVID-19
On 9/27/22 the surveyor was provided with a letter from the IP to family members regarding the COVID-19 outbreak. The letter included the following notification to families:
9/19/22 - the facility had one positive staff member who had direct resident care responsibilities on 9/18/22 with zero positive residents
During an interview on 9/28/22 at 2:15 P.M., the Director of Nursing (DON) said the IP was primarily responsible for family and resident notifications for each COVID-19 staff or resident case, but he was out. The DON said the Administrator was also responsible.
On 9/29/22 the surveyor was provided with a letter from the Administrator to family members regarding the COVID-19 outbreak. The letter included the following notification to families:
9/29/22 - the facility had one positive staff member with zero positive residents
The facility was unable to provide to the surveyor documentation of notification letters from the positive staff cases identified on 9/2/22, 9/10/22, 9/11/22, and 9/14/22.
Review of two out of three sampled medical records on 10/5/22 indicated the following:
Resident #1 - No documentation of resident/representative notification of the facility's COVID-19 status for positive staff cases on 9/2/22, 9/10/22, 9/11/22, and 9/14/22
Resident #196 - No documentation of resident/representative notification of the facility's COVID-19 status for positive staff cases on 9/18/22
During an interview on 9/29/22 at 9:58 A.M., the DON said she spoke to the IP who said the only notification letters available had already been provided to the surveyor.
During an interview on 9/29/22 at 3:34 P.M., Consulting Staff #2 said the two letters provided to the surveyor were the only notifications the facility had documentation of as being sent during the current outbreak.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0886
(Tag F0886)
Could have caused harm · This affected most or all residents
Based on observation, interview, policy review, and document review, the facility failed to ensure staff conducted testing and specimen collection in a manner that was consistent with current standard...
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Based on observation, interview, policy review, and document review, the facility failed to ensure staff conducted testing and specimen collection in a manner that was consistent with current standards of practice for conducting COVID-19 tests. Specifically, the facility failed to:
1. Ensure testing of staff whose COVID-19 vaccination status was not up to date was based on the level of community transmission according to the recommended frequency;
2. Ensure documentation of COVID-19 testing was completed including the results of each staff test, and
3. Perform BinaxNOW COVID-19 Ag Card testing (rapid testing) correctly for five out of five staff members observed.
Findings include:
1. During an interview on 9/27/22 at 1:15 P.M., the Infection Preventionist (IP) said the facility used BinaxNOW rapid testing and all staff, including contract staff, were being tracked for compliance with COVID-19 testing protocols by utilizing an alphabetical spreadsheet. The IP said he was responsible for oversight and checked the spreadsheet three times a day to ensure staff were testing as required, but said it was really based on an honor system.
During an interview on 9/28/22 at 2:15 P.M., the Director of Nursing (DON) said the facility followed the most updated Centers for Disease Control and Prevention (CDC), Centers for Medicare and Medicaid Services (CMS), and the Massachusetts Department of Public Health (DPH) guidance in regard to testing protocols and infection control.
Review of Centers for Medicare and Medicaid Services (CMS) Memorandum titled Interim Final Rule (IFC), CMS-3401-IFC, Additional Policy and Regulatory Revisions in Response to the COVID-19 Public Health Emergency related to Long-Term Care (LTC) Facility Testing Requirements, revised 3/10/22, indicated but was not limited to the following:
Routine Testing of Staff
-Routine testing of staff who are not up to date, should be based on the extent of the virus in the community
Routine Testing Intervals by County COVID-19 Level of Community
High (red) - twice a week
Review of County Level Timeseries Data for Barnstable County indicated the following:
8/1/22 through 9/25/22 - high level of community transmission
One of three staff sampled for purposes of determining compliance with surveillance testing indicated the following:
-Staff #10 (Unvaccinated, granted an exemption)
BinaxNOW Surveillance Testing Logs:
Week of Aug. 1 - 7, 2022
-No documentation of BinaxNOW testing (worked 8/2/22, 8/7/22)
Week of Aug. 8-14, 2022
-No documentation of BinaxNOW testing (worked 8/11/22, 8/13/22)
Week of Aug. 15-21, 2022
-No documentation of BinaxNOW testing (worked 8/16/22)
Week of Aug. 22-29, 2022
-No documentation of BinaxNOW testing (worked 8/24/22, 8/28/22, 8/29/22)
Week of Aug. 29-Sept. 4, 2022
-No documentation of BinaxNOW testing (worked 8/29/22, 9/1/22, 9/4/22)
Week of Sept. 5-10, 2022
-No documentation of BinaxNOW testing (worked 9/5/22, 9/7/22, 9/9/22)
-Tested positive for COVID-19 on 9/10/22
During an interview on 10/3/22 at 5:11 P.M., the DON said Staff #10 should have tested twice each week for surveillance based on high county level transmission rates but did not.
2. During an entrance interview on 9/27/22 at 9:01 A.M., the Administrator said the facility was currently experiencing a COVID-19 outbreak.
Review of the week of September 26-October 1, 2022 BinaxNOW testing log on 9/27/22 at 1:15 P.M. indicated the following:
Staff #8 - failed to document 9/27/22 BinaxNOW testing result
Staff #17 - failed to document 9/27/22 BinaxNOW testing result
During an interview on 9/27/22 at 1:15 P.M., the IP said staff should wait 15 minutes for their testing card to process then immediately document the results before arriving to their specified locations within the facility. The IP said if the results were not documented then he could not be sure if the staff members had a negative or positive result which was of concern as the facility was in the middle of a COVID-19 outbreak.
Review of the week of September 26-October 1, 2022 BinaxNOW testing log on 9/28/22 at 11:11 A.M. indicated the following:
-Staff #7 - failed to document 9/28/22 BinaxNOW testing result
-Staff #16 - failed to document 9/28/22 BinaxNOW testing result
3. Review of Centers for Disease Control and Prevention (CDC) guidance titled Specimen Collection, updated May 2022, indicated but was not limited to the following:
-Proper specimen collection is the most important step in the laboratory diagnosis of infectious diseases. A specimen that is not collected correctly may lead to false or inconclusive test results.
-Follow the manufacturer's instructions for specimen collection.
The BinaxNOW COVID-19 Ag Card is a type of test called an antigen test. Antigen tests are designed to detect proteins from the virus that causes Covid-19 in respiratory specimens, for example nasal swabs. This is considered a form of rapid testing as the results are displayed in 15 minutes.
Review of the BinaxNOW COVID-19 Ag Card product insert, revised April 2021, instructions for completing the test included but was not limited to the following:
Precautions
-Wear appropriate personal protective equipment (PPE) and gloves when running each test and handling specimens.
-Inadequate or inappropriate sample collection, storage, and transport may yield false positive or false negative results.
-Proper sample collection, storage and transport are essential for correct results.
Test Procedure
-Read result window 15 minutes after closing the card. In order to ensure proper test performance, it is important to read the result promptly at 15 minutes, and not before. Results should not be read after 30 minutes.
Note: False negative results can occur if test results are read before 15 minutes.
Specimen Collection and Handling
-Test specimens immediately after collection for optimal test performance. Inadequate specimen collection or improper sample handling/storage/transport may yield erroneous results.
a. During an observation with interview on 9/29/22 at 6:50 A.M., the surveyor observed Rehabilitation Services Staff #1 perform BinaxNOW antigen testing in the designated testing room near the lobby. After Rehabilitation Services Staff #1 closed and securely sealed the test card, she set it down on the table without placing a protective barrier underneath. 16 other testing cards were observed on the same table without protective barriers underneath including 10 cards that were dated 9/28/22, the day before. Rehabilitation Services Staff #1 said the IP checks the cards and writes down the test results before placing them in the pink plastic container on the right side of the table. She then left the testing area without waiting for her results.
On 9/29/22 at 7:38 A.M., Rehabilitation Services Staff #1's test results were not documented on the testing log, 48 minutes after testing.
b. During an observation with interview on 9/29/22 at 6:55 A.M., the surveyor observed Nurse #10 perform BinaxNOW antigen testing in the designated testing room near the lobby. Nurse #10 did not perform hand hygiene prior to performing the test, applied six drops of the reagent very quickly and said it might be too much, did not sanitize the table after testing, walked around the lobby with her testing card in hand then returned to the testing room and placed the card on the tray table without a protective barrier underneath. Nurse #10 said she did not know what the procedure for testing was so took her card to the lobby. Nurse #10 said she should have performed hand hygiene prior to specimen collection and should have disinfected the tray table after use. Nurse #10 said she was not sure if she used too much reagent because it came out so fast but did not repeat the test. Nurse #10 left after seven minutes but not before asking the next staff member in line to document the results for her so she could go to the nursing unit.
During an interview on 9/29/22 at 10:37 A.M., Nurse #10 said she should not have been carrying her testing card around with her and said it should have been lying flat on a surface. She said usually she just leaves it on the table. Nurse #10 said she should have waited 15 minutes to ensure her results were negative and document them herself prior to arriving on a unit. She said she had not had any education on testing at the facility for over two years.
c. During an observation with interview on 9/29/22 at 7:08 A.M., the surveyor observed Nurse #11 perform BinaxNOW antigen testing in the designated testing room near the lobby. Nurse #11 said she was not sure of the process and a lot of times she did this quick so she could head to the nursing unit. She said she did not necessarily wait the 15 minutes and that the IP would check the results. She said as soon as she would see the control line she would leave and not wait for the results. Nurse #11 did not wait 15 minutes for her result and went to the unit.
On 9/29/22 at 7:35 A.M., Nurse #11 returned to the testing area, 20 minutes after placing her card down on the table to check the results and documented a negative result on the testing log.
During an interview on 9/29/22 at 10:34 A.M., Nurse #11 said she did not know she had to wait the full 15 minutes for results prior to arriving on the unit but said she was aware the results may not be valid after 15 minutes.
d. During an observation with interview on 9/29/22 at 7:15 A.M., the surveyor observed Staff #1 perform BinaxNOW antigen testing in the designated testing room near the lobby. The reagent bottle was nearly touching the top hole of the swab well. Staff #1 did not perform hand hygiene after performing the test and did not disinfect the table after use. Staff #1 placed her testing card on the table then exited the testing room and lobby area without waiting 15 minutes.
During an interview on 9/29/22 at 10:56 A.M., Staff #1 said she was not properly trained on how to conduct BinaxNOW testing.
e. During an observation with interview on 9/29/22 at 7:18 A.M., the surveyor observed Certified Nursing Assistant (CNA) #13 perform BinaxNOW antigen testing in the designated testing room near the lobby. CNA #13 touched the top hole of the swab well for every six drops applied, swabbed only her right nostril, held the testing card vertically after it was closed and sealed then said the blue line is gone now, but did not repeat the test. CNA #13 placed the testing card on top of the table without a protective barrier underneath and said, I'll check in an hour. CNA #13 exited the testing area without first performing hand hygiene then went to the nursing unit.
During an interview on 9/29/22 at 10:43 A.M., CNA #13 said she had worked 34 shifts at the facility, and no one had observed her or instructed her on how to properly perform BinaxNOW testing. CNA #13 said she did not wait the 15 minutes to document her results and her name was not even listed on the staff testing spreadsheet. She said she would go now, three hours and 25 minutes later to check her results and said it should still be good. CNA #13 said she should not have touched the top hole with the reagent bottle and said it was okay to not lay the testing card flat afterwards. She said she should have performed hand hygiene when done and should have waited for her results prior to arriving on the unit.
During an interview on 9/29/22 at 11:00 A.M., the surveyor reviewed the staff testing observations with the DON who said the IP was responsible for oversight of the COVID-19 testing and said it was not being done the way she would like it. The DON said there was no consistency and lacked direct oversight. She was unable to provide the surveyor with BinaxNOW staff competencies or performance monitoring upon request and said she could not find any. The DON said education should have been provided that was the most up to date information. She said the expectation was not met by any of the staff for BinaxNOW antigen testing and said the current process was ineffective and a concern that could potentially affect the whole house.
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
- • No fines on record. Clean compliance history, better than most Massachusetts facilities.
- • 27% annual turnover. Excellent stability, 21 points below Massachusetts's 48% average. Staff who stay learn residents' needs.
Concerns
- • Multiple safety concerns identified: 3 harm violation(s). Review inspection reports carefully.
- • 56 deficiencies on record, including 3 serious (caused harm) violations. Ask about corrective actions taken.
- • Grade F (38/100). Below average facility with significant concerns.
Bottom line: Trust Score of 38/100 indicates significant concerns. Thoroughly evaluate alternatives.
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About This Facility
What is Cape Heritage Rehabilitation & Health's CMS Rating?
CMS assigns CAPE HERITAGE REHABILITATION & HEALTH CARE CENTER an overall rating of 2 out of 5 stars, which is considered below average nationally. Within Massachusetts, this rating places the facility higher than 0% of the state's 100 nursing homes. A rating at this level reflects concerns identified through health inspections, staffing assessments, or quality measures that families should carefully consider.
How is Cape Heritage Rehabilitation & Health Staffed?
CMS rates CAPE HERITAGE REHABILITATION & HEALTH CARE CENTER's staffing level at 4 out of 5 stars, which is above average compared to other nursing homes. Staff turnover is 27%, compared to the Massachusetts average of 46%. This relatively stable workforce can support continuity of care.
What Have Inspectors Found at Cape Heritage Rehabilitation & Health?
State health inspectors documented 56 deficiencies at CAPE HERITAGE REHABILITATION & HEALTH CARE CENTER during 2022 to 2025. These included: 3 that caused actual resident harm, 52 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 Cape Heritage Rehabilitation & Health?
CAPE HERITAGE REHABILITATION & HEALTH CARE CENTER is owned by a for-profit company. For-profit facilities operate as businesses with obligations to shareholders or private owners. The facility is operated by ATHENA HEALTHCARE SYSTEMS, a chain that manages multiple nursing homes. With 123 certified beds and approximately 111 residents (about 90% occupancy), it is a mid-sized facility located in SANDWICH, Massachusetts.
How Does Cape Heritage Rehabilitation & Health Compare to Other Massachusetts Nursing Homes?
Compared to the 100 nursing homes in Massachusetts, CAPE HERITAGE REHABILITATION & HEALTH CARE CENTER's overall rating (2 stars) is below the state average of 2.9, staff turnover (27%) is significantly lower than the state average of 46%, and health inspection rating (2 stars) is below the national benchmark.
What Should Families Ask When Visiting Cape Heritage Rehabilitation & Health?
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 Cape Heritage Rehabilitation & Health Safe?
Based on CMS inspection data, CAPE HERITAGE REHABILITATION & HEALTH CARE CENTER has a clean safety record: no substantiated abuse findings (meaning no confirmed cases of resident harm), no Immediate Jeopardy citations (the most serious violation level indicating risk of serious injury or death), and is not on the Special Focus Facility watch list (a federal program monitoring the lowest-performing 1% of nursing homes). The facility has a 2-star overall rating and ranks #100 of 100 nursing homes in Massachusetts. While no facility is perfect, families should still ask about staff-to-resident ratios and recent inspection results during their visit.
Do Nurses at Cape Heritage Rehabilitation & Health Stick Around?
Staff at CAPE HERITAGE REHABILITATION & HEALTH CARE CENTER tend to stick around. With a turnover rate of 27%, the facility is 19 percentage points below the Massachusetts average of 46%. Low turnover is a positive sign. It means caregivers have time to learn each resident's needs, medications, and personal preferences. Consistent staff also notice subtle changes in a resident's condition more quickly. Registered Nurse turnover is also low at 19%, meaning experienced RNs are available to handle complex medical needs.
Was Cape Heritage Rehabilitation & Health Ever Fined?
CAPE HERITAGE REHABILITATION & HEALTH CARE CENTER has no federal fines on record. CMS issues fines when nursing homes fail to meet care standards or don't correct problems found during inspections. The absence of fines suggests the facility has either maintained compliance or corrected any issues before penalties were assessed. This is a positive indicator, though families should still review recent inspection reports for the full picture.
Is Cape Heritage Rehabilitation & Health on Any Federal Watch List?
CAPE HERITAGE REHABILITATION & HEALTH CARE CENTER is not on any federal watch list. The most significant is the Special Focus Facility (SFF) program, which identifies the bottom 1% of nursing homes nationally based on persistent, serious quality problems. Not being on this list means the facility has avoided the pattern of deficiencies that triggers enhanced federal oversight. This is a positive indicator, though families should still review the facility's inspection history directly.