WILLOW BROOK REHABILITATION AND HEALTHCARE CENTER
For profit - Corporation
142 Beds
MARQUIS HEALTH SERVICES
Data: November 2025
Trust Grade
40/100
#336 of 338 in MA
Last Inspection: September 2024
Within standard 12-15 month inspection cycle. Federal law requires annual inspections.
Overview
Willow Brook Rehabilitation and Healthcare Center has a Trust Grade of D, indicating below-average quality and some concerning issues. It ranks #336 out of 338 facilities in Massachusetts, placing it in the bottom half of nursing homes in the state, and #72 out of 72 in Middlesex County, meaning there are no better local options. The facility is showing improvement, having decreased from 19 issues in 2024 to just 1 in 2025, which is a positive sign. However, staffing poses a significant challenge, with a poor rating of 1 out of 5 stars and a high turnover rate of 52%, compared to the state average of 39%, which means that residents may not receive consistent care from familiar staff. While the facility has not incurred any fines, which is a good sign of compliance, there are notable concerns regarding staff training. Recent inspections revealed that none of the sampled staff had received the required annual abuse training, and five Certified Nursing Assistants had not completed the mandatory 12 hours of in-service training in the past two years. Additionally, there were issues with maintaining proper catheter care, as the facility failed to ensure that the catheter tubing was kept off the floor. Overall, families should weigh the facility's improvements against its staffing challenges and training deficiencies before making a decision.
- Trust Score
- D
- In Massachusetts
- #336/338
- Safety Record
- Low Risk
- Inspections
- Getting Better
- Staff Stability ⚠ Watch
- 52% turnover. Above average. Higher turnover means staff may not know residents' routines.
- Penalties ✓ Good
- No fines on record. Clean compliance history, better than most Massachusetts facilities.
- Skilled Nurses ○ Average
- Each resident gets 39 minutes of Registered Nurse (RN) attention daily — about average for Massachusetts. RNs are the most trained staff who monitor for health changes.
- Violations ⚠ Watch
- 58 deficiencies on record. Higher than average. Multiple issues found across inspections.
40/100
Bottom 1%
No red flags
19 → 1 violations
★☆☆☆☆
1.0
Overall Rating
★☆☆☆☆
1.0
Staff Levels
★★★☆☆
3.0
Care Quality
★★☆☆☆
2.0
Inspection Score
↔
Stable
2024: 19 issues
2025: 1 issues
The Good
-
Full Sprinkler Coverage · Fire safety systems throughout facility
-
No fines on record
Facility shows strength in fire safety.
The Bad
1-Star Overall Rating
Below Massachusetts average (2.9)
Significant quality concerns identified by CMS
Staff Turnover: 52%
Near Massachusetts avg (46%)
Higher turnover may affect care consistency
Chain: MARQUIS HEALTH SERVICES
Part of a multi-facility chain
Ask about local staffing decisions and management
The Ugly 58 deficiencies on record
Feb 2025
1 deficiency
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Comprehensive Care Plan
(Tag F0656)
Could have caused harm · This affected 1 resident
Based on records reviewed and interviews for one of three sampled residents (Resident #1) whose comprehensive care plan indicated he/she required assistance of two staff members for transfers, the Fac...
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Based on records reviewed and interviews for one of three sampled residents (Resident #1) whose comprehensive care plan indicated he/she required assistance of two staff members for transfers, the Facility failed to ensure staff consistently implemented and followed interventions in his/her care plan, when on 11/17/25, during the evening shift, Certified Nurse Aide (CNA #1), transferred Resident #1 back to bed by physically lifting him/her from his/her wheelchair and putting him/her in bed, without another staff member present to assist with the transfer.
Findings include:
Review of the Facility's policy, titled Care Plan, Comprehensive Person-Centered, dated as revised in March 2022, indicated a comprehensive, person-centered care plan that includes measurable objectives and timetable to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. Each resident's comprehensive person-centered care plan will be consistent with the resident's rights to participate in the development and implementation of his or her plan of care, including the right to receive the services and /or items included in the plan of care.
Resident #1 was admitted to the Facility in October 2020, diagnoses included Alzheimer's, Failure to Thrive, Atrial Fibrillation and Aphasia (language disorder that affects a person's ability to communicate effectively).
Resident #1 was transitioned to Hospice Services (to be provided in the facility) in September 2024, related to end of life care needs.
Review of Resident #1's Quarterly Minimum Data Set (MDS) Assessment, dated 09/06/24, indicated he/she was severely cognitively impaired with a score of 3 out 15 on his/her Brief Interview for Mental Status (BIMS) Assessment (0-7 suggests severe cognitive impairment, 8-12 suggests moderately impaired cognition, and 12-15 suggests a resident is cognitively intact).
The MDS also indicated that Resident #1 was dependent on staff for bathing, dressing, hygiene, transfers, bed mobility, incontinent care and was non-ambulatory.
Review of Resident #1's Activities of Daily Living (ADL) Care Plan, reviewed and renewed with his/her September 2024 MDS, indicated he/she required assistance of two persons with ADL's. The Care plan indicated that Resident #1 required physical assistance of two for all transfers.
Review of Resident #1's Care Card (used by the CNAs to determine individual resident care needs) indicated he/she required assistance of two staff members for transfers.
Review of the Report submitted by the Facility via the Health Care Facility Reporting System (HCFRS), dated 11/18/24, indicated that Resident #1 sustained a bump above his/her left eye, bruising to his/her left eye and had left shoulder redness of unknown origin.
Review of the Facility's Root Cause Analysis (RCA) document, undated, indicated CNA #1 did not review Resident #1's Care Card, transferred him/her by herself, and did not follow the Care Plan on 11/17/24, when she transferred him/her to bed.
During a telephone interview on 03/3/24 at 1:54 P.M., Certified Nurse Aide (CNA) #1 said that she had worked at the Facility since November of 2024 and has been a CNA for 18 years. CNA #1 said she worked on 11/17/24, during the 3:00 P.M. through 11:00 P.M. shift and was assigned to provide care to Resident #1. CNA #1 said at some point during the shift (exact time unknown) she transferred Resident #1 back to bed, and had the assistance of CNA #2 with transferring Resident #1 to his/her bed.
During a telephone interview on 03/04/25 at 9:14 A.M., Certified Nurse Aide (CNA) #2 said that he had worked at the Facility since November of 2024 and worked on 11/17/24, during the 3:00 P.M. through 11:00 P.M. shift. CNA #2 said that he had not provided care for Resident #1 and did not assist CNA #1 with his/her care or transfers.
Although CNA # 1 said that she had an assist by CNA #2 with the transfer into bed of Resident #1, this was inconsistent with staff statements obtained by the facility related to their RCA into how Resident #1 sustained an injury of unknown origin, as well as staff interviews during this survey.
During an interview on 02/27/25 at 2:15 P.M., the Director of Nurses (DON) said the Facility began an investigation after Resident #1 was noted to have a bruise on his/her left eye of unknown origin on 11/17/24 by the oncoming staff on the 11:00 P.M. to 7:00 A.M. shift. The DON said that during her investigation she became aware that CNA #1, had transferred Resident #1 on 11/17/24 without assistance of another staff member, as indicated in his/her care plan.
The DON said during the investigation that CNA #1 told her she had transferred Resident #1 by herself and that she performed the transfer by reaching her arms around Resident #1's body, like she was hugging him/her, stood Resident #1 up, and pivoted him/her to a sitting position on the bed. The DON said it is her expectation that staff follow the plan of care and in this case, it was not followed.
Sept 2024
18 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Resident Rights
(Tag F0550)
Could have caused harm · This affected 1 resident
Based on observations, interviews and record review, the facility failed to ensure a dignified existence was maintained for two Residents (#471 and #117) out of 27 total sampled residents. Specificall...
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Based on observations, interviews and record review, the facility failed to ensure a dignified existence was maintained for two Residents (#471 and #117) out of 27 total sampled residents. Specifically,
1.) For Resident #471, the facility failed to provide a privacy bag for a urinary catheter drainage bag.
2.) For Resident #117, the facility failed to provide a privacy bag for a urinary catheter drainage bag.
Findings include:
Review of the facility policy titled Resident Rights, revised January 2022, indicated:
- Federal and state law guarantee certain basic rights to all residents of this facility. These rights include the resident's right to privacy and confidentiality.
1.) Resident #471 was admitted to the facility in September 2024 with diagnoses including benign prostatic hyperplasia with lower urinary tract symptoms, brain cancer, and hemiplegia affecting the right dominant side.
Review of Resident #471's medical record indicated there was no Minimum Data Set (MDS) data available.
Review of Resident #471's assessment titled Brief Interview for Mental Status (BIMS) Evaluation, dated 9/16/24, indicated Resident #471 was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) score of 14 out of 15.
Review of Resident #471's active physician's orders, initiated 9/13/24, indicated:
- Privacy bag for foley cath (urinary catheter) drainage bag, every shift.
On 9/17/24 at 7:54 A.M., the surveyor observed Resident #471 sitting in a wheelchair. His/her urinary catheter drainage bag was observed clipped to the bottom of the wheelchair. There was no privacy bag on the urinary catheter drainage bag and clear, yellow urine was observed. Resident #471 said staff do not offer any type of privacy cover for the urinary catheter drainage bag but would be interested in having one.
The following additional observations were made by the surveyor:
- On 9/17/24 at 10:12 A.M., Resident #471 was observed talking with staff in the hallway with a urinary catheter drainage bag clipped to the front arm rest of his/her wheelchair. There was no privacy bag on the urinary catheter drainage bag and clear, yellow urine was observed.
- On 9/17/24 at 2:16 P.M., Resident #471 was observed in bed with a urinary catheter drainage bag attached to the bedframe. The urinary catheter drainage bag did not have a privacy bag, and the clear, yellow urine was visible from the hallway.
Review of Resident #471's plan of care, dated 9/13/24, failed to indicate rejection of care or refusal of privacy bag for his/her urinary catheter drainage bag.
During an interview on 9/19/24 at 10:50 A.M., Certified Nurse Assistant (CNA) #3 said urinary catheter drainage bags should always have a privacy bag.
During an interview on 9/19/24 at 12:33 P.M., Nurse #3 said urinary catheter drainage bags should always have a privacy bag because the urine should not be visible to others.
During an interview on 9/19/24 at 9:43 A.M., The Director of Nursing (DON) said urinary catheter drainage bags should always have a privacy bag, even when in bed, because the urine should not be visible to others.
2.) Resident #117 was admitted to the facility in June 2024 with diagnoses including Parkinson's disease and benign prostatic hyperplasia with lower urinary tract symptoms.
Review of the Minimum Data Set (MDS) assessment, dated 7/31/24, indicated Resident #117 was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) score of 13 out of 15. This MDS also indicated Resident #117 had an indwelling urinary catheter.
Review of Resident #117's active physician's orders, initiated 8/5/24, indicated:
- Privacy bag for suprapubic cath (urinary catheter) drainage bag, every shift.
On 9/17/24 at 7:54 A.M., 9/17/24 at 8:19 A.M., and 09/17/24 10:02 AM, the surveyor observed Resident #117 in bed with a urinary catheter drainage bag attached to the bedframe. The urinary catheter drainage bag did not have a privacy bag, and the clear, yellow urine was visible from the hallway.
During an interview on 9/17/24 at 7:56 A.M., Resident #117 said staff do not offer any type of privacy cover for the urinary catheter drainage bag but would be interested in having one.
Review of Resident #117's plan of care, last revised 8/28/24, failed to indicate rejection of care or refusal of privacy bag for his/her urinary catheter drainage bag.
During an interview on 9/19/24 at 10:50 A.M., Certified Nurse Assistant (CNA) #3 said urinary catheter drainage bags should always have a privacy bag.
During an interview on 9/19/24 at 12:33 P.M., Nurse #3 said urinary catheter drainage bags should always have a privacy bag because the urine should not be visible to others.
During an interview on 9/19/24 at 9:43 A.M., The Director of Nursing (DON) said urinary catheter drainage bags should always have a privacy bag, even when in bed, because the urine should not be visible to others.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0554
(Tag F0554)
Could have caused harm · This affected 1 resident
Based on observation, interviews and record review, the facility failed to ensure the interdisciplinary team was involved in determining whether the self-administration of medications was clinically a...
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Based on observation, interviews and record review, the facility failed to ensure the interdisciplinary team was involved in determining whether the self-administration of medications was clinically appropriate for one Resident (#78), out of 27 total sampled residents. Specifically, the facility failed to assess if it was clinically appropriate for Resident #78 to self-administer an injection prior to the Resident self-administering the injection.
Findings include:
Review of the facility policy titled Self Administration of Medications, revised January 2023, indicated:
- Criteria must be met to determine if a resident is both mentally and physically capable of self-administering medication.
- The staff and practitioner will assess each resident's mental and physical abilities to determine whether self-administering medications is clinically appropriate for the resident upon request.
- In addition to general evaluation of decision-making capacity, the nurse will perform a more specific skill assessment, this can be accomplished on paper or through the EHR (electronic health record) system.
- The EMAR (electronic medication administration record)/MAR (medication administration record) must identify meds that are self-administered.
- If residents are determined to be able to self-administer Resident/Representative will complete a consent for Self-Administration.
Resident #78 was admitted to the facility in October 2023 with diagnoses including diabetes and hyperlipidemia.
Review of the most recent Minimum Data Set (MDS) assessment, dated 8/6/24, indicated Resident #78 was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) score of 15 out of 15.
Review of Resident #78's physician order, dated 7/31/24, indicated:
- Trulicity Subcutaneous Solution Pen-Injector 1.5 ml (milliliter)/0.5 mg (milligram), which is an injectable medication used to treat diabetes, Inject 0.5 milliliter subcutaneously one time a day every Wed (Wednesday).
Review of Resident #78's medical record failed to indicate any assessment of the Resident's mental and physical abilities by the staff, nurse, or practitioner to determine whether self-administering the trulicity injection was clinically appropriate.
Review of Resident #78's physician's orders and September 2024 Medication Administration record (MAR) failed to indicate the trulicity injection may be self-administered.
Review of medical record failed to indicate a consent for self-administration was completed.
On 9/18/24 at 9:38 A.M., the surveyor observed Nurse #2 prepare and administer medications to Resident #78 with the Assistant Director of Nursing (ADON) present. Nurse #2 said Resident #78 liked to self-administer the trulicity injection. Nurse #2 handed the injection to the Resident who injected the medication into his/her abdomen. Resident #78 said he/she always self-administered the trulicity injection.
Review of Resident #78's nursing progress note, dated 9/18/24, indicated:
- Self administered injection w/ (with) good technique and little instruction.
During an interview on 9/18/24 at 9:50 A.M., the Assistant Director of Nursing (ADON) said any resident who self-administers medication needs to be assessed to determine if it is clinically appropriate and a consent must be obtained prior to self-administration. The surveyor and ADON reviewed the medical record together and were unable to locate that a self-administration of medication assessment was completed or that a consent for medication self-administration was completed by the Resident/Resident Representative. The ADON said these should have been completed but were not.
During an interview on 9/19/24 09:43 A.M., the Director of Nursing (DON) said Resident #78 should have had an assessment completed to determine if self-administration of medication was clinically appropriate and consent for medication self-administration should have been obtained prior to the Resident self-administering the trulicity injection.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Comprehensive Care Plan
(Tag F0656)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to develop and implement a comprehensive person-centered care plan for ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to develop and implement a comprehensive person-centered care plan for one Resident (#48) out of a total sample of 27 residents. Specifically, the facility failed to a.) implement weekly weights as care planned, and b.) develop a care plan for Resident #48's history of suicide attempts.
Findings Include:
Review of the facility policy, titled Care Plan - Comprehensive, indicated, but was not limited to, the following:
- A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident.
- Facility utilizes and electronic health record for resident care plans (sic.).
- The comprehensive, person-centered care plan will:
o Describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being.
o Describe services that would otherwise be provided for the above, but are not provided due to the resident exercising his or her rights to refuse.
o Incorporate identified problem areas.
o Incorporate risk factors associated with identified problems.
o Reflect currently recognized standards of practice for problem areas and conditions.
- Identifying problem areas and their causes, and developing interventions that are targeted and meaningful to the resident, are the endpoint of an interdisciplinary process.
- Assessments of residents are ongoing and care plans are revised as information about the residents and the residents conditions change.
Review of the facility policy, titled Weights Assessment and Interventions, revised May 2019, indicated, but was not limited to, the following:
- Monthly weights will be obtained each month or as ordered by the physician.
- Weights will be recorded in the medical record (electronic medical record where available) for each resident.
Resident #48 was admitted to the facility in March 2024 with diagnoses of heart failure (inability of the heart to maintain adequate blood circulation), renal insufficiency, anxiety disorder, depression, and post-traumatic stress disorder.
Review of the Minimum Data Set (MDS) assessment dated [DATE], indicated that Resident #48 scored a 12 out of 15 on the Brief Interview for Mental Status (BIMS) indicating the Resident had moderate cognitive impairment.
a. Review of Resident #48's care plans indicated the Resident had decreased/alteration in cardiac output related to CHF and hypertension (high blood pressure, defined as repeatedly elevated blood pressure) with the following intervention: Weekly wts (weights), initiated 3/20/24.
Review of Resident #48's Weights and Vitals Summary indicated the following weight readings:
7/24/24 - 150 lbs. (pounds)
8/27/24 - 189.4 lbs.
9/4/24 - 192 lbs.
9/11/24 - 192 lbs.
9/18/24 - 188 lbs.
Further review of Resident #48's Weights and Vitals Summary indicated that weekly weights were not obtained on the weeks of 7/31/24, 8/7/24, 8/14/24, or 8/21/24, and that the Resident had gained a clinically significant 39.4 lbs. during that time period (26.2% of the Resident's total body weight gained in one month).
Review of the Dietitian follow-up note, dated 8/28/24, indicated that Resident #48 had experienced a significant weight gain and that the Resident was placed on diuretic therapy due to increased edema.
Review of Resident #48's medical record failed to indicate the Resident had refused to be weighed.
During an interview on 9/18/24 at 11:39 A.M., Nurse #3 said certified nursing aides (CNAs) will obtain weights which the nurse then enters into the resident's electronic health record. Nurse #3 said that residents at risk for fluid retention, such as those who have CHF, should be weighed weekly and that she would expect a care plan for weekly weights to be followed. Nurse #3 said that Resident #48 was at risk for weight gain and fluid retention.
During an interview on 9/18/24 at 12:20 P.M., the Registered Dietitian (RD) said that CNAs obtain weights which are then entered by the nurse into the electronic health record. The RD said that she would defer to the Nurse Practitioner (NP) for the required frequency of weighing a resident with CHF, and that weight refusals should be documented.
During an interview on 9/19/24 at 11:10 A.M., the NP said she would have expected Resident #48 to be weighed weekly throughout the Resident's entire admission. The NP said that the Resident's diuretic needed to be increased recently due to fluid retention, and that the risk of not weighing a resident as often as needed was that the Resident could accumulate fluid.
During an interview on 9/18/24 at 1:38 P.M., the Director of Nursing (DON) said that she would expect weights to be recorded in the electronic health record according to the frequency outlined in a resident's care plan.
b. Review of Resident #48's active diagnoses indicated the following diagnosis: Personal history of suicidal behavior.
Review of the physician note, dated 8/2/24, indicated the Resident had a history of two suicide attempts related to severe depression around the time of his/her gastric bypass surgery.
Review of Resident #48's medical record indicated the Resident had gastric bypass surgery in 2020.
Review of Resident #48's care plans failed to indicate that a care plan addressing Resident #48's history of suicide attempts was developed.
During an interview on 9/18/24 at 11:36 A.M., Nurse #3 said she was currently assigned to Resident #48 and that she was unaware of Resident #48's history of suicide attempts. Nurse #3 said she would expect a care plan to be developed specific to the Resident's history of suicide attempts.
During an interview on 9/18/24 at 11:36 A.M., the Social Worker (SW) said she would expect a resident with a history of suicide attempts to have a care plan developed which specifically addresses the history of suicide attempts; the SW said she was unaware of Resident #48's history of suicide attempts.
During an interview on 9/18/24 at 1:41 P.M., the Director of Nursing (DON) said she would expect a resident with a history of suicide attempts to have a care plan developed which specifically addresses the history of suicide attempts.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0658
(Tag F0658)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review the facility failed to provide services that met professional standards of ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review the facility failed to provide services that met professional standards of quality to two Residents (#473 and #14) out of a total sample of 27 residents. Specifically,
1.) For Resident #473, the facility failed to implement a skin graft wound treatment as ordered by the physician.
2.) For Resident #14, the facility failed to arrange a follow up urology appointment.
Findings include:
Review of the Massachusetts Board of Registration in Nursing Advisory Ruling on Nursing Practice, dated as revised April 11, 2018, indicated:
- Nurse's Responsibility and Accountability: Licensed nurses accept, verify, transcribe, and implement orders from duly authorized prescriber's that are received by a variety of methods (i.e., written, verbal/telephone, standing orders/protocols, pre-printed order sets, electronic) in emergent and non-emergent situations. Licensed nurses in a management role must ensure an infrastructure is in place, consistent with current standards of care, to minimize error.
1.) Resident #473 was admitted to the facility in September 2024 with diagnoses including diabetes and soft tissue disorder.
Review of Resident #473's medical record indicated a there was no Minimum Data Set (MDS) data available.
Review of Brief Interview for Mental Status (BIMS) Evaluation, dated 9/16/24, indicated Resident #473 was cognitively intact as evidenced by a score of 14 out of 15.
Review of the Clinical admission assessment, dated 9/13/24, indicated Resident #473 had the following wounds:
- Left posterior thigh skin graft.
- Left thigh skin graft.
- Left inguinal region skin graft.
Review of Resident #473's active physician's order, initiated 9/13/24, indicated:
- Prescribed treatment: (Wounds with soap and water, pat dry, apply triple-antibiotic to wounds and cover with xeroform (non-adhesive dressing). Secure wound dressing with gauze tape, gauze pads, and/or tap [sic]. Daily or PRN (as needed) when soiled (Location: Left leg wounds).
On 9/17/24 at 10:20 A.M., the surveyor observed Nurse #2 perform a wound dressing change on the Resident #473's left leg skin graft wounds. After removing the previous dressing, Nurse #2 cleansed three left leg wounds with normal saline. Nurse #2 then applied xeroform to the three left leg wounds and covered with gauze. During this wound dressing change, Nurse #2 did not apply the triple-antibiotic cream as ordered by the physician.
During an interview on 9/17/24 at 2:06 P.M., Nurse #2 and the surveyor reviewed Resident #473's active physician's treatment orders for the three skin graft wounds on his/her left leg. Nurse #2 said she should have applied triple-antibiotic cream to the wound but did not. Nurse #2 said that based on the physician's order in place she should have cleansed the wounds with soap and water, not normal saline.
During an interview on 9/19/24 at 9:43 A.M., the Director of Nursing (DON) said physician's orders must be followed as ordered. The DON said Nurse #2 should have applied triple-antibiotic cream during the dressing change and should have washed the wounds with soap and water instead of normal saline.
2. Resident #14 was admitted to the facility in August 2022 with diagnoses including neuromuscular dysfunction of the bladder, obstructive and reflux uropathy, and schizoaffective disorder.
Review of the Minimum Data Set Assessment (MDS) dated [DATE] indicated Resident #14 was unable to participate in the Brief Interview for Mental Status Exam and staff assessed him/her as having severely impaired cognitive skills. The MDS also indicated he/she is dependent on staff for activities of daily living and utilized an indwelling catheter.
Review of the clinical record indicated Resident #14 was hospitalized in March 2024.
Review of the discharge hospital paperwork, dated 4/3/24, indicated: Will need out-patient follow up with urology for management of neurogenic bladder and chronic foley.
Review of the clinical record failed to indicate an appointment with urology had been arranged.
During an interview on 9/19/24 at 9:56 A.M., Nurse Supervisor #1 said she would look into when Resident #14 had been seen by urology.
The facility was unable to provide evidence that Resident #14 had been seen by urology since his/her hospitalization.
On 9/19/24 at approximately 3:00 P.M., the Director of Nursing (DON) told the surveyor that Resident #14 has an appointment on 9/25/24 with the urologist for follow up. The DON said that the appointment had been made that day, (9/19/24); approximately five months after Resident #14's hospital discharge.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Quality of Care
(Tag F0684)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review and interviews, the facility failed to ensure quality of care was provided according to fac...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review and interviews, the facility failed to ensure quality of care was provided according to facility protocol and professional standards of practice for one Resident (#101), out of a total sample of 27 residents. Specifically, the facility failed to ensure physician orders were in place for a skin tear.
Findings include:
Resident #101 was admitted to the facility in August 2024 with diagnoses including muscle wasting and atrophy, end stage renal disease.
Review of Resident #101 Minimum Data Set (MDS), dated [DATE], indicated the Resident scored a 10 out of a possible 15 on the Brief Interview for Mental Status (BIMS), indicating he/she was moderately cognitively impaired.
On 9/17/24 at 1:00 P.M., the surveyor observed Resident #101 sitting in his/her wheelchair. His/her left elbow had a dressing that was saturated with bloody drainage, and the dressing was undated. The Resident said he/she got the skin tear at an outside hospital during transportation.
On 9/19/24 at 9:00 A.M., the surveyor and Nurse #3 observed Resident #101's left elbow. Nurse #3 removed the dressing covering the skin tear, (the dressing was undated), and underneath was a xeroform gauze covering the skin tear which was open with bloody drainage.
Review of the medical record failed to indicate treatment orders were in place for the skin tear.
Review of a nurse progress note, dated 9/16/24, indicated the following: Wound doctor seen this shift, left elbow resolved discontinue dressing orders.
Review of care plan with focus of skin tear, dated revised 9/3/24, indicated the following interventions: Apply treatment as ordered by MD (physician). Position left arm on a pillow.
During an interview on 9/19/24 at 9:05 A.M., Nurse #3 said the Resident should have treatment orders in place for the left elbow as it was still open with drainage.
During an interview on 9/19/24 at 9:33 A.M., the Assistant Director of Nursing read the progress note, dated 9/16/24, and said the wound treatment orders for Resident #101 should not have been discontinued. She further said dressing treatments should be applied with physician orders.
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 observations, interviews, and record review for one Resident (#39), out of 27 total sampled residents, the facility failed to provide the necessary treatment to promote healing of a pressure ...
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Based on observations, interviews, and record review for one Resident (#39), out of 27 total sampled residents, the facility failed to provide the necessary treatment to promote healing of a pressure ulcer. Specifically, the facility failed to obtain a physician's order for wound treatment of a pressure ulcer on Resident #39's left hip.
Findings include:
Resident #39 was admitted to the facility in March 2023 with diagnoses including anoxic brain damage (occurs when the brain's oxygen supply is completely cut off).
Review of the most recent Minimum Data Set (MDS) assessment, dated 9/5/24, indicated the Brief Interview for Mental Status (BIMS) should not be conducted as Resident #39 is rarely/never understood. The MDS indicated Resident #39 was at risk of pressure ulcers, currently had unhealed pressure ulcers, and received pressure ulcer care.
Review of the current physician's order did not include any treatments related to pressure ulcers for Resident #39.
Review of Resident #39's Treatment Administration Record (TAR) dated 9/1/24 through 9/19/24, failed to include a treatment for pressure ulcers for Resident #39.
Review of Resident #39's Wound Physician's evaluation and management summary, dated 9/4/24, indicated a stage two pressure wound of the left hip partial thickness. The dressing treatment plan included alginate calcium, covered with gauze dressing. The measurements were:
-length- 4.7 centimeters (cm).
-width- 1.8 cm.
-depth-0.2 cm.
Review of Resident #39's Wound Physician's evaluation and management summary, dated 9/9/24, indicated a stage two pressure ulcer of the left hip partial thickness. The dressing treatment plan included alginate calcium, covered with gauze dressing. The measurements were:
-length- 12.8 cm.
-width- 3.5 cm.
-depth-0.2 cm.
Review of Resident #39's Wound Physician's evaluation and management summary, dated 9/16/24, indicated a stage two pressure ulcer of the left hip partial thickness. The dressing treatment plan included alginate calcium, covered with gauze dressing. The measurements were:
-length-2 cm.
-width-1 cm.
-depth-0.2 cm.
On 9/19/24 at 9:29 A.M., the surveyor observed Nurse #5 doing wound care for Resident #39. Resident #39 had a dressing on his/her left hip. Nurse #5 removed that dressing, cleansed the wound and applied alginate calcium covered with a gauze dressing.
During an interview on 9/19/24 at 9:45 A.M., the surveyor asked Nurse #5 how she knew what treatment was required to Resident #39's pressure ulcer and she indicated the copy of the wound physician's recommendation.
During an interview on 9/19/24 at 10 A.M., the surveyor and Nurse #5 reviewed the attending physician's orders and were not able to find an active order for the treatment of the Resident's left hip pressure ulcer. Nurse #5 said the Director of Nursing usually makes rounds with the wound physician and any recommendations are communicated to nursing so they can obtain an order from the attending physician. Nurse #5 said the recommendation from wound physician should have been confirmed with attending physician and transcribed as a physician's order for Resident #39.
During an interview on 9/19/24 at 2:15 P.M., the Director of Nursing said she would expect that orders recommended by the Wound Physician and ordered by the attending Physician would be put into the electronic health record.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Accident Prevention
(Tag F0689)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview, the facility failed to ensure the environment was free from accident hazards ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview, the facility failed to ensure the environment was free from accident hazards for one Resident (#93) out of a total sample of 27 residents. Specifically, the facility failed to implement an intervention intended to prevent further falls after Resident #93 had sustained multiple falls.
Findings include:
Review of the facility policy, titled Fall Prevention and Management, revised January 2022, indicated, but was not limited to, the following:
- The interdisciplinary team identifies and implements appropriate interventions to reduce the risk of falls or injuries while maximizing dignity and independence.
Resident #93 was admitted to the facility in March 2024 with diagnoses of cancer and malnutrition.
Review of the Minimum Data Set (MDS), dated [DATE], indicated that Resident #93 scored a 5 out of 15 on the Brief Interview for Mental Status (BIMS) indicating the Resident had severe cognitive impairment.
Review of Resident #93's fall incident reports indicated the Resident had fallen attempting to self-transfer in his/her room on 3/20/24, 4/24/24, and 9/3/24.
Review of Resident #93's falls care plan indicated the Resident was at risk for injuries related to fall history due to experiencing a fall in the last month, decreased mobility, and impaired balance normal progression of disease process with unavoidable and/or predictable decline, use of assistive devices recent fall, with the following intervention: Keep walker within resident's reach while in bed (sic.), initiated on 4/30/24.
On 9/18/24 at 8:20 A.M., the surveyor observed Resident #93 in bed, the Residents walker was folded and leaning against the wall out of reach of the Resident.
On 9/18/24 at 10:57 A.M., the surveyor observed Resident #93 in bed, the Residents walker was folded and leaning against the wall out of reach of the Resident.
On 9/18/24 at 12:18 A.M., the surveyor observed Resident #93 in bed, the Residents walker was folded and leaning against the wall out of reach of the Resident.
On 9/19/24 at 8:32 A.M., the surveyor observed Resident #93 in bed, the Residents walker was folded and leaning against the wall out of reach of the Resident.
During an interview on 9/19/24 at 10:40 A.M., Certified Nursing Aide (CNA) #5 said Resident #93 was at risk for falls and that the Resident had fallen in the past attempting to self-transfer.
During an interview on 9/19/24 at 10:42 A.M., Nurse #6 said Resident #93 has had multiple falls attempting to self-transfer. Nurse #6 said he would expect care-plan interventions for fall prevention to be implemented.
During an interview on 9/19/24 at 11:21 A.M., Nurse #7 said Resident #93 utilizes his/her walker to transfer into his/her wheelchair, and that the Resident has fallen attempting to self-transfer in the past. Nurse #7 said she would expect care plan interventions for fall prevention to be implemented.
During an interview on 9/19/24 at 11:54 A.M., the Director of Nursing (DON) said she would expect care plan interventions for fall prevention to be implemented.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0692
(Tag F0692)
Could have caused harm · This affected 1 resident
Based on record review and interview, the facility failed to maintain acceptable parameters of nutrition status for one Resident (#77) out of a total sample of 27 residents. Specifically, the facility...
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Based on record review and interview, the facility failed to maintain acceptable parameters of nutrition status for one Resident (#77) out of a total sample of 27 residents. Specifically, the facility failed to implement the Dietitian's recommendation for increasing the frequency of Resident #77's nutritional supplement.
Findings include:
Review of the facility policy titled Nourishments - Supplements, revised January 2023, indicated:
- To prevent or respond to unplanned and unfavorable weight loss and malnutrition, the Dietitian will assess the nutritional status of all residents and recommends supplements as needed with the Physicians approval.
- Refusal or poor intake acceptance should be reported to the Physician and Dietitian for further evaluation.
Resident #77 was admitted to the facility in August 2024 with diagnoses including protein calorie malnutrition, diabetes, and dependent on dialysis chronic kidney disease.
Review of the most recent Minimum Data Set (MDS) assessment, dated 8/27/24, indicated Resident #77 was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) score of 14 out of 15. The MDS also indicated Resident #77 had significant weight loss of 5% or more in the last month or weight loss of 10% or more in the last 6 months and received greater than 51% of total calories by tube feeding.
On 9/17/24 at 8:15 A.M., the surveyor observed Resident #77 in his/her room with a tube feeding pole in the corner of the room. Resident #77 said he/she now eats by mouth.
Review of Resident #77's plan of care related to nutrition, revised 9/13/24, indicated:
- Goal: Resident will not lose weight below [sic] 155.
- Supplements a/o (as ordered).
Review of Resident #77's Weight Summary report indicated the following weights:
- 8/27 112.8 lbs. (pounds)
- 8/28 113.0 lbs.
- 9/4 102.5 lbs.
- 9/9 115.3 lbs.
- 9/19: 110.4 lbs.
Review of Dietitian progress note, dated 9/10/24, indicated: Met with Resident to discuss regarding his refusal to accept the TF (tube feeding). Rec (recommend) Nepro 240ml three times a day and explained to Resident that it is important that he/she should consume the Nepro.
Review of Resident #77's physician's order, initiated 9/10/24, indicated: Nepro Oral Liquid (Nutritional Supplements), Give 240 ml (milliliters) by mouth two times a day.
Review of Resident #77's Medication Administration Record (MAR), dated 9/10/24 to 9/19/24, failed to indicate that Nepro 240 ml was ever increased to three times a day.
Review of Resident #77's medical record, dated 9/10/24 to 9/19/24, failed to indicate a rationale for why Nepro 240 ml was not increased to three times a day.
During an interview on 9/19/24 at 10:50 A.M., Nurse #5 said Resident #77's tube feeding was recently discontinued and his/her nutritional status is followed by the Dietitian.
During an interview on 9/19/24 at 10:21 A.M., the Dietitian said she evaluated Resident #77 on 9/10/24 because she was notified, he/she was refusing tube feeding. The Dietitian said, in collaboration with the physician, his/her tube feeding was discontinued and Nepro 240 ml was supposed to be increased to three times a day. The Dietitian said, based on her assessment, Resident #77 needed to have the increased nutritional supplement. The Dietitian said she discussed this with the physician, who approved the increased frequency of Nepro 240ml to three times a day, and she was supposed to enter the physician order herself but forgot.
During an interview on 9/19/24 at 11:15 A.M., the Director of Nursing (DON) said nutritional supplements that are recommended and approved by a physician should be input by the Dietitian. The DON said the Dietitian should have input the physician order for increased frequency of Nepro 240 ml to three times on 9/10/24 but did not.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0694
(Tag F0694)
Could have caused harm · This affected 1 resident
Based on observation, interview, and record review, the facility failed to provide care and maintenance of a peripherally inserted IV (intravenous) catheter (a thin flexible tube that is inserted into...
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Based on observation, interview, and record review, the facility failed to provide care and maintenance of a peripherally inserted IV (intravenous) catheter (a thin flexible tube that is inserted into a vein for delivery of medication, blood or fluids directly into the bloodstream), consistent with professional standards of practice for one Resident (#70), out of a total sample of 27 residents. Specifically, for Resident #70, the facility failed consistently flush the peripheral IV catheter and failed to monitor the peripheral IV site for complications.
Findings include:
Review of the facility policy titled Peripheral Catheter Flushing, revised January 2023, indicated:
- Specific flush orders must be documented.
- Flushing is performed to ensure and maintain catheter patency.
- A physician's order is required to flush a peripheral catheter. The order must include the flushing agent, the amount, and the frequency.
Resident #70 was admitted to the facility in March 2024 with diagnoses including heart failure and hypertension.
Review of the most recent Minimum Data Set (MDS) assessment, dated 9/13/24, indicated Resident #70 had moderate cognitive impairment evidenced by a Brief Interview for Mental Status (BIMS) score of 10 out of 15.
On 9/17/24 at 2:21 P.M., the surveyor observed Resident #70 with a peripheral IV catheter port in his/her left forearm. Resident #70 said he/she received IV fluids a few days ago. Resident #70 said staff had not flushed the peripheral IV catheter port since the fluids were discontinued a few days ago.
Review of nursing progress note, dated 9/13/24, indicated a peripheral IV catheter was inserted into Resident #70's left forearm.
Review of Resident #70's Medication Administration Record (MAR), dated 9/13/24, 9/14/24, and 9/15/24, indicated the following physician's order was implemented:
-Peripheral IV: D5 1/2 NS (an IV fluid used for hydration) at 75 ml (milliliters)/hr (hour) x (times) 1.5 L (liters).
Review of nursing progress note, dated 9/15/24, indicated peripheral IV fluids (D5 1/2 NS) were completed on 9/15/24.
Review of medical record, dated 9/13/24 to 9/17/24, failed to indicate any physician's orders to flush Resident #70's peripheral IV catheter or to monitor the peripheral IV catheter site for complications.
During an interview on 9/18/24 at 1:26 P.M., Nurse #4 reviewed Resident #70's physician's orders with the surveyor. Nurse #4 said there should have been a physician's order put in place to monitor the peripheral IV site for complications when it was inserted on 9/13/24 but was not. Nurse #4 also said that after the IV fluids were completed on 9/15/24, there should have been a physician's order to flush the peripheral IV catheter to maintain patency, but there was not. Nurse #4 said a physician's order is needed to flush peripheral IV catheters. Nurse #4 said Resident #70's peripheral IV catheter should have been flushed when not infusing IV fluids from 9/15/24 to 9/17/24 but was not.
During an interview on 9/19/24 at 9:43 A.M., the Director of Nursing (DON) said there should always be an order in place to monitor peripheral IV catheter sites for complications and should be monitored at least shiftly. The DON said if a peripheral IV catheter is not actively infusing IV fluids, then there needs to be an order to flush the peripheral IV catheter to maintain patency. The DON said peripheral IV catheter ports should be flushed at least twice daily when not infusing IV fluids. The DON said Resident #70 should have had physician's orders to flush and monitor the peripheral IV catheter but did not.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Respiratory Care
(Tag F0695)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record review, the facility failed to provide respiratory care consistent with professiona...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record review, the facility failed to provide respiratory care consistent with professional standards of practice for one Resident (#372) out of 27 total sampled residents. Specifically, for Resident #372, the facility failed to ensure the oxygen filter was cleaned as ordered.
Findings include:
Review of the facility policy titled 'Oxygen Administration' dated October 2022, indicated the following but not limited to:
-Check the physician order. If it is unclear, clarification must be obtained.
-Do not operate a concentrator without a filter or with a dirty filter.
Resident #372 was admitted to the facility in August 2024 with diagnoses including chronic obstructive pulmonary disease (COPD) with hypoxia and hypercapnia and was dependent on oxygen.
Review of Resident #372 Minimum Data Set (MDS), dated [DATE], indicated the Resident scored a 14 out of a possible 15 on the Brief Interview for Mental Status (BIMS) indicating the Resident was cognitively intact. The MDS further indicated the Resident is on oxygen therapy.
On 9/17/24 at 7:54 A.M., the surveyor observed Resident #372 lying in his/her bed wearing a nasal oxygen cannula oxygen in his/her nasal. The oxygen concentrator was set at a flow rate of 1.5 liters per minute, the tubing was dated 9/17/24, and the Resident said he/she was being weaned off the oxygen. The surveyor observed the concentrator filter to be visibly dirty with a thick layer of dust on it.
Review of the current physician order, dated 9/5/24, indicated the following:
-Oxygen at 0.5-2 Liters/Minute via nasal cannula continuous to maintain oxygen saturation at or greater than 89%. Oxygen every shift.
-Change o2 (oxygen) tubing and bottle weekly and PRN. Rinse o2 filter with H2O pat dry and replace. Initial tubing and bottle at time of change place tubing in dated plastic bag when not in use. Every night shift every sat COPD and as needed COPD.
During an interview on 9/19/24 at 9:09 A.M., Nurse #3 said oxygen tubing and filters are changed weekly per the orders.
During an interview on 9/19/24 at 12:27 P.M., the Director of Nursing said the oxygen filters are to be cleaned weekly.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0698
(Tag F0698)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Resident #372 was admitted to the facility in August 2024 with diagnoses including end stage renal disease and dependence on ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Resident #372 was admitted to the facility in August 2024 with diagnoses including end stage renal disease and dependence on dialysis.
Review of Resident #372's Minimum Data Set (MDS), dated [DATE], indicated the Resident scored a 14 out of a possible 15 on the Brief Interview for Mental Status indicating he/she was cognitively intact. The MDS further indicated that the Resident was on dialysis.
Review of Resident #372 current physician order indicated the following:
-Dialysis log vital signs and weight one time a day every Monday, Wednesday and Friday for pre dialysis vital signs and one time a day every Monday, Wednesday and Friday for post dialysis vital signs. (weight on dialysis day should be post dialysis dry weight)
Review of the Medication Administration Record (MAR) for September indicated the following documented post dialysis weights:
9/6/24-251.5 lbs (pounds)
9/13/24- 252 lbs
Review of the dialysis communication book indicated the following weights in kilograms (kg):
9/6/24 - 115. Kg (253.2) lbs.
9/13/24 -115.6 kg (254.1) lbs.
During an interview on 9/19/24 at 9:09 A.M., Nurse #3 said post dialysis weights should be calculated by multiplying by 2.2 from kilograms to pounds.
During an interview on 9/19/24 at 9:51 A.M., the Assistant Director of Nursing said post dialysis weights should be entered accurately in the medical records.
Based on record review and interview, the facility failed to: 1. ensure physicians orders for dialysis treatment and post dialysis weights were obtained for one Resident (#77) and 2. failed to ensure post dialysis weights were obtained after treatment for two 2 Residents (#117 and #372) out of a total of 27 sampled residents.
Findings include:
Review of facility's Dialysis Management policy, dated as revised October 2022, indicated the following but not limited to:
-Facility will establish open communication with the Resident's Dialysis Center utilizing a dialysis communication book' completing the dialysis communication form.
-Nutritional/fluid management including documentation of weights, resident compliance with food/fluid restrictions or the provisions of meals before, during and/or after dialysis and monitoring intake and output measurements as ordered.
-On return from the dialysis center the nurse will review the communication returning from dialysis center. The nurse should review specifically, pre and post vital signs, treatment tolerance, any meds given and any new orders for resident care.
According to the National Kidney Foundation: Normal weight without any extra fluid in your body is called dry weight. Extra fluid can be dangerous and cause extra strain on your body, including your heart and lungs. When you have kidney failure, your body depends on dialysis to get rid of the extra fluid and wastes that build up in your body between treatments. If you have too much extra fluid in your body, you may need longer or more frequent hemodialysis treatments. There is a limit to how much fluid can safely be removed during each dialysis treatment.
1. Resident #77 was admitted to the facility in August 2024 with diagnoses including acute kidney failure and type 2 diabetes.
Review of the Minimum Data Set Assessment (MDS), dated [DATE], indicated Resident #77 was cognitively intact and required assistance with bathing, dressing and toileting. The MDS also indicated Resident #77 received dialysis treatment.
Review Resident #77's care plans indicated he/she received dialysis treatment three days a week.
Review of Resident #77's physicians orders indicated:
-Monitor right chest wall hemodialysis every shift, 8/25/24
-Weight every week for 4 weeks one time every day 7 days to monitor weight, 8/25/24
There were no active orders for Resident #77 to receive dialysis treatment or for post dialysis weights to be obtained.
Review of Resident #77's weights indicated he/she had been weighed twice in the month of August 2024 and three times from 9/1/24 through 9/19/24.
During an interview with Nurse #3 on 9/19/24 at 12:19 P.M., she said that when residents are on dialysis, they have physicians orders and weights are supposed to be obtained before and after treatment. Nurse #3 said that weights are logged both in the electronic record and Dialysis communication binder. The surveyor was unable to locate a communication binder for Resident #77.
During an interview with the Director of Nursing on 9/19/24 at approximately 2:30 P.M., she said that residents who are receiving dialysis treatment should have physicians orders in place and weights should be obtained. The DON said she was not aware that Resident #77 had no physicians orders for dialysis treatment and weights were not being obtained.
2. Resident #117 was re-admitted to the facility in July 2024 with diagnoses including dependence on renal dialysis and type two diabetes.
Review of the Minimum Data Set Assessment, dated 7/31/24, indicated he/she was cognitively intact and required assistance with activities of daily living. The MDS also indicated he/she received dialysis treatment.
Review of Resident #117's physicians orders indicated:
-Access port for Dialysis is located L (left) chest wall, 8/12/24
-Dialysis [Center], Dialysis days M-W-F (Monday, Wednesday, Friday) 8/12/24
-Dialysis log vital signs and weight one time a day every Mon, Wed, Fri for pre dialysis vital signs before dialysis please follow schedule, 8/12/24
-Dialysis log vital signs and weight one time a day every Mon, Wed, Fri for post dialysis vital signs (weight on dialysis day should be post-dialysis dry weight), 8/12/24
Review of Resident #117's weights indicated he/she was weighed four times in August 2024 and twice from 9/1/24 through 9/19/24.
During an interview with Nurse #3 on 9/19/24 at 12:19 P.M., she said that when residents are on dialysis, they have physicians orders and weights are supposed to be obtained before and after treatment. Nurse #3 said that weights are logged both in the electronic record and dialysis communication binder. The surveyor and Nurse #3 reviewed Resident #117's dialysis communication binder and all pages were blank. Nurse #3 said that the binder may be new as the previous one may have been misplaced.
During an interview with the Director of Nursing on 9/19/24 at approximately 2:30 P.M., she said she was not aware weights were not being obtained for Resident #117.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Unnecessary Medications
(Tag F0759)
Could have caused harm · This affected 1 resident
Based on observations, interviews, and record review for one Resident (#89) out of four residents observed, the facility failed to ensure it was free from a medication error rate of greater than 5%. O...
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Based on observations, interviews, and record review for one Resident (#89) out of four residents observed, the facility failed to ensure it was free from a medication error rate of greater than 5%. One out of four nurses observed made two errors out of 32 opportunities resulting in a medication error rate of 6.25%. Specifically, Nurse #1 administered the incorrect form of aspirin and administered the incorrect dose of calcium plus vitamin d3.
Findings include:
Review of the facility policy titled Medication Administration, revised October 2022, indicated:
- The medication nurse shall assure that the correct medication is administered by checking the physician's order and the medication label.
Resident #89 was admitted to the facility in September 2022 with diagnoses including heart failure and hypertension.
Review of the most recent Minimum Data Set (MDS) assessment, dated 6/13/24, indicated Resident #89 had moderate cognitive impairment as evidenced by a Brief Interview for Mental Status (BIMS) score of 11 out of 15.
During the medication pass observation on 9/18/24 at 7:58 A.M., the surveyor observed Nurse #1 prepare and administer the following medications to Resident #89:
- One aspirin 81 oral tablet enteric coated.
- One calcium 600 mg (milligrams)/10 mcg (micrograms) vitamin d3 tablet.
Review of Resident #89's physician orders indicated:
- Aspirin 81 Oral Tablet Chewable, give 81 mg in the morning.
- Calcium 600+D3 Oral Tablet 600-5 mg-mcg, give 1 tablet one time a day.
During an interview on 9/18/24 at 1:15 P.M., Nurse #1 said he administered enteric coated aspirin instead of the chewable form. Nurse #1 said he knew it wasn't the ordered form but was unaware that medications needed to be in the form ordered by the physician. Nurse #1 said he administered the incorrect dose of calcium plus vitamin d3. Nurse #1 said he administered calcium 600 mg/10 mcg but should have administered calcium 600 mg/5 mcg.
During an interview on 9/19/24 at 9:43 A.M., the Director of Nursing (DON) said the medication form and dose administered needs to match the physician's order. The DON said Nurse #1 should not have administered the incorrect form of aspirin because Resident #89's order indicated chewable form instead of enteric coated form. The DON said Nurse #1 should not have administered the incorrect dose of calcium 600 mg/10 mcg because the physician's order was for calcium 600 mg/5 mcg.
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, record review, and interviews the facility failed to implement the infection prevention and control program. Specifically, the facility failed to ensure staff performed appropri...
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Based on observations, record review, and interviews the facility failed to implement the infection prevention and control program. Specifically, the facility failed to ensure staff performed appropriate hand hygiene after removing gloves during wound care.
Findings include:
Review of the facility policy titled Hand Washing, revised December 2019, indicated:
6. Use an alcohol-based hand rub, or, alternatively, soap (antimicrobial or non-antimicrobial) and water for the following situations: after removing gloves.
9. The use of gloves does not replace hand washing/hand hygiene. Integration of glove use along with routine hand hygiene is recognized as the best practice for preventing healthcare-associated infections.
a. Perform hand hygiene before and after glove use.
On 9/17/24 at 10:20 A.M., the surveyor observed Nurse #2 perform wound care for a Resident with three left leg wounds in bed with a large amount of bloody drainage completely covering an area of approximately two feet by 1 foot of the bed sheets/bed sheet protector and the Resident's left leg. Certified Nurse Assistant (CNA) #4 assisted with positioning the Resident during wound care. Nurse #2 and CNA #4 did not perform any hand hygiene during the wound care observation. The following observations were made:
- After removing the soiled dressing from the Resident's wound, Nurse #2 removed her soiled gloves to reach into her pocket and did not perform hand hygiene prior to applying a new pair of gloves.
- CNA #4, who had been elevating the Resident's left leg where there was bloody drainage, also removed her soiled gloves and did not perform hand hygiene prior to applying a new pair of gloves.
- Nurse #2 continued to cleanse the wound before she removed her soiled gloves to use an electronic tablet to take a photograph of the wound without performing hand hygiene.
- Nurse #2 then handed the electronic tablet to CNA #4, who removed her gloves to assist with taking photographs using the electronic tablet, without performing hand hygiene.
- Nurse #2 and CNA #4 then applied a new pair of gloves without performing hand hygiene.
- Nurse #2 cleansed another area of the wound, and then removed one glove, which was visibly soiled with blood, to touch the electronic tablet, and then applied a new glove without performing hand hygiene.
- CNA #4 also removed soiled gloves to use the electronic tablet again and did not perform any hand hygiene before applying a new pair of gloves.
- Nurse #2 applied part of the dressing and removed her soiled gloves to open another dressing package and did not perform any hand hygiene before applying a new pair of gloves.
- Nurse #2 applied another portion of the dressing and then used her gloved hands to reach into a plastic bag, being used for discarded wound dressing supplies, to push down on soiled dressings and soiled gauze to make more room. Nurse #2 then used the same soiled gloves to cleanse another area of the wounds, without changing gloves or performing hand hygiene.
- Nurse #2 then removed her soiled gloves and did not perform any hand hygiene before applying a new pair of gloves.
- Nurse #2 applied another dressing and then removed her soiled gloves and did not perform any hand hygiene before applying a new pair of gloves.
During an interview on 9/19/24 at 12:44 P.M., Certified Nurse Assistant (CNA) #4 said she should have performed hand hygiene after removing her gloves while assisting the nurse with the Resident's wound care observed with the surveyor but did not.
During an interview on 9/17/24 at 2:06 P.M., Nurse #2 said she should have performed hand hygiene after removing her gloves during the Resident's wound care observed by the surveyor but did not because she forgot to bring sanitizer into the room.
During an interview on 9/19/24 at 9:43 A.M., the Director of Nursing (DON) said hand hygiene should be performed every time gloves are removed and before new gloves applied during wound care.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Incontinence Care
(Tag F0690)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4. Review of the facility policy titled Catheter Guidelines, revised January 2023, indicated: Be sure the catheter tubing and dr...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4. Review of the facility policy titled Catheter Guidelines, revised January 2023, indicated: Be sure the catheter tubing and drainage bag are kept off the floor.
Resident #471 was admitted to the facility in September 2024 with diagnoses including benign prostatic hyperplasia with lower urinary tract symptoms, brain cancer, and hemiplegia affecting the right dominant side.
Review of Resident #471's assessment titled Brief Interview for Mental Status (BIMS) Evaluation, dated 9/16/24, indicated Resident #471 was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) score of 14 out of 15.
Review of Resident #471's active physician's orders, initiated 9/15/24, indicated:
- Foley Catheter (urinary catheter)12 FR (french size) /10 ML (milliliter) continuous to drainage bag. May Reinsert for dislodgment or malfunctioning, every shift.
Review of Resident #471's plan of care related to indwelling urinary catheter, revised 9/15/24, indicated: Provide catheter care per policy.
On 9/17/24 at 7:54 A.M., the surveyor observed Resident #471 sitting in a wheelchair. His/her urinary catheter drainage bag was observed attached to the bottom of the wheelchair with the bottom of the bag resting directly on the floor. There was no barrier between the urinary drainage bag and the floor. Resident #471 said staff provides all urinary catheter care, including drainage bag management, because his/her hands shake and can't manage it him/herself.
On 9/18/24 at 6:48 A.M., the surveyor observed Resident #471 in bed with a urinary catheter drainage bag attached to the bedframe. The bed was in a low position with the urinary catheter drainage bag and tubing directly on the floor without a barrier.
On 9/18/24 at 9:01 A.M., the surveyor observed Resident #471 self-propelling wheelchair in the hall using his/her feet. His/her urinary catheter drainage bag was observed attached to the bottom of the wheelchair and was dragging along the floor without a barrier.
During an interview on 9/19/24 at 10:50 A.M., Certified Nurse Assistant (CNA) #3 said urinary catheter drainage bags and tubing should never be directly touching the floor. CNA #3 said she often finds urinary catheter bags on the floor and was unaware of expectations for what to do if they are found on the floor but is worried about the risk of infection. CNA #3 said Resident #471 is physically unable to lower the bed or manage urinary catheter drainage bag/tubing by him/herself because of dexterity in hands.
During an interview on 9/19/24 at 12:33 P.M., Nurse #3 said urinary catheter drainage bags should never directly touch the floor because of the risk for infection. Nurse #3 said if for any reason the urinary catheter drainage bag or tubing needed to be touching the floor, a barrier should be placed between the urinary catheter drainage bag/tubing and the floor.
During an interview on 9/19/24 at 9:43 A.M., The Director of Nursing (DON) said urinary catheter drainage bags or tubing should never be directly touching floor without a barrier to protect from infection.
Based on observations, record reviews, and interviews, the facility failed to maintain professional standards in the management and caring for urinary catheter devices for 4 Residents (#30, #103, #108 and #471). Specifically,
1. For Resident #30, the facility failed to empty urinary drainage bag as ordered.
2. For Resident #103, the facility failed to empty urinary drainage as ordered and maintain urinary drainage bag off the floor.
3. For Resident #108, the facility failed to empty urinary drainage bag as ordered.
4. For Resident #471, the facility failed ensure urinary catheter drainage bags and tubing were not stored directly touching the floor.
Findings include:
Review of the facility policy titled 'Catheter Drainage Bag', dated January 2023, indicated:
-The purpose of this procedure are to prevent the drainage bag from becoming full and allowing urine to flow back into the bladder, to measure output, and to obtain sterile specimen.
-Empty the urinary drainage bag at least every eight hours or more often if needed to keep the bag from becoming full.
-Keep the drainage bag and tubing off the floor at all times to prevent contamination and damage.
1. Resident #30 was admitted to the facility with diagnoses including malignant neoplasm of kidneys except renal pelvis, infection and inflammatory reaction due to indwelling urethral catheter and hematuria (blood in urine).
Review of Resident #30's Minimum Data Set (MDS), dated [DATE], indicated the Resident scored a 15 out of a possible 15 on the Brief Interview for Mental Status (BIMS) indicating he/she was cognitively intact. The MDS further indicated the Resident had an indwelling catheter.
On 9/17/24 at 8:54 A.M., the surveyor observed Resident #30 laying in his/her bed. The urinary drainage bag had 1200 (ML)milliliters of urine in it. The Resident said that the staff does not empty the drainage bag frequently.
Review of Resident #30's current physician orders indicated the following:
-Foley catheter care every shift.
-Measure output from indwelling catheter every shift.
Review of the current Treatment Administration Record (TAR) indicated the night shift documented the catheter had been emptied a total of 600 milliliters on 9/17/24
Review of the care plan with a focus of indwelling urinary catheter, dated revised 7/5/24, indicated the following intervention: Provide catheter care per policy.
During an interview on 9/19/24 at 9:04 A.M., Nurse #3 said the urinary catheters are emptied at the end of the shift. When asked if the drainage bag should contain 1200 milliliters at the beginning of the shift Nurse #3 said no.
During an interview on 9/19/24 at 9:26 A.M., the Assistant Director of Nursing said urinary catheters should be emptied every shift as ordered and as needed if the resident is on a diuretic.
2. Resident #103 was admitted to the facility in July 2024 with diagnoses including urinary retention, obstructive and reflux uropathy and hematuria (blood in urine).
Review of Resident #103's Minimum Data Set (MDS), dated [DATE], indicated the Resident scored a 9 out of a possible 15 on the Brief Interview for Mental Status (BIMS) indicating he/she was moderately cognitively impaired. The MDS further indicated the Resident had an indwelling urinary catheter.
On 9/17/24 at 8:18 A.M., the surveyor observed Resident #103 laying in his/her bed the urinary drainage bag was lying on the floor.
On 9/19/24 at 9:19 A.M., the surveyor observed Resident #103 laying in his/her bed, the drainage bag had 600 ml of bloody urine.
Review of Resident #103 current physician orders indicated the following:
-Check placement of urinary drainage bag to assure it is hanging below the level of the bladder every shift.
-Foley catheter care every shift.
Review of the current Treatment Administration Record (TAR) indicated the night shift documented an output of 450 ml for the overnight shift on 9/19/24.
Review of care plan with focus of indwelling urinary catheter, dated revised 9/18/24, indicated the following intervention: Provide catheter care per policy.
During an interview on 9/19/24 at 9:23 A.M., Nurse #2 said the Resident's catheter should be emptied every shift, and the catheter should be maintained off the floor to prevent infections. She also said the hematuria in the urinary drainage bag was ongoing and that the Resident was being followed by urology.
During an interview on 9/19/24 at 9:26 A.M., the Assistant Director of Nursing said urinary catheters should be emptied every shift as ordered and as needed if the resident is on a diuretic.
3. Resident #108 was admitted to the facility in April 2024 with diagnoses including neuromuscular dysfunction of bladder and urinary retention.
Review of Resident #108's Minimum Data Set (MDS), dated [DATE], indicated the Resident scored a 15 out of a possible 15 on the Brief Interview for Mental Status (BIMS) indicating he/she was cognitively intact. The MDS further indicated the Resident had an indwelling catheter.
On 9/17/24 at 8:02 A.M., the surveyor observed Resident #108 laying in his/her bed, the urinary drainage bag was hooked to the bed rail and had approximately 600 ml of urine. The Resident said that the staff does not empty his/her catheter and at times his/her parent will empty the catheter when they come to visit the Resident.
On 9/18/24 at 7:07 A.M., the surveyor observed the Resident laying in his/her bed and his/her urinary drainage bag had 1200 ml of urine.
On 9/18/24 at 1:03 P.M., the surveyor and Nurse #4 observed Resident #108's foley catheter, the Resident had a 16 French 10 ml catheter size. Nurse #4 said the catheter size should match the physician orders.
On 9/19/24 at 8:58 A.M., the surveyor observed the Resident laying in his/her bed the urinary drainage bag had approximately 800 ml of urine.
Review of current physician orders indicated the following:
-Foley catheter care every shift.
-Foley catheter 14 French 10 ml continuous drainage bag every shift
Review of care plan with focus of indwelling urinary catheter, dated revised 4/16/24, indicated the following interventions: Provide catheter care per policy. Change catheter per policy/medical director (MD) orders.
During an interview on 9/19/24 at 9:04 A.M., Nurse #3 said catheters should be emptied every end of shift.
During an interview on 9/19/24 at 9:26 A.M., the Assistant Director of Nursing said urinary catheters should be emptied every shift as ordered and as needed if the resident is on a diuretic.
During an interview on 9/19/24 at 12:26 P.M., the Director of Nursing said the Resident had been in and out of the hospital and the staff should have ensured that the Resident's catheter was the same as the orders.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0761
(Tag F0761)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations and interviews, the facility failed to ensure staff stored all drugs and biologicals in accordance with ac...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations and interviews, the facility failed to ensure staff stored all drugs and biologicals in accordance with accepted professional standards of practice. Specifically,
1.) The facility failed to ensure medications were dated once opened and discarded as appropriate according to manufacturer's guidelines.
2.) The facility failed to ensure medications were not prepared in advance and stored in original, labeled containers in the medication cart.
3.) The facility failed to properly secure medication carts on one of three units
4.) The facility failed to ensure unauthorized nurses did not have access to medication cart.
Findings include:
Review of the facility policy titled Medication Storage [sic], revised [DATE], indicated:
- All medications will be stored in a locked cabinet, cart or medication room that is accessible only to authorized personnel, as defined by the facility policy.
- Medications will be stored in the original, labeled containers received from the pharmacy.
- Multi-dose vials which have been opened or accessed (e.g., needle punctured) should be dated and discarded within 28 days unless the manufacturer specifies a differed (shorter or longer) date for the opened vial.
- Expired, discontinued and/or contaminated medications will be removed from the medication storage area and disposed of in accordance with facility policy.
1a.) On [DATE] at 8:10 A.M., the surveyor observed the following on the Concord Unit medication cart #2:
- Fluticasone propionate and salmeterol inhaler, dated [DATE], which was 55 days prior to observation.
- One bottle of proheal liquid protein, undated.
- One open vial of lantus 100u (units)/ml (milliliter) insulin, undated.
- One bottle of atropine 1% sublingual drops, undated.
During an interview on [DATE] at 8:13 A.M., Nurse #1 said the resident currently used the fluticasone propionate and salmeterol inhaler that was dated [DATE], but it should have been discarded within 30 days after opening based on manufacturers guidelines. Nurse #1 said proheal liquid protein was not dated but should have been because it needs to be discarded 60 days after opening. Nurse #1 said the lantus insulin vial and the atropine drops were not dated but should have been because they need to be discarded 28 days after opening.
During an interview on [DATE] at 9:43 A.M., the Director of Nursing (DON) said all inhalers and medications with shortened expiry dates once opened must be dated so they can be discarded according to manufacturer's guidelines. The DON said fluticasone propionate and salmeterol inhaler should have been discarded within 30 days after opening. The DON said proheal liquid protein should have been dated because it needs to be discarded 60 days after opening. The DON said insulin vials and atropine drops should have been dated because they need to be discarded 28 days after opening.
1b.) On [DATE] at 8:20 A.M., the surveyor observed the following on the [NAME] Unit medication cart #2:
- One bottle of proheal liquid protein, undated.
- One open vial of lantus 100u (units)/ml (milliliter) insulin, dated [DATE], which was 32 days prior to observation.
- One lupinhaler, with a capsule preloaded, unlabeled, stored directly on the bottom of the medication cart drawer not in a box.
During an interview on [DATE] at 8:24 A.M., Nurse #3 said proheal liquid protein was not dated, but should have been because it needs to be discarded 60 days after opening. Nurse #1 said insulins need to be discarded 28 days after opening. Nurse #1 said the lantus insulin vial should have been discarded on [DATE] but was still being used by the resident. Nurse #3 said the lupinhaler should not have a capsule preloaded because there is not expiration date on the capsule. Nurse #3 said the lupinhaler should be labeled with the resident's name and stored in a box for infection control purposes.
During an interview on [DATE] at 9:43 A.M., the Director of Nursing (DON) said all medications with shortened expiry dates once opened must be dated so they can be discarded according to manufacturer's guidelines. The DON said proheal liquid protein should have been dated because it needs to be discarded 60 days after opening. The DON said insulin vials and atropine drops should have been dated because they need to be discarded 28 days after opening. The DON said the lupinhaler should be labeled with the resident's name and stored in a box for infection control purposes.
2a.) On [DATE] at 8:13 A.M., the surveyor observed the following on the Concord Unit medication cart #2:
- Three unsealed clear pill packet sleeves containing crushed medications. Each clear pill packet sleeve was labeled a resident name written in black marker.
During an interview on [DATE] at 8:13 A.M., Nurse #1 said he had prepared and crushed the medications in advance and was planning on administering to the residents later. Nurse #1 said he wasn't supposed to prepare medications in advance.
During an interview on [DATE] at 9:43 A.M., the Director of Nursing (DON) said medications should only be prepared immediately before administering and should never be prepare or pre-poured and stored in the medication cart to administer later.
2b.) On [DATE] at 8:10 A.M., the surveyor observed the following on the Concord Unit medication cart #2:
- One unknown, unlabeled pill stored in an orange prescription bottle with a label indicating haloper dec inj (haloperidol decanoate injection, which is an injectable antipsychotic medication) 50 mg (milligrams)/ml (milliliter).
During an interview on [DATE] at 8:13 A.M., Nurse #1 said he did not know what that pill was, but it was not a haloperidol decanoate injection. Nurse #1 said the unknown pill should not have been stored in that orange prescription bottle, and should have been stored in the original, labeled container.
During an interview on [DATE] at 9:43 A.M., the Director of Nursing (DON) said pills should always be stored in the original, labeled containers, and the unknown pill should not have been in that orange prescription bottle.
3a.) On [DATE] at 8:20 A.M., the surveyor observed Andover Unit medication cart unlocked in the hallway. The nurse was not within sight line of the medication cart.
During an interview on [DATE] at 8:22 A.M., Nurse #4 said she should have locked her medication cart before walking away.
During an interview on [DATE] at 2:49 P.M., the Director of Nursing (DON) said medication carts should never be left unlocked if unattended.
3b.) On [DATE] at 12:31 P.M., the surveyor observed Andover Unit medication cart unlocked in the hallway. The nurse was not within sight line of the medication cart.
During an interview on [DATE] at 12:33 P.M., Nurse #3 said she should have locked her medication cart before walking away. Nurse #3 said medication carts should always be locked if unattended.
During an interview on [DATE] at 2:49 P.M., the Director of Nursing (DON) said medication carts should never be left unlocked if unattended.
4.) On [DATE] at 9:27 A.M., the surveyor observed the Assistant Director of Nursing (ADON) preparing and administering medications for a resident from the Andover unit medication cart #2. The ADON said she borrowed the medication cart keys from Nurse #2, who was down the hall in another resident's room. The ADON said she was not authorized to administer medications from this medication cart because she never completed the narcotic count or signed out the medication cart from Nurse #2 but should have before administering medications from the medication cart.
On [DATE] at 9:30 A.M., Nurse #2 came back to the medication cart and retrieved the keys from the ADON.
During an interview on [DATE] at 9:43 A.M., the Director of Nursing (DON) said only nurses who have completed the narcotic count in order to sign out the medication cart should have access to administer medications from the medication cart.
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 store food in accordance with professional standards ...
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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 store food in accordance with professional standards for food service safety. Specifically, the facility failed to ensure food was labeled in the unit kitchenette refrigerators, and that dented cans were not accepted into storage/circulation.
Findings include:
Review of the facility's undated policy titled Food Storage (Dry, Refrigerated, and Frozen), indicated, but was not limited to, the following: Dented cans are set aside in a separate labeled area of the storeroom to avoid using them and discarded according to vendor procedure.
Review of the facility's undated policy titled Food from Outside indicated, but was not limited to, the following:
- Residents have the right to have foods brought in by family and friends. Due to the potential for foodborne illness or interfere with nutritional treatment, family members and/or visitors who bring food in from the outside will be educated on safe food handling practices and the importance of diet order compliance. Food or beverage that is brought in from the outside will be monitored by nursing staff for spoilage, contamination and safety.
- Food brought by family/visitors that is left with the resident to consume later will labeled (sic.) and stored in a manner that it is clearly distinguishable from the facility-prepared food. (label will identify resident name, room number, item, date received and discard date).
o All refrigerated food shall be discarded within 48 hrs. (hours)
o Perishable foods should be stored in re-sealable containers with tightly fitting lids in a refrigerator. Containers will be labeled with the resident's name, the item and the discard date.
- The nursing staff will discard perishable foods on or before the discard date. Resident and/or family should be notified when food is being discarded.
On 9/17/24 at 7:17 A.M., the surveyor observed a significantly dented can of pumpkin and a significantly dented can of mandarin oranges on the can rack in the kitchen.
On 9/17/24 at 7:53 A.M., the surveyor made the following observations in the Concord unit kitchenette refrigerator:
- Two water bottles, opened and filled with a green liquid undated and unlabeled.
- A white plastic bag containing two containers of food, the white plastic bag was labeled with a resident name but the food was undated.
On 9/17/24 at 8:01 A.M., the surveyor made the following observations in the [NAME] unit kitchenette refrigerator:
- Two undated plastic pitchers of cranberry juice.
- One undated plastic pitcher of apple juice.
- One undated plastic pitcher of orange juice.
On 9/17/24 at 11:21 A.M., the surveyor made the following observations in the Andover unit kitchenette refrigerator:
- Two undated containers of resident food.
During an interview on 9/17/24 at 7:17 A.M., the cook said that dented cans should not go on the can rack and should instead be placed in the office.
During an interview on 9/17/24 at 7:55 A.M., Nurse #6 said that all food in the kitchenette refrigerators should be dated and discarded after three days. Nurse #6 said that the bottles of green liquid were brought in for a resident by family members.
During an interview on 9/17/24 at 11:03 A.M., the Food Service Director (FSD) said dented cans should be set aside in the office to be returned as they pose a risk for botulism if consumed (a rare but serious illness caused by a toxin that attacks the nervous system and can lead to paralysis and death). The FSD said that juice and resident food in the unit kitchenette refrigerators should be dated and discarded after three days.
MINOR
(B)
Minor Issue - procedural, no safety impact
MDS Data Transmission
(Tag F0640)
Minor procedural issue · This affected multiple residents
Based on record review and interview, the facility failed to transmit Minimum Data Set (MDS) data to the Centers for Medicare and Medicaid Services (CMS) System timely for two Resident (#18 and #99), ...
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Based on record review and interview, the facility failed to transmit Minimum Data Set (MDS) data to the Centers for Medicare and Medicaid Services (CMS) System timely for two Resident (#18 and #99), out of 27 total sampled residents. Specifically:
1.) For Resident #18, the facility failed to transmit an MDS discharge assessment within 14 days after completion.
2.) For Resident #99, the facility failed to transmit an MDS discharge assessment within 14 days after completion.
Findings include:
Review of the Centers for Medicare and Medicaid Services (CMS) Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual indicated an MDS discharge assessment must be transmitted within 14 days after the MDS completion date.
1.) Resident #18 was admitted to the facility in April 2024 with diagnoses including low back pain and repeated falls.
Review of facility census indicated Resident #18 was discharged from the facility on 5/10/24.
Review of medical record indicated the MDS discharge assessment, dated 5/10/24, was completed 5/14/24, but was never transmitted.
During an interview on 9/19/24 at 9:43 A.M., the Director of Nursing (DON) said all MDS assessments should be transmitted timely by an MDS Nurse as required by RAI guidelines.
During an interview on 9/19/24 at 8:06 A.M., MDS Nurse #1 said the MDS discharge assessment that was completed for Resident #18 was never transmitted but should have been.
2.) Resident #99 was admitted to the facility in April 2024 with diagnoses including adult failure to thrive and repeated falls.
Review of facility census indicated Resident #99 was discharged from the facility 5/6/24.
Review of medical record indicated the MDS discharge assessment, dated 5/6/24, was completed 5/16/24, but was never transmitted.
During an interview on 9/19/24 at 9:43 A.M., the Director of Nursing (DON) said all MDS assessments should be transmitted timely by an MDS Nurse as required by RAI guidelines.
During an interview on 9/19/24 at 8:06 A.M., MDS Nurse #1 said the MDS discharge assessment that was completed for Resident #99 was never transmitted but should have been.
MINOR
(B)
Minor Issue - procedural, no safety impact
Assessment Accuracy
(Tag F0641)
Minor procedural issue · This affected multiple residents
Based on interview and record review, the facility failed to accurately code the Minimum Data Set (MDS) for one Resident (#92) out of 27 total sampled residents. Specifically, the facility inaccuratel...
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Based on interview and record review, the facility failed to accurately code the Minimum Data Set (MDS) for one Resident (#92) out of 27 total sampled residents. Specifically, the facility inaccurately coded the MDS to indicate the Resident was comatose or in a persistent vegetative state.
Findings include:
Resident #92 was admitted to the facility in April 2023 with diagnosis including traumatic subdural hemorrhage.
Review of the most recent MDS assessment, dated 9/6/24, indicated Resident #92's hearing, speech, vision, cognitive patterns, mood, activity preferences and pain had not been assessed.
On 9/17/24 7:49 A.M., the surveyor observed Resident #92 in bed. Resident #92 was able to answer questions appropriately, follow commands and was watching a show on his/her electronic device.
Review of nurse practitioner #1's progress note, dated 8/12/24, indicated Resident #92 had started to be more interactive with more speaking.
Further review of the nursing clinical assessment, dated 9/4/24, indicated Resident #92 had short term memory loss, was oriented to person and place, coherent, usually made self understood and understands others, speech was improving and the Resident used words and phrases.
During an interview on 9/19/24 at 8:11 A.M., Nurse #7 said Resident #92 had improved since admission and was able to communicate. Nurse #7 said the Resident could be understood, understands when spoken to, and can spell words out if unable to say the word.
During an interview on 9/19/24 at 8:15 A.M., Certified Nursing Aide (CNA) #5 said Resident #92 was able to speak and understands what is being said to him/her.
During an interview on 9/19/24 at 10:08 A.M., the MDS Nurse #2 said she didn't know how nursing assessed that Resident #92 was in a coma/vegetative state, but it's the nursing clinical evaluation assessment that populates the MDS. The MDS nurse said the coding of the MDS would depend on the look back period as Resident #92's cognition and awareness fluctuated. The MDS nurse said that if the Resident was coded as being in a coma or vegetative state that all interview questions would be grayed out or skipped.
During an interview on 9/19/24 at 2:17 P.M., the Director of Nursing (DON) said that Resident #92 was not in a vegetative state and that Resident has improved since admission. The DON said the MDS should reflect Resident #92's status.
Mar 2024
1 deficiency
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0604
(Tag F0604)
Could have caused harm · This affected 1 resident
Based on records reviewed and interviews, for one of four sampled residents (Resident #1), whose behavior included being resistive to care, the Facility failed to ensure he/she was free from the use o...
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Based on records reviewed and interviews, for one of four sampled residents (Resident #1), whose behavior included being resistive to care, the Facility failed to ensure he/she was free from the use of physical restraints, when on 02/29/24 during morning care, Certified Nurse Aide #1 held Resident #1's left wrist firmly to restrict his/her left arm movement, as he/she displayed combative behavior.
Findings include:
Review of the Facility's Restraint Use Policy, revised January 2023, indicates all residents have the right to be free from any form of physical restraint, imposed by staff as a means of coercion, discipline, convenience or retaliation and not required to treat the resident's medical symptoms.
Review of Resident #1's medical record indicated his/her diagnoses include Morbid Obesity, hemiplegia (paralysis on one side of body) )and hemiparesis (loss of strength) following cerebral infarction affecting his/her right dominant side.
Resident #1's Quarterly Minimum Data Assessment, dated 01/11/24, indicated he/she was dependent on others to roll left and right in bed.
Resident #1's Behavior Care Plan, with target goal date of 03/23/24, included a potential concern related to resisting care, socially inappropriate and verbally abusive behaviors. The Care Plan interventions included to provide a non-confrontational environment for care, and reapproach when agitated at a later time when less agitated.
Resident #1's Behavior Management Care Plan, with target goal date of 03/23/24, included interventions to attempt an alternate time to provide care refused per his/her preference, and provide verbal feedback regarding behavior, monitor emotional factors that may contribute to new behaviors and establish boundaries and limits with him/her.
Review of the Report submitted by the Facility via the Health Care Facility Reporting System (HCFRS) dated 03/11/24, indicated that during morning care on 02/29/24, Certified Nurse Aide #1 grabbed and held Resident #1's left wrist very tightly. The Report indicated CNA #1 insisted she get Resident #1 washed and dressed, and continued to provide care disregarding Resident #1's wishes. The Facility's final Report indicated that their Investigation determined that CNA #1 grabbed and held Resident #1's left wrist applying unnecessary pressure that created bruising.
During an interview on 03/19/24 at 12:05 P.M., Resident #1 said on 02/29/24 while lying in bed, he/she kept telling Certified Nurse Aide (CNA) #1 how to provide his/her care. Resident #1 said CNA #1 became frustrated. Resident #1 said he/she did not recall rolling from side to side in bed, but said during care he/she accidentally struck CNA #1's face causing a scratch.
Resident #1 said CNA #1 squeezed and held onto his/her left wrist to prevent him/her from hitting her (CNA #1). Resident #1 said CNA #1 had a good hold of his/her left wrist, preventing him/her from hitting her again. Resident #1 said he/she apologized for striking CNA #1. Resident #1 said CNA #1 continued to provide care for him/her without any further incident.
During a telephone interview on 03/25/24 at 3:40 P.M., Certified Nurse Aide (CNA) #1 said during morning care on 02/29/24, Resident #1 wanted petroleum jelly applied to his/her back while being washed lying on his/her right side in bed. CNA #1 said she tried to explain that it would be applied after he/she was dried.
CNA #1 said while positioned closely to Resident #1's body, Resident #1 released his/her hold of the bed's side rail with his/her left hand and began to roll onto his/her back. CNA #1 said Resident #1 quickly slapped her face with his/her left hand causing a scratch. CNA #1 said Resident #1 immediately attempted to slap her a second time.
CNA #1 said in an automatic attempt to protect herself, she grabbed Resident #1's left wrist firmly with her right hand. CNA #1 said while holding Resident #1's left wrist firmly, she told Resident #1 that he/she needed to calm down, let her do her work, and told Resident #1 to stop because it was not alright to hit her. CNA #1 said she was unsure exactly, but thought she held Resident #1's wrist for a minute or less.
During an in person interview on 03/19/24 at 11:15 A.M., and a telephone interview on 04/01/24 at 1:35 P.M., the Administrator said the Facility was unaware that CNA #1 had restrained Resident #1 by his/her left wrist during morning care on 02/29/24, and were not made aware until 03/04/24 after Resident #1's initial report of the incident to a family member.
The Administrator said during an interview with CNA #1, she stated she held Resident #1's left wrist firmly, restraining Resident #1 until he/she promised to stop resisting care. The Administrator said CNAs, including CNA #1, should explain the care being provided to residents. The Administrator said if any resident resists care or communicates any concerns during care, CNAs should leave the resident (when safe to do so) and reapproach them at a later time. The Administrator said CNAs should not restrict a resident's movement by restraining them.
Sept 2023
24 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Resident Rights
(Tag F0550)
Could have caused harm · This affected 1 resident
Based on observations, interview and policy review, the facility failed to provide a dignified dining experience for Residents on one of three units, specifically, the Concord Unit.
Findings include:...
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Based on observations, interview and policy review, the facility failed to provide a dignified dining experience for Residents on one of three units, specifically, the Concord Unit.
Findings include:
Review of the facility policy titled Dining dated and revised April 2023 indicated the following:
*All residents at one table should receive their meal before moving to the next table.
*Provide napkins and non-disposable cutlery and dishware (include cups and glasses)
*Sit next to residents while assisting them to eat, rather than standing over them.
The surveyor made the following observations:
During the breakfast service on 9/6/23 at approximately 8:29 A.M., the following was observed in the dining room:
*Residents were being served breakfast in Styrofoam take-out containers with plastic, disposable cutlery.
*At a table, the first Resident was served breakfast at 8:30 A.M., the last Resident received his/her breakfast at 8:53 A.M., 23 minutes later. While waiting for his/her breakfast, the Resident was calling out loud I'm hungry, what about my breakfast.
*Residents were observed sitting at tables eating with their hands without any redirection or encouragement from staff members.
During the lunch service on 9/6/23 at approximately 12:00 P.M., the following was observed in the dining room:
*At a table, the first Resident was served lunch at 12:11 P.M., the last Resident received his/her lunch at 12:26 P.M., 15 minutes later.
*Residents were observed sitting at tables eating with their hands without any redirection or encouragement from staff members.
During the breakfast service on 9/7/23 at approximately 8:10 A.M., the following was observed in the dining room:
*At a table, the first Resident was served breakfast at 8:21 A.M., the last Resident received his/her breakfast at 8:33 A.M., 12 minutes later.
*At another table, the first Resident was served breakfast at 8:25 A.M., the last Resident received his/her breakfast at 8:36 A.M., 11 minutes later.
*At another table, the first Resident was served breakfast at 8:24 A.M., the last Resident received his/her breakfast at 8:41 A.M., 15 minutes later.
*At another table, the first Resident was served breakfast at 8:15 A.M., the last Resident received his/her breakfast at 8:27 A.M., 12 minutes later.
*The surveyor observed staff standing over four residents feeding them breakfast, not sitting at the Resident's eye level.
During an interview on 9/8/23 at 9:46 A.M., the Administrator and Director of Nursing said staff members should be seated at eye level when assisting residents with feeding. They continued to say residents should be fed at the same time when sitting at the same table, and Styrofoam containers should not be used.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Safe Environment
(Tag F0584)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interviews the facility failed to maintain a homelike environment for one Resident # 311 out of a total...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interviews the facility failed to maintain a homelike environment for one Resident # 311 out of a total sample of 43 residents.
Findings include:
Resident #311 was admitted to the facility in August 2023 with diagnoses including depression.
Review of Resident #311's Nursing Evaluation V 7 assessment dated [DATE], indicated the Resident was alert and oriented times four and had an intact memory.
During environmental rounds on 9/6/23 at 8:37 A.M., Resident #311 reported to the surveyor that since his/her admission to the facility in August 2023 his/her privacy curtain had dark brown matter on it and he/she had told multiple staff and said no one had taken care of it.
During an observation on 9/8/23 at 9:15 A.M., the surveyor observed Resident #311 in his/her bed the privacy curtain still had dark brown matter on it.
During an interview on 9/8/23 at 9:17 A.M., Nurse #1 inspected the privacy curtain and said that should not have been there and said rooms should be cleaned thoroughly before a resident is admitted to the facility.
During an interview on 9/8/23 at 10:02 A.M., the Administrator said that cleaning of the privacy curtains is coordinated with the room of the day and that the curtain should have been cleaned.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0658
(Tag F0658)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Resident #38 was re-admitted to the facility in July 2022 with diagnoses including type 1 diabetes, chronic kidney disease an...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Resident #38 was re-admitted to the facility in July 2022 with diagnoses including type 1 diabetes, chronic kidney disease and major depressive disorder.
Review of Resident #38's most recent Minimum Data Set (MDS) dated [DATE], indicated he/she scored a 14 out a possible score of 15 indicating he/she was cognitively intact. Further review of the MDS indicated he/she required assistance of a staff member for activities of daily living.
Review of Resident #38's physician orders, dated 5/10/23, indicated Weight Weekly on Thursday 7-3 (7:00 A.M. to 3:00 P.M.).
Review of Resident #38's medical record indicated the last weight obtained was on 6/7/23 which was 251.2 lbs (pounds).
During an interview on 9/7/23 at 1:30 P.M., the Dietitian said she expects weekly weights to be obtained weekly as ordered for Resident #38.
During an interview on 9/8/23 at 10:01 A.M., the Director of Nurses (DON) said the expectation for nursing staff is to obtain weights as ordered.
3. Resident #51 was admitted to the facility in June 2022 with diagnoses including Parkinson's, type 2 diabetes, dementia and chronic kidney disease.
Review of Resident #51's most recent Minimum Data Set (MDS) dated [DATE], indicated he/she was assessed by staff to have severe cognitive impairment.
Review of Resident #51's physician orders, dated 6/24/22, indicated: Weight Weekly Tuesday.
Review of Resident #51's nutrition note, dated 9/6/23, indicated: Note Text: F/U (follow up) note: Will reinforce nursing to obtain his/her weekly weights to assess his/her weight status and cease further weight loss. Care Plan updated accordingly.
Review of Resident #51's medical record indicated a weight taken on 8/13/23 was 154 lbs (pounds) and the weight taken prior was on 6/28/23 which was 165.4 lbs.
During an interview on 9/7/23 at 1:29 P.M., the Dietitian said if the resident has an order for weekly weight then staff should be obtaining the weights weekly. The Dietitian said that weekly weights are not happening as they should be for Resident #51.
During an interview on 9/8/23 at 10:01 A.M., the Director of Nurses (DON) said the expectation for nursing staff is to obtain weights as ordered.
Based on observation, record review, and interview, the facility failed to ensure three Residents (#77,#38, #51), out of a sample of 43 residents received care consistent with professional standards of practice. Specifically, the facility failed:
1. For resident #77, the facility failed to administer Quetiapine (a medication used to treat schizophrenia, bipolar disorder), Keppra (a medication used to treat seizures), and Vimpat (a medication used to treat seizures), timely.
2. For Resident #38 and #51, the facility failed to to implement a physician's order to obtain weekly weights.
Findings include:
Standard of Practice for medication administration are as follow:
-Nurses are responsible for administering medications within their scope of practice.
-Nurses are knowledgeable about the effects, side effects, interaction of medications and take action as necessary.
-Nurses adhere to Five Rights of medication administration:
1. Right patient
2. Right drug
3. Right time
4. Right dose
5. Right route
Review of the facility policy titled Medication Administration, dated 10/2022 indicated the following:
-medication shall be administered only upon the order of the physician's who are members of the medical staff.
-medication must be administered in accordance with orders, including any required time frame.
1.) Resident #77 was admitted to the facility in May 2021 with diagnoses that included seizures and anxiety.
Review of the Minimum Data Set (MDS) assessment, dated 6/9/23, indicated the Resident was assessed to be alert and oriented with a Brief Interview for Mental Status (BIMS) score of 15 out of 15 (no cognitive deficits) and indicated he/she had no memory issues.
During an interview on 9/6/23 at 8:30 A.M., Resident #77 voiced being upset and said that most of the time he/she gets his/her morning medication late, including Quetiapine, Keppra, and Vimpat. Resident #77 said that it tends to happen more when the nurse giving the medications is new or does not work on the unit often. Resident #77 said that there are times that his/her medications for seizures that he/she is supposed to take at 8:00 A.M., will be given 1 to 3 hours late and that it causes anxiety to him/her.
Review of Resident #77's Physician's order indicated the following:
-an order dated 5/25/21 for Quetiapine 50 milligram (mg) by mouth twice a day at 8:00 A.M. and 8:00 P.M., for post-traumatic stress disorder (PTSD).
-an order dated 10/20/22 for Keppra 500 mg by mouth twice a day at 8:00 A.M. and 8:00 P.M., for seizures.
-an order dated 12/12/22 for Vimpat 150 mg by mouth twice a day at 9:00 A.M., and 9:00 P.M., for seizures.
Review of August 2023 Medication Administration Record indicated the following:
-8/1/2023 Quetiapine and Keppra were given at 9:55 A.M., 1 hour and 55 minutes after the scheduled times.
-8/2/2023 Quetiapine and Keppra were given at 9:47 A.M., 1 hour and 47 minutes after the scheduled time.
-8/4/2023 Quetiapine and Keppra were given at 9:34 A.M., 1 hour and 34 minutes after the scheduled time.
-8/8/2023 Quetiapine and Keppra were given at 11:17 A.M., 3 hours and 17 minutes after the scheduled time. Vimpat were given at 11:17 A.M., 2 hours and 17 minutes after the scheduled time.
-8/9/2023 Quetiapine and Keppra were given at 9:44 A.M., 1 hour and 44 minutes after the scheduled time.
-8/11/2023 Quetiapine and Keppra were given at 9:57 A.M., 1 hour and 57 minutes after the scheduled time.
-8/15/2023 Quetiapine and Keppra were given at 10:00 A.M., 2 hours after the scheduled time.
-8/16/2023 Quetiapine and Keppra were given at 10:53 A.M., 2 hours and 53 minutes after the scheduled time. Vimpat were given at 10:53 A.M., 1 hour and 53 minutes after the scheduled time.
-8/23/2023 Quetiapine and Keppra were given at 10:47 A.M., 2 hours and 47 minutes after the scheduled time. Vimpat were given at 10:47 A.M., 1 hour and 47 minutes after the scheduled time.
-8/25/2023 Quetiapine and Keppra were given at 9:20 A.M., 1 hour and 20 minutes after the scheduled time.
-8/29/2023 Quetiapine and Keppra were given at 9:26 A.M., 1 hour and 26 minutes after the scheduled time.
-8/31/2023 Quetiapine and Keppra were given at 9:48 A.M., 1 hour and 48 minutes after the scheduled time.
During an interview on 9/7/23 at 10:30 A.M., Nurse #8, said that she comes in after 8:00 A.M. She said that she starts medication administration right away after she gets a report from the previous shift but said she sometimes gets interrupted by other staff members that need help with residents. She said that there are times that scheduled medications are not given on time.
During an interview on 9/7/23 at 11:23 A.M., the Director of Nursing said that medication should be given within one hour of its scheduled time.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
ADL Care
(Tag F0677)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to provide the necessary activities of daily living for o...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to provide the necessary activities of daily living for one Resident (#57) who is dependent on staff out of a total sample of 43 residents. Specifically, the facility failed to remove unwanted facial hair for Resident #57.
Findings include:
Review of the facility policy titled ADL Support, dated and revised October 2022, indicated the following:
*Residents who are unable to carry out activities of daily living (ADLs) independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene.
*Appropriate care and services will be provided for residents who are unable to carry out ADLs independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with: Hygiene (grooming)
Review of the facility policy titled ADL - Personal Hygiene, dated and revised October 2022, indicated the following:
*Facial hair will be groomed as needed
Resident #57 was admitted to the facility in December 2020 with diagnoses including Alzheimer's disease and dementia.
Review of Resident #57's most recent Minimum Data Set (MDS) dated [DATE] indicated that the Resident had a Brief Interview for Mental Status score of 12 out of possible 15 indicating that he/she has moderate cognitive impairment. The MDS further indicated that Resident #57 requires extensive assistance with all ADLs including shaving.
The surveyor made the following observations:
*On 9/6/23 at 11:16 A.M., Resident #57 was observed having visible chin and upper lip hair. He/she said he/she would like it removed.
*On 9/7/23 at 12:12 P.M., Resident #57 was observed having visible chin and upper lip hair. He/she said he/she would really like it removed and it would be great if someone could shave it.
Review of Resident #57's Activities of Daily Living (ADL) self care deficit care plan, dated 12/10/20 indicated the following intervention:
*Grooming: assist of one
Review of Resident #57's document titled Personal Hygiene - Self Performance - How the resident maintains personal hygiene - including shaving indicated that the Resident required Total Dependence - full staff performance and one-person physical assist
Review of Resident #57's care plan did not indicate a history of refusing ADL care.
During an interview on 9/7/23 at 12:22 P.M., Certified Nursing Assistant (CNA) #2 said we ask residents if they would like their facial hair shaved when we notice it. She continued to say that Resident #57 was total dependent in all care. The surveyor and CNA #2 interviewed Resident #57 together and the Resident said he/she would like to have his/her facial hair removed and that it has been there for at least a month.
During an interview on 9/8/23 at 8:35 A.M., Nurse #6 said CNA's will ask residents if they want facial hair removed. She continued to say Resident #57 can refuse care, the surveyor and Nurse #6 went through Resident #57's medical record and did not see documentation for refusal of care, she said refusal of care should be documented.
During an interview on 9/8/23 at 9:58 A.M., the Director of Nursing and Administrator said CNA's should be asking dependent residents if they would like facial hair removed.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Quality of Care
(Tag F0684)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to notify the physician or nurse practitioner (NP) of the recommendat...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to notify the physician or nurse practitioner (NP) of the recommendation made by a consultant, for one Resident (#64), out of a total sample of 43 residents. Specifically, the staff failed to notify the physician or NP that the prescription for diabetic shoes provided by the podiatrist surgeon was misplaced, thus delaying Resident #64 in receiving the diabetic shoes.
Findings include:
Resident # 64 was admitted to the facility in April 2022 with diagnoses including type 2 diabetes mellitus and peripheral vascular disease.
Review of the Minimum Data Set (MDS), dated [DATE], indicated that Resident #64 scored a 12 out of a possible 15 on the Brief Interview of Mental Status (BIMS), which indicates moderate cognitive impairment.
During an interview on 9/6/23 at 12:24 P.M., Resident #64 said he/she was upset about a staff member not taking accountability. Resident #64 said that he/she is diabetic and has weakness on the left side of his/her body from a stroke. Resident #64 said that on 8/14/23, he/she went to see a podiatrist surgeon and he/she returned to the facility with a script for diabetic shoes and physical therapy. Resident #64 said that he/she gave the prescription for the diabetic shoes to the nurse on duty that day. Resident #64 said that he/she has not received the diabetic shoes because the nurse misplaced the prescription for the shoes. Resident #64 said that nobody has called the diabetic surgeon to request another script for the diabetic shoes.
Review of Resident #64's medical record, including nursing progress notes failed to indicate that the physician or NP was notified of the recommendation and script of diabetic shoe were misplaced.
During an interview on 9/7/23 at 10:22 A.M., the Director of Nursing said that she just found out about the recommendation and missing script for diabetic shoes yesterday. She said that the nurse that was on duty that day showed the prescription to the physical therapist, but no one knew what happened to the script.
During an interview on 9/7/23 at 10:43 A.M., the Rehab Director said that she was notified via phone call by nursing staff about the recommendation for physical therapy service for Resident #64. She said that she told the nursing staff that Resident #64 was already receiving rehab services at that time. She said that she did not see any script for Resident #64. She said that she was not aware of a script for diabetic shoes.
During an interview on 9/7/23 at 10:55 A.M., Nurse #1 said that Resident #64 gave her the script for diabetic shoes on 8/14/23 after returning from an appointment. Nurse #1 said that she left the script at the nurse's station desk to be filed. She said that the next day, she could not find the script. She said that she cannot recall if she notified anyone about the recommendation and that the script for diabetic shoes was misplaced.
During an interview on 9/7/23 at 11:50 A.M., the Nurse Practitioner said that she was not notified about the missing script for diabetic shoes.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Pressure Ulcer Prevention
(Tag F0686)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review and interview the facility failed to follow a physician's order for prevention of a pressur...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review and interview the facility failed to follow a physician's order for prevention of a pressure ulcer for one Resident (#43) out of a total sample of 43 residents.
Findings include:
Resident #43 was admitted to the facility in July 2022 with diagnoses including an unstageable pressure ulcer of right heel and left femur fracture.
Review of Resident #43's most recent Minimum Data Set (MDS) dated [DATE], indicated the Resident had a Brief Interview for Mental Status (BIMS) score of 11 out of a possible 15, which indicated he/she had moderate cognitive impairment. The MDS further indicated that Resident #43 requires extensive assistance with all activities of daily living and has pressure ulcers to bilateral heels.
On 9/6/23 at 8:18 A.M., the surveyor observed Resident #43 lying in his/her bed on a regular mattress.
On 9/7/23 at 6:56 A.M., the surveyor observed Resident #43 lying in his/her bed on a regular mattress.
On 9/7/23 at 9:47 A.M., the surveyor observed Resident #43 lying in his/her bed on a regular mattress.
Review of Resident #43's physician's orders indicated the following:
*Patient on air mattress, setting 200, monitor for functioning and right setting every shift. Initiated 8/16/22.
*Cleanse bilateral heel wounds daily with normal saline or wound cleanser. Apply calcium alginate and gauze island dressing with border. Off-load heels at all times, heel boots in bed or float on pillows.
Review of Resident #43's actual skin pressure/ non pressure care plan, initiated on 8/26/22 indicated the following intervention:
*Put a low air loss mattress on bed.
During an interview on 9/7/23 at 9:49 A.M., Nurse #5 said Resident #43 should be on an air mattress per the physician orders as he/she has open wounds to his/her bilateral heels.
During an interview on 9/7/23 at 2:43 P.M., the Director of Nursing said the expectation is that the physician's orders for Resident #43 are to be followed and said he/she should have an air mattress on his/her bed.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0692
(Tag F0692)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, policy review and record review, the facility failed to identify and address a significant weig...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, policy review and record review, the facility failed to identify and address a significant weight gain for 1 Resident (#6) out of a total sample of 43 Residents.
Findings include:
Review of the facility policy titled Weight Assessment and Interventions, dated and revised May 2019, indicated the following:
*Weights will be recorded in the medical record (electronic health record where available) for each resident.
*Any weight change of 5 lbs. (pounds) in a month and 3 lbs. in a week since their last assessment should be retaken within 72 hours for confirmation and verified by Nursing.
*Re weight should be reviewed by the Licensed Nursing
*Licensed Nurse should notify Dietitian of identified weight change once reviewed
*Dietitian notification should be documented within Resident's medical record
*The threshold for significant unplanned and undesired weight change will be based on the following criteria: 1 month - 5% weight change is significant, greater than 5% is severe.
Resident #6 was admitted to the facility in March 2023 with diagnoses including Alzheimer's disease, acute kidney failure and chronic obstructive pulmonary disease.
Review of Resident #6's most recent Minimum Data Set (MDS) dated [DATE], indicated that the Resident had a Brief Interview for Mental Status score of 3 out of a possible 15 indicating that he/she has severe cognitive impairment. Further review of the MDS indicated that the Resident required extensive assistance with all activities of daily living.
Review of Resident #6's weight history indicated the following:
*6/11/23: 192.6 lbs. (pounds)
*7/12/23: 205.4 lbs. - a 6.65% weight gain in one month
Review of Resident #6's nutritional risk care plan related to variable intake, dated and revised 6/12/23 indicated the following interventions:
*Diet consult PRN (as needed)
*Monitor wt. (weight) per facility protocol as ordered
Review of Resident #6's progress notes written by the Registered Dietitian (RD), dated 7/21/23 indicated the following:
*6/11/23, 192.6 lbs., po (by mouth) intake excellent, wt. gain is not desired. Continues on heart healthy diet. Rec (recommend) reweigh.
Review of Resident #6's medical record failed to indicate that a reweigh, assessment or any interventions were put into place for the Resident's significant weight gain from 6/11/23 to 7/12/23.
During an interview on 9/7/23 at 1:25 P.M., the Registered Dietitian said she would expect the RD to see a resident if a significant weight change is identified. She continued to say if a significant weight change is identified a reweigh would be done first and she depends on the aides for performing the reweigh and letting her know of the weight. She said getting reweighs are hard lately with staffing. She then said, following a reweigh the RD will always see the resident and do an assessment as soon as possible, typically when a significant weight change is first identified. The RD said she would then input the Resident's assessment and care plan and interventions if appropriate. The surveyor and RD went through Resident #6's care plan together and did not see any acknowledgement of the significant weight gain.
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, record review and interview, the facility failed to provide care according to professional standards of practice for one Resident (#310) with a Jejunostomy tube (a feeding tube: ...
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Based on observation, record review and interview, the facility failed to provide care according to professional standards of practice for one Resident (#310) with a Jejunostomy tube (a feeding tube: medical device used to provide liquid nourishment, fluids and medications by bypassing oral intake) out of a total sample of 43 residents.
Findings include:
Review of the facility's policy titled 'enteral feeding' last revised 10/22 indicated the following but not limited to:
*It is the policy of this center to provide enteral nutrition therapy to residents unable to obtain nutrition orally when such therapy is ordered by the physician and not clinical contraindicated.
* Jejunostomy tube a feeding tube placed directly into the small intestine.
*Continuous feeding: Enteral feeding delivered around the clock. Feedings are only stopped for medication administration and routine tube flushes. This type of feeding may or may not use and electronic pump but typically a pump is used.
*Administration and feeding sets:
-Feeding may be re-used for next scheduled feed as long as it is free from contamination, however
-Replace tubing and feeding sets every 24 hours or if contamination has occurred before that time.
Resident #310 was admitted to the facility in August 2023 with diagnoses that included dysphagia (swallowing difficulty), and gastrostomy status.
Review of Resident #310's Nursing evaluation V7 indicated the Resident has short term memory loss.
On 9/6/23 at 8:46 A.M., the surveyor observed a bottle of Osmolite 1.5 Cal which hung from the tube feed pole in Resident #310's room. The enteral feed formula bottle tube was connected to the Resident. The front of the bottle indicated it had been hung on 9/4/23 at 6:25 P.M.
Review of Resident #310's physician's orders indicated the following, initiated 8/17/23:
*Enteral feed orders every 24 hours related to dysphagia following other nontraumatic intracranial hemorrhage. Osmolite 1.5 at 50 ml/ hr. (milliliter/hour) continuously. Water flush 100 ml every four hours through the jejunostomy tube.
Review of Resident #310's Nutrition care plan, initiated 8/19/23 included the following intervention:
-Diet as ordered osmolite 1.5 60 ml for 22 hours, water flushes 200 ml every four hours.
During an interview on 9/6/23 at 2:23 P.M., Nurse #1 said a bottle of feeding should be changed every 24 hours. She further said that the Resident had been sent to the hospital on 9/5/23 and upon his/her return a new bottle of osmolite feed should have been initiated.
During an interview on 9/7/23 at 2:39 P.M., the Director of Nursing said enteral feeding should not be hung for more than 24 hours. She further said Resident #310's feeding should have been changed upon return from the hospital.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0694
(Tag F0694)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, policy review, and record review, the facility failed to provide care and maintenance of a peripherally inse...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, policy review, and record review, the facility failed to provide care and maintenance of a peripherally inserted IV (a thin flexible tube that is inserted into a vein for delivery of medication, blood or fluids directly into the bloodstream), consistent with professional standards of practice for one Resident (#51), out of a total sample of 43 residents. Specifically, the facility failed to date Resident #51's IV line on the day of insertion.
Findings include:
Review of the facility policy titled Peripheral Catheter Removal, dated 1/23, indicated Peripheral catheters are routinely discontinued every 72 hours and rotated to another site if therapy continues. If the resident has very poor venous access, the site is without problem, and a physician's order has been secured, the catheter may be left in greater than 72 hours. Peripheral catheter/needles are removed at the completion of therapy, and if the site is reddened, swollen, painful, or leaking/draining.
Resident #51 was admitted to the facility in June 2022 with diagnoses including Parkinson's, type 2 diabetes, dementia and chronic kidney disease.
Review of Resident #51's most recent Minimum Data Set (MDS) dated [DATE], indicated he/she was assessed by staff to have severe cognitive impairment.
On 9/6/23 at 9:01 A.M., the surveyor observed a peripheral IV in Resident #51's right upper arm not dated, the IV site was observed to be red at the insertion site.
On 9/6/23 at 12:11 P.M., the surveyor observed a peripheral IV in Resident #51's right upper arm not dated, the IV site was observed to be red at the insertion site.
On 9/7/23 at 7:12 A.M., the surveyor observed a peripheral IV in Resident #51's right upper arm not dated, the IV site was observed to be red at the insertion site.
Review of Resident #51's physician orders, dated 9/1/23, indicated May insert Peripheral line for IV hydration.
Review of Resident #51's nursing note, dated 9/6/23 time 5:07 P.M., indicated Completed his/her IV hydration this morning: Peripheral line to Right arm is in place, site is benign.
During an observation and interview on 9/7/23 at 8:53 A.M., Nurse #8 said that Resident #51's IV should have a date on it, so the nurses know how long the IV has been in. Nurse #8 said that the IV insertion site is very red.
During an interview on 9/7/23 at 8:58 A.M., the Assistant Director of Nurses (ADON) said that an IV should be labeled with the date it was inserted.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0698
(Tag F0698)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation and interview, the facility failed to provide care and services consistent with professional...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation and interview, the facility failed to provide care and services consistent with professional standards for one Resident (#22) who required renal dialysis (a life sustaining treatment that helps your body remove extra fluid and waste products from your blood when the kidneys are not able to) out of a total sample of 43 residents.
Specifically, the facility failed to ensure that clamps and pressure dressings were kept in Resident #22's room for an emergency related to a tunneled hemodialysis catheter (a plastic tube used for exchanging blood between a patient and a hemodialysis machine).
Findings include:
Resident #22 was admitted to the facility in September 2020 with diagnoses including type 2 diabetes, hypertension, end stage renal disease, and anemia.
Review of the most recent Minimum Data Set (MDS) dated [DATE], indicated he/she had severe cognitive impairments. Further review of the MDS indicated he/she required extensive assistance from a staff for activities of daily living (ADLs).
On 9/6/23 at 8:50 A.M., the surveyor observed Resident #22's room and there was not an emergency kit for his/her dialysis catheter and fistula.
On 9/6/23 at 12:10 P.M., the surveyor observed Resident #22's room and there was not an emergency kit for his/her dialysis catheter and fistula.
Review of Resident #22's physician orders, dated 8/30/22, indicated Dialysis M-W-F (Monday, Wednesday, Friday) 6:20 am (A.M.).
Review of Resident #22's nurses note, dated 8/4/23, indicated Have fistula at left arm,+ bruit. Right chest has tunnel catheter, dressing CDI (clean, dry and intact), continues on dialysis M, W, F.
During an interview on 9/7/23 at 8:44 A.M., Nurse #2 said he is not sure what emergency supplies should be bedside for a resident who is on dialysis.
During an interview on 9/7/23 at 8:59 A.M., the Assistant Director of Nurses (ADON) said that a Resident with a dialysis catheter or fistula should always have a emergency kit bedside with a clamp incase of an emergency.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0740
(Tag F0740)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview the facility failed to provide behavioral health services as recommended by th...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview the facility failed to provide behavioral health services as recommended by the behavioral health service therapist for one Resident (#78) out of a total sample of 43 residents.
Findings include:
Resident #78 was admitted to the facility in July 2023 with diagnoses including mood disorder and attention deficit hyperactive disorder.
Review of Resident #78's most recent Minimum Data Set (MDS) dated [DATE], indicated the Resident had a Brief Interview for Mental Status (BIMS) score of 12 out of a possible 15 indicating he/she has moderate cognitive impairment.
On 9/6/23 at 9:04 A.M., Resident #78 was observed in his/her room, Resident #78 said that he/she has not been receiving mental health therapy and really needs it. The Resident further said that he/she sees a therapist weekly in the community and said he/she is concerned of not receiving the services while at the rehab facility.
Review of the psychiatric evaluation and consultation report dated 8/2/23, indicated potential for decline in the setting of chronic illness and rehab placement. The report further indicated that patient will continue to benefit from supportive services, patient will also benefit from therapy multiple times per week.
Further review of medical record failed to indicate that behavioral therapy services had been provided weekly for Resident #78.
Review of Resident #78's psychotropic medication use care plan, revised 8/28/23 indicated the following intervention:
*Consult psych services as needed.
During an interview on 9/8/23 at 10:30 A.M., Social Worker (SW) #1 said that behavioral services are planned by the Director of Nursing and that she is the one that sends the names of the residents to be seen to the behavioral health service group. The SW said that she had not heard any concerns about Resident #78 not receiving services. The SW further said that if the behavioral therapy services were recommending weekly visits to the resident then the service should have been provided.
During an interview on 9/8/23 at 11:09 A.M., the Director of Nursing (DON) said the Resident should have continued to receive weekly behavioral therapy services for his/her well being. The DON further said she reached out to the behavioral health service group and said that the recommendations should have been followed and Resident #78 should have been seen weekly for behavioral health service therapy.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Drug Regimen Review
(Tag F0756)
Could have caused harm · This affected 1 resident
Based on record review and staff interview, the facility failed to ensure that the pharmacy recommendations were addressed by the attending physician for 1 Resident (#64), out of a total of 43 sampled...
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Based on record review and staff interview, the facility failed to ensure that the pharmacy recommendations were addressed by the attending physician for 1 Resident (#64), out of a total of 43 sampled residents.
Findings include:
Resident # 64 was admitted to the facility in April 2022 with diagnoses including type 2 diabetes mellitus and peripheral vascular disease.
Review of the monthly pharmacist recommendations for Resident #64 indicated the following:
- January 10, 2023, licensed pharmacist recommends to the physician checking for vitamin D level.
- February 14,2023, licensed pharmacist recommends to the physician checking for vitamin D level.
- March 14, 2023, licensed pharmacist recommends to the physician checking for vitamin D level.
- April 11, 2023, licensed pharmacist recommends to the physician checking for vitamin D level.
- May 9, 2023, licensed pharmacist recommends to the physician checking for vitamin D level.
- June 13, 2023, licensed pharmacist recommends to the physician checking for vitamin D level and strength of vitamin D tablet.
- July 11, 2023, licensed pharmacist recommends to the physician checking for vitamin D level and strength of vitamin D tablet.
- August 3, 2023, licensed pharmacist recommends to the physician checking for vitamin D level and strength of vitamin D tablet.
Review of Resident #64's medical record failed to indicate that the physician responded to the pharmacist's repeated recommendations.
During an interview on 9/7/23 at 2:30 P.M., the Director of Nurses reviewed Resident #64's medical chart and was unable to locate any evidence that the physician had reviewed and addressed the pharmacist recommendations for vitamin D level and strength of vitamin D tablet.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Medical Records
(Tag F0842)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. For Resident #43 staff signed off on Medication Administration Record (MAR) that the Resident had an air mattress when the Re...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. For Resident #43 staff signed off on Medication Administration Record (MAR) that the Resident had an air mattress when the Resident did not have one in his/her bed.
Resident #43 was admitted to the facility in July 2022 with diagnoses including unstageable pressure ulcer of right heel and left femur fracture.
Review of Resident #43's most recent Minimum Data Set (MDS) dated [DATE], indicated the Resident had a Brief Interview for Mental Status (BIMS) score of 11 out of a possible 15, which indicated he/she had moderate cognitive impairment. The MDS further indicated that Resident #43 requires extensive assistance with all activities of daily living and has pressure ulcers to bilateral heels.
On 9/6/23 at 8:18 A.M., the surveyor observed Resident #43 lying in his/her bed on a regular mattress.
On 9/7/23 at 6:56 A.M., the surveyor observed Resident #43 lying in his/her bed on a regular mattress.
On 9/7/23 at 9:47 A.M., the surveyor observed Resident #43 lying in his/her bed on a regular mattress.
Review of Resident #43's physician's orders indicated the following:
*Patient on air mattress, setting 200, monitor for functioning and right setting every shift. Initiated 8/16/22.
Review of Resident #43's actual skin pressure/ non pressure care plan, initiated on 8/26/22 indicated the following intervention:
*Put a low air loss mattress on bed.
Review of Resident #43's document titled 'Medication Administration Record' for the month of September 2023 indicated that staff signed off that Resident #43 had an air mattress and were monitoring for function and right setting when the Resident did not have an air mattress.
During an interview on 9/7/23 at 9:49 A.M., Nurse #5 said the Resident should have the air mattress on per the physician's orders and nurses should not be documenting if the Resident does not have the air mattress.
During an interview on 9/7/23 at 2:43 P.M., the Director of Nursing said nurses should not be documenting if the task is not completed and that Resident #43 should have the air mattress as per the physician's orders.
Based on observations, record reviews and interviews, the facility failed to maintain accurate medical records for two Residents (#80 and #43) out of a total sample of 43 residents. Specifically,
1. For Resident #80 staff signed off on the Treatment Administration Record (TAR) that a Resident was wearing a wander guard (a bracelet around the wrist or ankle that locks or alarms facility doors when resident is near them) when the Resident was not.
2. For Resident #43 staff signed off on Medication Administration Record (MAR) that the Resident had an air mattress when the Resident did not have one in his/her bed.
Findings include:
1. For Resident #80 staff signed off on the Treatment Administration Record (TAR) that a Resident was wearing a wander guard (a bracelet around the wrist or ankle that locks or alarms facility doors when resident is near them) when the Resident was not.
Resident #80 was admitted to the facility in May 2021 with diagnoses including cerebral infarction and dementia.
Review of Resident #80's most recent Minimum Data Set (MDS) dated [DATE] indicated that the Resident had a Brief Interview for Mental Status score of 4 out of a possible 15 indicating that he/she has severe cognitive impairment. Further review of the MDS indicated that the Resident has a history of wandering.
Review of Resident #80's physician's orders indicated the following:
*Wander guard to RLE (right lower extremity). Check for placement every shift. Initiated on 5/17/2021.
The surveyor made the following observations:
*On 9/6/23 at 11:01 A.M., the surveyor did not observe a wander guard on Resident #80.
*On 9/7/23 at 8:44 A.M., the surveyor did not observe a wander guard on Resident #80.
*On 9/8/23 at 8:21 A.M., the surveyor did not observe a wander guard on Resident #80.
Review of Resident #80's elopement care plan, initiated on 5/13/21 indicated the following intervention:
*Wander guard in place, check placement and function every shift.
Review of Resident #80's document titled Treatment Administration Record for the month of September 2023 indicated that staff signed off on Resident #80 wearing his/her wander guard when he/she was not wearing one.
During an interview on 9/8/23 at 8:35 A.M., Nurse #6 said she was not sure why staff are documenting that Resident #80 is wearing a wander guard when he/she has not been. She said staff are likely being lazy and checking things off when they should not be.
During an interview on 9/8/23 at 9:58 A.M., the Director of Nursing and the Administrator said staff should not be incorrectly documenting medical records.
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, and interviews the facility failed to ensure infection control practices were maintained to prevent the spread of infection during medication pass.
Findings include:
Review of f...
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Based on observations, and interviews the facility failed to ensure infection control practices were maintained to prevent the spread of infection during medication pass.
Findings include:
Review of facility policy titled 'Medication Administration' revised October 2022 indicated the following:
*Staff shall follow established facility infection control procedures (e.g. handwashing, antiseptic technique, gloves, isolation precautions) when these apply to the administration of medications.
During medication pass observation on 9/7/23 at 9:07 A.M., on the Andover resident care unit, Nurse #5 was observed placing two syringes directly on top of the medication cart then use them to withdraw medication from the bottles and administer medication into a resident's mouth. The syringes were placed inside the resident's mouth.
During medication pass observation on 9/7/23 at 9:42 A.M., on the Andover resident care unit. Nurse #5 was observed preparing to administer subcutaneous injection to a resident's abdomen. Nurse #5 was observed palpating the resident's abdomen without gloves on, then proceeded to put on gloves without performing hand hygiene then administered the subcutaneous injection.
During an interview on 9/7/23 at 1:31 P.M., Nurse #5 said she should not have placed the syringes directly on the medication cart and then used them to administer oral medications to the resident, she further said she should have performed hand hygiene prior to wearing the gloves as to prevent transmission of infectious material.
During an interview on 9/7/23 at 2:22 P.M., the Director of Nursing said nurses should observe infection control practices during medication administration and that syringes placed directly on medication cart and into the resident's mouth is an infection control breach. She further said Nurse #5 should have performed hand hygiene prior to putting her gloves on as she had come in contact directly with the resident's bare skin.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0552
(Tag F0552)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Resident #43 was admitted to the facility in [DATE] with diagnoses including depression.
Review of Resident #43's most recent...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Resident #43 was admitted to the facility in [DATE] with diagnoses including depression.
Review of Resident #43's most recent Minimum Data Set (MDS) dated [DATE], indicated the Resident had a Brief Interview for Mental Status (BIMS) score of 11 out of a possible 15, which indicated he/she had moderate cognitive impairment.
Review of Resident #43's physician orders indicated the following orders:
*Mirtazapine tablet 15 mg (Milligram) give one tablet by mouth at bedtime for appetite stimulant. Initiated on [DATE].
Review of Resident #43's medical record indicated the psychotropic medication consent had expired on [DATE].
Review of Resident #43's Medication Administration Record (MAR) for August and [DATE], indicated the Resident received the psychotropic medication.
During an interview on [DATE] at 9:04 A.M., Nurse #1 said psychotropic consents should be reviewed and updated yearly.
During an interview on [DATE] at 9:56 A.M., the Director of Nursing said psychotropic medication consents should be updated yearly.
2. Resident #31 was admitted to the facility in [DATE] with diagnoses including unspecified psychosis, unspecified dementia, and major depressive disorder.
Review of Resident #31's most recent Minimum Data Set (MDS) dated [DATE] indicated the Resident had Brief Interview for Mental Status score of 00 indicating that he/she has severe cognitive impairment. Further review of the MDS indicated that Resident #31 currently uses psychotropic medications.
Review of Resident #31's physician orders indicated the following orders:
*Zoloft Oral Tablet (Sertraline HCl) (a medication for major depressive disorder). Give 75 mg (milligrams) by mouth one time a day for depression. Initiated on [DATE].
*Seroquel Tablet 25 mg (Quetiapine Fumarate) (an anti-psychotic medication). Give 1.5 tablet by mouth one time a day related to unspecified psychosis. Initiated on [DATE].
Review of Resident #31's medical record indicated his/her psychotropic medication consents for Zoloft and Seroquel had expired on [DATE].
Review of Resident #31's Medication Administration Record indicated that the Resident is actively taking both medications.
During an interview on [DATE] at 2:17 P.M., Nurse #11 said psychotropic consents should be renewed yearly and the facility is training someone new to complete them.
During an interview on [DATE] at 9:58 A.M., the Director of Nursing and Administrator said psychotropic consent forms should be updated yearly.
3. Resident #57 was admitted to the facility in [DATE] with diagnoses including Alzheimer's disease and dementia.
Review of Resident #57's most recent Minimum Data Set (MDS) dated [DATE] indicated that the Resident had a Brief Interview for Mental Status score of 12 out of possible 15 indicating that he/she has moderate cognitive impairment. The MDS further indicated that Resident #57 currently uses psychotropic medications.
Review of Resident #57's physician orders indicated the following orders:
*Zyprexa Tablet 2.5 mg (milligrams) (Olanzapine) (a medication psychosis). Give 1 tablet by mouth two times a day for agitation/psychosis related to dementia. Initiated [DATE].
*Sertraline HCl Tablet 50 mg (a medication for major depressive disorder). Give 1 tablet by mouth one time a day related to dementia.
Review of Resident #57's medical record indicated his/her psychotropic medication consents for Zyprexa and Sertraline expired on [DATE].
Review of Resident #57's Medication Administration Record indicated that the Resident is actively taking both medications.
During an interview on [DATE] at 2:17 P.M., Nurse #11 said psychotropic consents should be renewed yearly and the facility is training someone new to complete them.
During an interview on [DATE] at 9:58 A.M., the Director of Nursing and Administrator said psychotropic consent forms should be updated yearly.
Based on record reviews and interviews, the facility failed to obtain consent for the use of psychotropic medications for four Residents (#22, #31, #57, #43) out of a total sample of 43 Residents.
Findings include:
Review of the facility policy titled Psychotropic Medication, dated [DATE], indicated Psychotropic drugs- any drug that affects brain activities associated with mental processes and behavior. These drugs include but are not limited to drugs in the following categories:
- Anti-psychotic
- Anti-anxiety
- Anti-depressant
- Hypnotic
1. Resident #22 was admitted to the facility in [DATE] with diagnoses including type 2 diabetes, hypertension, end stage renal disease, and anemia.
Review of the most recent Minimum Data Set (MDS) dated [DATE], indicated he/she had severe cognitive impairments. Further review of the MDS indicated he/she required extensive assistance from a staff for activities of daily living (ADLs).
Review of Resident #22's physician orders, dated [DATE], indicated: Remeron Tablet (antidepressant) Give 7.5 mg by mouth at bedtime for depression take THREE half tabs to equal 22.5 mg (milligrams) dose.
Review of Resident #22's physician orders, dated [DATE], indicated: Wellbutrin SR (antidepressant) Tablet Extended Release 12 Hour 100 mg. Give 100 mg by mouth one time a day for depression.
Review of Resident #22's [DATE] Medication Administration Record (MAR), indicated his/her Remeron and Wellbutrin was administered daily from [DATE] to [DATE].
Review of Resident #22's medical record failed to indicate that a psychotropic consent was obtained for Remeron and Wellbutrin.
During an interview on [DATE] at 8:51 A.M., Nurse #1 said psychotropic medication consents are obtained on admission and then yearly.
During an interview on [DATE] at 10:01 A.M., the Director of Nurses (DON) said the expectation for psychotropic medications consent is to obtain them on admission, with a new medication order and yearly.
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** 5.) For Resident #43, the facility failed to follow physician's orders for floating heels while in bed using off-loading boots.
...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 5.) For Resident #43, the facility failed to follow physician's orders for floating heels while in bed using off-loading boots.
Resident #43 was admitted to the facility in July 2022 with diagnoses including unstageable pressure ulcer of right heel and left femur fracture.
Review of Resident #43's most recent Minimum Data Set (MDS) dated [DATE], indicated the Resident had a Brief Interview for Mental Status (BIMS) score of 11 out of a possible 15, which indicated he/she had moderate cognitive impairment. The MDS further indicated that Resident #43 requires extensive assistance with all activities of daily living and has pressure ulcers to bilateral heels.
On 9/6/23 at 8:18 A.M., the surveyor observed Resident #43 lying in his/her bed his/her heels were observed to be directly on the mattress, the offloading boots were observed on the wheelchair.
On 9/7/23 at 6:56 A.M., the surveyor observed Resident #43 lying in his/her bed his/her heels were observed to be directly on the mattress, the offloading boots were observed on the wheelchair.
On 9/7/23 at 9:47 A.M., the surveyor observed Resident #43 lying in his/her bed his/her heels were observed to be directly on the mattress, the offloading boots were observed on the wheelchair.
Review of Resident #43's physician's orders indicated the following:
*Offload bilateral heels using pressure off-loading boots, float heels while in bed every shift for heels wounds. Initiated 8/15/23.
*Offload heels when in bed with pillows every shift. Initiated 8/17/22.
Review of Resident #43's actual skin pressure/ non pressure care plan, initiated on 8/26/22 indicated the following intervention:
*Heel protectors in bed.
*Elevated heels off mattress.
During an interview on 9/7/23 at 9:49 A.M., Nurse #5 said the Resident #43's heels should be off the mattress and said the off-loading boots should be on.
During an interview on 9/7/23 at 2:43 P.M., the Director of Nursing said the expectation is that the physician's orders for Resident #43 are to be followed and said the off-loading boots should have been on when in bed.
6.) For Resident #78 the facility failed to develop a plan of care for seizure diagnosis.
Resident #78 was admitted to the facility in July 2023 with diagnoses including generalized epilepsy and epileptic syndromes, symptomatic epilepsy and epileptic syndromes with complex partial seizures.
Review of Resident #78's most recent Minimum Data Set (MDS) dated [DATE], indicated that the Resident had a Brief Interview for Mental Status (BIMS)score of 12 out of a possible 15 indicating he/she had moderate cognitive impairment.
On 9/6/23 at 9:04 A.M., Resident #78 was observed in his/her room, he/she said he/she has seizures mostly in his/her sleep and has reported this to the nurses.
Review of Resident #78's medical record failed to indicate a care plan for seizure diagnosis.
During an interview on 9/8/23 at 12:06 P.M., Nurse #1 said Resident #78 should have a care plan for seizure diagnosis.
During an interview on 9/8/23 at 12:28 P.M., the Director of Nursing said Resident #78 should have a care plan for seizures.
3.) Resident #74 was admitted to the facility in December 2020 with diagnoses including adult failure to thrive and unspecified dementia.
Review of Resident #74's most recent Minimum Data Set (MDS) dated [DATE] indicated that the Resident was unable to complete Brief Interview for Mental Status exam indicating that he/she has severe cognitive impairment. The MDS further indicated that Resident #74 requires extensive assistance with all activities of daily living and is at risk for developing pressure ulcers.
The surveyor made the following observations:
*On 9/6/23 at 12:46 P.M., Resident #74 was observed sleeping in bed with his/her heels directly on the mattress, not offloaded.
*On 9/7/23 at 6:59 A.M. and 8:53 A.M., Resident #74 was observed sleeping in bed with his/her heels directly on the mattress, not offloaded.
*On 9/8/23 at 8:45 A.M., Resident #74 was observed lying in bed with his/her heels directly on the mattress, not offloaded.
Review of Resident #74's physician's orders indicated the following:
* Off load heels while in bed, three times a day off load heels when in bed. Initiated 8/29/23
* Apply skin prep to right heel. Offload when in bed, two times a day. Initiated 8/30/23
* Monitor right red boggy heel. Elevate when in bed, three times a day. Initiated 8/30/23.
Review of Resident #74's pressure area care plan, initiated on 8/31/23 indicated the following intervention:
*Use heels up/elevate feet while in bed
During an interview on 9/8/23 at 8:35 A.M., Nurse #6 said Resident #74's heels should be elevated while in bed and physician's orders should be followed. The surveyor and Nurse #6 went into Resident #74's room and observed him/her lying in bed with his/her heels directly in the mattress. Nurse #6 then elevated his/her heels and said they should not be on the mattress.
During an interview on 9/8/23 at 9:58 A.M., the Director of Nursing and Administrator said their expectations are for physician's orders to be followed and Resident #74's heels should have been elevated when in bed.
4.) Resident #80 was admitted to the facility in May 2021 with diagnoses including cerebral infarction and dementia.
Review of Resident #80's most recent Minimum Data Set (MDS) dated [DATE] indicated that the Resident had a Brief Interview for Mental Status score of 4 out of a possible 15 indicating that he/she has severe cognitive impairment. Further review of the MDS indicated that the Resident has a history of wandering.
Review of Resident #80's physician's orders indicated the following:
*Wander guard to RLE (right lower extremity). Check for placement every shift. Initiated on 5/17/2021.
The surveyor made the following observations:
*On 9/6/23 at 11:01 A.M., the surveyor did not observe a wander guard on Resident #80.
*On 9/7/23 at 8:44 A.M., the surveyor did not observe a wander guard on Resident #80.
*On 9/8/23 at 8:21 A.M., the surveyor did not observe a wander guard on Resident #80.
Review of Resident #80's elopement care plan, initiated on 5/13/21 indicated the following intervention:
*Wander guard in place, check placement and function every shift.
Review of Resident #80's document titled NSH Nursing Evaluation, dated 6/2/22 indicated the following under the elopement section:
*Resident is at risk for elopement
During an interview on 9/8/23 at 8:35 A.M., Nurse #6 said Resident #80 is a wanderer, but she has no knowledge of him/her wearing a wander guard. Nurse #2 said the Resident does not wear a wander guard. The surveyor and Nurse #6 reviewed Resident #80's medical record and she was unaware of the physician's order for a wander guard.
During an interview on 9/8/23 at 9:58 A.M., the Director of Nursing and Administrator said their expectations are for physician's orders to be followed.
2.) Resident #22 was admitted to the facility in September 2020 with diagnoses including type 2 diabetes, hypertension, end stage renal disease, and anemia.
Review of the most recent Minimum Data Set (MDS) dated [DATE], indicated he/she had severe cognitive impairments. Further review of the MDS indicated he/she required extensive assistance from a staff for activities of daily living (ADLs).
On 9/6/23 at 12:14 P.M., the surveyor observed Resident #22 in bed, the air mattress was set to 220 pounds (lbs). The surveyor also observed a sticker on the air mattress pump that read Bed setting set at 170.
On 9/7/23 at 7:10 A.M., the surveyor observed Resident #22 in bed, the air mattress was set to 220 pounds. The surveyor also observed a sticker on the air mattress pump that read Bed setting set at 170.
On 9/7/23 at 12:20 P.M., the surveyor observed Resident #22 in bed, the air mattress was set to 220 pounds. The surveyor also observed a sticker on the air mattress pump that read Bed setting set at 170.
Review of Resident #22's actual skin care plan dated 4/30/21, indicated Perimeter Air mattress to bed, Check function and placement. Set to setting appropriate for weight in 160-170 range.
Review of Resident #22's Norton Scale, dated 7/9/23, indicated he/she scored a 6 which indicates Resident #22 is at high risk for skin breakdown.
Review of Resident #22's most recent weight, dated 9/6/23, indicated he/she weighed 140.6 lbs.
During an interview and observation on 9/7/23 at 12:58 P.M., Nurse #2 said the air mattress should be set to the residents' weight and said Resident #22's mattress is currently set to 220 lbs.
Based on observation, record review and interview the facility failed to implement the plan of care for six Residents (#161, #22, #74, #80, #43, #78) out of a total sample of 43 residents. Specifically:
1.) For Resident #161, the facility failed to implement a physician's order for a lymphedema pump (a medical device that helps reduce swelling and discomfort caused by lymphedema).
2.) For Resident #22, who is at high risk for skin breakdown, the facility failed to set his/her air mattress to the correct settings.
3.) For Resident #74, the facility failed to follow physician's orders for heels to be offloaded when in bed.
4.) For Resident #80, the facility failed to ensure he/she was wearing a wanderguard (a bracelet around the wrist or ankle that locks or alarms facility doors when resident is near them) as ordered.
5.) For Resident #43, the facility failed to follow physician's orders for floating heels while in bed using off-loading boots.
6.) For Resident #78, the facility failed to develop a plan of care for his/her seizure diagnosis.
Findings include:
1.) Resident #161 was admitted to the facility in October 2021, and had diagnoses that included lymphedema (a condition that results in swelling of the leg and arm).
Review of the most recent Minimum Data Set (MDS) assessment, dated 7/20/23, indicated that on the Brief Interview for Mental Status (BIMS) Resident #161 scored a 15 out of a possible 15, indicating intact cognition. The MDS further indicated Resident #161 required assistance from staff for personal hygiene.
On 9/6/23 at 9:19 A.M., the surveyor observed Resident #161 having breakfast in his/her room. The surveyor observed a large amount of swelling in his/her bilateral lower extremities (BLE). Resident #161 said that he/she has lymphedema in his/her BLE. The surveyor observed a compression sleeve pump hanging on the bathroom door. Resident #161 said that he/she has not used the lymphedema pump for more than a month because the hose connected to the compression sleeve pump is leaking air. Resident #161 said that he/she is supposed to use the lymphedema pump for at least an hour twice a day to help with the swelling. Resident #161 said that a Certified Nursing Assistant (CNA) would help him/her set up the lymphedema pump but then his/her CNA's stopped doing it when the lymphedema pump hose broke. Resident #161 said that nursing staff were made aware of the broken hose.
Review of Resident #161's medical record indicated a physician's order dated 1/30/2023 to apply lymphedema pump to BLE twice a day for lymphedema. Further review of the medical record, including progress notes failed to indicate that the lymphedema pump was not working.
During an interview on 9/6/23 at 1:59 P.M., Nurse #9 said that she does not assist Resident #161 in applying the lymphedema pump. Nurse #9 said was not aware that the lymphedema pump was not working.
During an interview on 9/6/23 at 2:11 P.M., CNA#6 said that she provides care to Resident #161 regularly. She said that the lymphedema pump broke over a month ago and that she notified someone from the rehab department but cannot recall who and when. She said that Resident #161 has not used the lymphedema pump for BLE for over a month.
During an interview on 9/6/23 at 2:18 P.M., the Director of Nursing said that she was not aware that Resident #161 has not used the lymphedema pump. She said that the staff should have notified her or the Administrator that the lymphedema pump is not working right away so that they could have contacted the company.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Respiratory Care
(Tag F0695)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4. Resident #85 was admitted to the facility in September 2022 with diagnoses including acute and chronic respiratory failure, u...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4. Resident #85 was admitted to the facility in September 2022 with diagnoses including acute and chronic respiratory failure, unspecified whether with hypoxia or hypercapnia.
Review of Resident #85's most recent Minimum Data Set (MDS) dated [DATE], indicated the Resident scored a 3 out of a possible 15 on the Brief Interview for Mental Status (BIMS) which indicated he/she was cognitively impaired.
During an observation on 9/6/23 at 8:24 A.M., Resident #85 was observed lying in bed wearing oxygen via nasal cannula at 1.5 liters/ minute.
During an observation on 9/7/23 at 6:56 A.M., Resident #85 was observed lying in bed wearing oxygen via nasal cannula at 1.5 liters/minute.
Review of Resident #85's medical record failed to indicate a physician order for oxygen use.
During an interview on 9/7/23 at 9:57 A.M., Nurse #5 said there should be a physician order for oxygen administration and should include changing tubes once a week.
During an interview on 9/7/23 at 2:41 P.M., the Director of Nursing said a physician order for oxygen use is required.
3. Resident #7 was admitted to the facility in August 2021 with diagnoses including anemia, obstructive sleep apnea and heart failure.
Review of Resident #7's most recent Minimum Data Set, dated [DATE] indicated that the Resident had a Brief Interview for Mental Score of 8 out of a possible 15 indicating that he/she has severe cognitive impairment. Further review of the MDS indicated that the Resident requires extensive assistance with all activities of daily living.
The surveyor made the following observations:
*On 9/6/23 at 12:41 P.M., Resident #7 was observed sleeping in bed receiving oxygen at 3.5 liters via nasal cannula. The oxygen tubing was not dated. The humidification bottle was empty. The filter for the oxygen machine was completely coated with debris and paper particles.
*On 9/7/23 at 6:55 A.M., Resident #7 was observed sleeping in bed receiving oxygen at 3.5 liters via nasal cannula. The oxygen tubing was not dated. The humidification bottle was empty.
*On 9/7/23 at 12:20 P.M., Resident #7 was observed sleeping in bed receiving oxygen at 3.5 liters via nasal cannula. The humidification bottle was empty.
Review of Resident #7's physician's orders indicated the following:
*Oxygen at 1 liters/minute via Nasal Cannula to maintain saturation above 92%. Initiated 1/13/23.
There was no physician order mentioning labeling and dating of oxygen tubing, cleaning the oxygen filter, or ensuring the humidification bottle is filled with water.
During an interview on 9/7/23 at 2:17 P.M., Nurse #7 said oxygen should be administered per physician's orders, that the oxygen tubing should be changed weekly, that the filter is changed weekly, and that the humidification bottle should have water in it to keep moisture in the oxygen for the Resident. She continued to say there should be physician's orders for changing of oxygen tubing and filters. The surveyor and Nurse #7 went into Resident #7's room and observed the oxygen at 3.5 liters and the humidification bottle empty.
During an interview on 9/8/23 at 8:35 A.M., Nurse #6 said Resident #7 should have an order for weekly oxygen tube changing, the humidification bottle should not be empty, and oxygen should be set to the physician's order.
During an interview on 9/8/23 at 9:58 A.M., the Director of Nursing and Administrator said their expectations are for oxygen to be set to physician's orders and for there to be orders to change tubing weekly, clean filters and that the humidification bottle should have water in it.
2. Resident #91 was admitted to the facility in April 2023 with diagnoses including chronic obstructive pulmonary disease and emphysema.
Review of the most recent Minimum Data Set (MDS) dated [DATE], indicated he/she scored a 15 out of 15 on the Brief Interview for Mental Status (BIMS) which indicated he/she was cognitively intact.
During an observation on 9/6/23 at 8:57 A.M., Resident #91 was observed lying in bed wearing oxygen via nasal cannula. The oxygen tubing was not dated.
Review of Resident #91's medical record on 9/6/23 at 9:45 A.M., the medical record failed to indicate a physician order for oxygen.
During an observation on 9/6/23 at 12:17 P.M., Resident #91 was observed lying in bed wearing oxygen via nasal cannula. The oxygen tubing was not dated.
During an interview on 9/7/23 at 8:44 A.M., Nurse #2 said that oxygen tubing should be dated and changed every week. Nurse #2 said that if a resident is on oxygen then there should be an oxygen order in place.
During an interview on 9/7/23 at 8:57 A.M., the Assistant Director of Nurses (ADON) said that oxygen tubing should be changed and dated weekly. The ADON also said that oxygen should have a physician order. Based on observation, record review, and interview the facility failed to ensure staff provided respiratory care consistent with professional standards for four Residents (#41, #91, #7 and #85) out of a total sample of 43 residents.
Specifically:
1. For Resident #41, the facility staff failed obtain a physician's order for the care of a tracheostomy (trach) (a surgically created artificial opening through the neck into the trachea, usually for the relief of difficulty in breathing) including the size and type of trach and failed to ensure that Nurse responsible for the care for 1 Resident (#41) out of 2 Resident's with a tracheostomy were trained, knowledgeable, and competent to provide safe care.
2. For Resident #91, the facility failed to obtain oxygen orders and date oxygen tubing.
3. For Residents #7, the facility failed to obtain oxygen orders, date oxygen tubing, fill humidification and clean oxygen filter.
4. For Resident #85, the facility failed to obtain oxygen orders.
Findings include:
Review of the facility's policy titled Oxygen Administration, dated 10/22, indicated Oxygen is administered by a Licensed Nurses with a Physician's Order in order to provide a resident with sufficient oxygen to their blood and tissues. Orders should specify the oxygen equipment and flow rate or concentration required as routine or PRN (as needed). When humidification is used, reusable bottle water will be changed every 24 hours and disposable bottles will be changed weekly or when empty. All tubing will be changed at least weekly, more often if soiling with secretions.
1. Resident #41 was admitted to the facility in August 2021 with diagnoses that included paralysis of vocal cord and larynx, and chronic respiratory failure with hypoxia.
Review of the Minimum Data Set (MDS) assessment, dated 8/17/23, indicated the Resident was assessed to be alert and oriented with a Brief Interview for Mental Status (BIMS) score of 13 out of 15 (no cognitive deficits) and had no memory issues.
On 9/6/23 at 8:53 A.M., the surveyor observed Resident #41 in a wheelchair with tracheostomy that is capped. Resident #41 told the surveyor that he/she has a disposable inner cannula that the nurses replace daily. Resident #41 does not know what type of tracheostomy or size he/she has used.
General observations of the emergency equipment item's available in Resident #41's room included the following:
-bag valve mask
-suction machine
-suction catheter kit
-oxygen concentrator
-multiple boxes of disposable inner cannula 6.5
-box of [NAME] trach 7.5
During an interview on 9/7/23 at 12:20 P.M., Nurse #3 told the surveyor that she was not certain what type and size of trach tube Resident #41 had. She reviewed Resident #41's medical record and said that there is no physician's order nor any information on what type and size of trach Resident #41 has. Nurse #3 said that she is a new Nurse and floats to different units and that she does not know Resident #41 very well.
During an interview on 9/7/23 at 12:50 P.M., the Director of Nursing said that the Nurse providing care for Resident #41 should know what type and size of trach he/she has. She reviewed Resident #41's medical record and said that there is no physician order or information on what type and size of trach Resident #41 has.
During an interview on 9/7/12 at 1:11 P.M., the Respiratory Therapist said that Resident #41 has a [NAME] 7.5 tach with disposable 6.5 inner cannula. She said that there should be a physician's order for the trach and the disposable inner cannula. She said that she provides education to the nursing staff and does a competency/hands-on every six months. She said that nursing staff should be aware of what was required to care for the trach.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0726
(Tag F0726)
Could have caused harm · This affected multiple residents
Based on the Facility Assessment, document review, in-servicing records, and interview, the facility failed to ensure that nursing staff completed annual competencies for Intravenous (IV) Therapy. Spe...
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Based on the Facility Assessment, document review, in-servicing records, and interview, the facility failed to ensure that nursing staff completed annual competencies for Intravenous (IV) Therapy. Specifically, the facility failed to train nursing staff on the care and treatment of a Peripherally Inserted Central Catheter (PICC- intravenous catheter inserted into a vein in the upper arm and is advanced until the internal tip of the catheter is in the superior vena cava which is one of the central venous system veins that carries blood to the heart) and a peripheral IV (a thin flexible tube that is inserted into a vein for delivery of medication, blood or fluids directly into the bloodstream).
Findings include:
According to the Board of Registration in Nursing, 244 CMR 9.00: Standards of Conduct, a competency is defined as the application of knowledge and the use of affective, cognitive, and psychomotor skills required for the role of a nurse licensed by the Board and for the delivery of safe nursing care in accordance with accepted standards of practice.
Competency is a measurable pattern of knowledge, skills, abilities, behaviors, and other characteristics that an individual needs to perform work roles or occupational functions successfully.
Review of the facility assessment (a document with a competency-based approach produced by the facility assessing the capability of the facility and its population), dated 8/7/23, included the following:
- The facility accepts residents with combinations of conditions that require complex care and management.
- All departments have annual competencies completed by the SDC and their Department Manager.
- The Following Nursing competencies are reviewed on hire and as needed (PRN):
* IV therapy- programming pump, peripheral and central lines
- Licensed Nurse Annually- IV administration, certified then annual education.
During the entrance conference on 9/6/23 at 8:06 A.M. the Director of Nurses said that currently in house the facility has two PICC lines and one peripheral IV.
On 9/6/23 at 8:41 A.M. the surveyor observed Resident #24's a PICC line in his/her right upper arm.
Review of Resident #24's physician orders, dated 8/31/23, indicated Saline Flush Intravenous Solution 0.9 % (Sodium Chloride Flush) Use 1 applicatorful intravenously three times a day for Before and after IV medication. PICC: Measure external catheter length on admission, with each dressing change, & as needed. PICC: Change transparent dressing 24 hours post-insertion or on admission, then every week & as needed. PICC Valved: Flush with 10 ML normal saline, infuse medication, then 10 ML normal saline. PICC: Change transparent dressing 24 hours post-insertion or on admission, then every week & as needed.
Review of Resident #24's September Medication Administration Record (MAR) indicated Saline Flush Intravenous Solution 0.9 % (Sodium Chloride Flush) Use 1 applicatorful intravenously three times a day for Before and after IV medication was administered twice on 9/7/23.
On 9/6/23 and 9/7/23 on multiple occasions the surveyor observed a peripheral IV in Resident #51's right upper arm.
Review of Resident #51's physician orders, dated 9/2/23, indicated Dextrose Intravenous Solution 5 %, Use 75 milliliter intravenously every shift for Weight loss and dehydration Infuse at 75 ML (milliliters) x (times) 2 liter.
Review of Resident #51's September MAR, indicated Dextrose Intravenous Solution 5 % was administered twice on 9/6/23.
During an interview on 9/8/23 at 12:16 A.M., Nurse #1 said she has worked at the facility for almost 4 years and said she has not had any trainings to manage an IV or PICC line. Nurse #1 said she has had many residents with IV's in this facility.
During an interview on 9/8/23 at 12:20 A.M., Nurse #9 said she is a new hire and said she has not had any IV training.
During an interview on 9/8/23 at 12:22 A.M., Nurse #2 said she has worked here for many years and said he has not had any IV training at this facility.
During an interview on 9/8/23 at 10:04 PM, the Director of Nurses (DON) and the Administrator said the required annual competencies and initial competencies had not been completed by nursing staff for the care and treatment of a PICC line or a peripheral IV.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Unnecessary Medications
(Tag F0759)
Could have caused harm · This affected multiple residents
Based on observations, record reviews, policy review, and interviews, the facility failed to ensure it was free from a medication error rate of greater than 5 percent. Three out of three nurses observ...
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Based on observations, record reviews, policy review, and interviews, the facility failed to ensure it was free from a medication error rate of greater than 5 percent. Three out of three nurses observed made seven errors in 34 opportunities on three of three units resulting in a medication error rate of 20.59%. These errors impacted three Residents (#1, #94 and #312), out of 4 residents observed.
Findings include:
Review of the facility policy titled Medication Administration, dated 10/2022 indicated the following but not limited to:
*The medication nurse shall assure that the correct medication is administered by checking the physician's order and the medication label.
*Medications ordered for a particular resident may not be administered to another resident.
* Medication must be administered in accordance with orders, including any required time frame.
1. During a medication pass on 9/7/23 at 8:50 A.M., the surveyor observed Nurse #3 prepare and administer the following medications to Resident #1:
*Sertraline 50 mg (milligram) one tablet by mouth, the name on the blister pack belonged to another resident.
*Multivitamin one tablet by mouth.
Review of current physician's orders indicated the following medications should have been administered at 9:00 A.M.
*Multivitamin-minerals tablet. Give one tablet by mouth one time a day for nutritional supplement.
*Zoloft oral Tablet 50 mg (sertraline HCL) give 50 mg by mouth one time a day related to major depressive disorder.
*Omeprazole oral capsule delayed release 40 mg give one tablet by mouth once a day for acid reflux.
During an interview at 1:19 P.M., Nurse #3 said during medication pass she checks the orders against what she administers, she said not giving omeprazole was a medication omission error, not giving multivitamin with mineral was a wrong medication error and using another resident's medication was an error per the facility policy.
2. During a medication pass on 9/7/23 at 9:21 A.M., the surveyor observed Nurse #5 prepare and administer the following medications to Resident #94:
*Sevelamer 800 mg one tablet by mouth.
*Aspirin EC (enteric coated) 81 mg by mouth
Review of current physician's orders indicated the following medications should have been administered:
*Sevelamer carbonate oral tablet 800 mg give one tablet by mouth with meals.
*Aspirin 81 mg oral tablet chewable give one tablet by mouth.
*Esomeprazole magnesium oral capsule delayed release 40 mg. Give one capsule by mouth two times a day.
During an interview on 9/7/23 at 1:31 P.M., Nurse #5 she should have administered sevelamer with breakfast per the orders, she said giving enteric coated aspirin was a wrong medication and not giving esomeprazole is an omission error and she should have mentioned that the medication was not available at the time of administration.
3. During a medication pass on 9/7/23 at 10:04 A.M., the surveyor observed Nurse #2 prepare and administer the following medications to Resident #312:
*Nicotine patch 7 mg two patches applied topically to the left upper back. The nicotine patches belonged to another resident and were not prescribed to Resident #312.
Review of current physician's orders indicated the following medications should have been administered at 9:00 A.M.
*Nicotine Transdermal patch 24 hour 14 mg/24 hour apply 14 milligram transdermally in the morning for smoking cessation and remove per schedule.
*Multivitamin with iron give one tablet by mouth
During an interview on 9/7/23 at 1:23 P.M., Nurse #2 said he should not borrow medications from other residents as the facility does not allow or encourage that per policy, he also said not giving the multivitamin with iron was a medication omission error.
During an interview on 9/7/23 at 2:22 P.M., the Director of Nursing said the nurses are to follow the seven rights of medication administration which are right patient, right drug, right dose, right time, right route, right reason and right documentation. She further said nurses should not be using other residents prescribed medications.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0760
(Tag F0760)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, policy review, and record review, the facility failed to ensure residents were free of significant medicatio...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, policy review, and record review, the facility failed to ensure residents were free of significant medication errors for two Residents (#78 and 310), out of a total sample of 43 residents. Specifically, the facility failed:
1. For Resident #78 , to ensure Clobazam and levetiracetam (medications used to treat seizure) were given timely per facility policy , resulting in a significant medication error.
2. For Resident #310, to ensure medication used for prophylaxis treatment for antiviral after a lung transplant was available for administration to the resident.
Findings include:
Standard of Practice for medication administration are as follow:
-Nurses are responsible for administering medications within their scope of practice.
-Nurses are knowledgeable about the effects, side effects, interaction of medications and take action as necessary.
-Nurses adhere to Five Rights of medication administration:
1. Right patient
2. Right drug
3. Right time
4. Right dose
5. Right route
Review of the facility policy titled Medication Administration, dated 10/2022 indicated the following:
-medication shall be administered only upon the order of the physician's who are members of the medical staff.
-medication must be administered in accordance with orders, including any required time frame.
1. For Resident #78 the facility failed to administer clobazam and levetiracetam (medications used to treat seizure) timely.
Resident #78 was admitted to the facility in July 2023 with diagnoses including seizure disorder.
Review of Resident #78's most recent Minimum Data Set (MDS) dated [DATE], indicated the Resident had a Brief Interview for Mental Status (BIMS) score of 12 out of a possible 15 indicating he/she has moderate cognitive impairment.
On 9/6/23 at 9:04 A.M., Resident #78 was observed in his/her room, Resident #78 said that he/she has been receiving his/her seizure medications late at times close to 12 P.M. The Resident further said she/he has had multiple seizures at night and has reported to the nursing staff.
Review of Resident #78's physician's orders indicated the following:
*Clobazam oral tablet 10 mg (milligram) give one time a day at 8 A.M. for anti-seizure
*Levetiracetam ER (extended release) oral tablet 24 hour 500 mg give four (4) tablets one time a day at 9:00 A.M. for anticonvulsant.
Review of August 2023 Medication Administration Record indicated the following:
8/1/23 clobazam 10 mg was given at 10:32 A.M., 2 hours and 32 minutes after scheduled time
8/1/23 Levetiracetam 2000 mg was given at 10:32 A.M., 1 hour and 32 minutes after scheduled time.
8/5/23 clobazam 10 mg was given at 10:47 A.M., 2 hours and 47 minutes after scheduled time
8/5/23 Levetiracetam 2000 mg was given at 10:43 A.M., 1 hour and 43 minutes after scheduled time.
8/7/23 clobazam 10 mg was given at 3:36 P.M., 7 hours and 36 minutes after scheduled time.
8/7/23 Levetiracetam 2000 mg was given at 3:36 P.M., 6 hours and 36 minutes after scheduled time.
8/9/23 clobazam 10 mg was given at 10:40 A.M., 2 hours and 40 minutes after scheduled time.
8/9/23 Levetiracetam 2000 mg was given at 10:40 A.M., 1 hour and 40 minutes after scheduled times.
8/10/23 clobazam 10 mg was given at 10:42 A.M., 2 hours and 42 minutes after scheduled time.
8/10/23 Levetiracetam 2000 mg was given at 10:45 A.M., 1 hour and 45 minutes after scheduled time.
8/11/23 clobazam 10 mg was given at 10:28 A.M., 2 hours and 28 minutes after scheduled time.
8/11/23 Levetiracetam 2000 mg was given at 10:28 A.M., 1 hour and 28 minutes after scheduled time.
8/12/23 clobazam 10 mg was given at 11:03 A.M., 3 hours and 3 minutes after scheduled time.
8/12/23 Levetiracetam 2000 mg was given at 1:13 P.M., 4 hours and 13 minutes after scheduled time
8/13/23 clobazam 10 mg was given at 10:36 A.M., 2 hours and 36 minutes after scheduled time.
8/13/23 Levetiracetam 2000 mg was given at 10:36 A.M., 1 hour 36 minutes after scheduled times.
8/23/23 clobazam 10 mg was given at 12:45 P.M., 4 hours and 45 minutes after scheduled time.
8/23/23 Levetiracetam 2000 mg was given at 12:48 P.M., 3 hours and 48 minutes after scheduled time.
8/25/23 clobazam 10 mg was given at 12:21 P.M., 4 hours and 21 minutes after scheduled time.
8/25/23 Levetiracetam 2000 mg was given at 12:23 P.M., 3 hours and 23 minutes after scheduled time.
8/30/23 clobazam 10 mg was given at 10:43 A.M., 2 hours and 43 minutes after scheduled time.
8/30/23 Levetiracetam 2000 mg was given at 12:45 P.M., 3 hours and 45 minutes after scheduled time.
During an interview on 9/8/23 at 12:06 P.M., Nurse #1 said medications are given one hour before and one hour after the scheduled time. Nurse #1 said the facility process for medication administration is pour give and then chart so the times showing on the medication administration records would be accurate. She further said the nurses gets pulled different ways during medication pass times, from answering phone calls, answering call lights and other forms of distractions that adds up to late medication administrations. Nurse #1 said if Resident #78 continues to receive medications late he/she could have a major seizure and be hospitalized .
During an interview on 9/8/23 at 12:28 P.M., the Director of Nursing said medications are to be given one hour before and one hour after the scheduled times. She further said if Resident #78 does not receive his/her medications on time could be in jeopardy of having a major seizure.
2. For Resident #310, to ensure medication used for prophylaxis treatment for antiviral after a lung transplant was available for administration to the resident.
Resident #310 was admitted to the facility in August 2023 with diagnoses that included lung transplant.
Review of Resident #310's Nursing evaluation V7 indicated the Resident has short term memory loss.
Review of Resident #310's medical record indicated the Resident had missed multiple doses of his/her antiviral medication.
Review of Resident #310's physician's orders indicated the following, initiated 8/17/23:
*Valganciclovir HCL (hydrochloride) oral solution reconstituted 50 mg/ ml (milligram/ milliliter) give 9 ml via gastrostomy tube two times a day related to immunodeficiency.
Review of September 2023 Medication administration Record indicated on the following days the Resident did not receive his/her medications:
9/1/23, 9/2/23, 9/3/23, 9/4/23, 9/5/23, 9/6/23 and 9/7/23.
During an interview on 9/7/23 at 9:03 A.M., Nurse #5 said they did not have the medication on hand, and that pharmacy had said they was an issue with insurance and were working with the Resident's family to find an alternative. She further said she was not sure if the physician had been notified of the medication not being available. Nurse #5 said if there was any notification it would be in the progress notes.
During an interview on 9/7/23 at 10:48 A.M., the Director of Nursing said she was not aware that there were issues with obtaining Resident #310's medications. She further said that per the facility policy the facility would have to pick up the cost of the medication for the Resident as they admitted him/her to the facility. The Director of Nursing said the medication is important for the Resident as he/she is a lung transplant patient and nursing staff should have notified the physician to either obtain an alternative treatment for Resident #310.
During an interview on 9/8/23 at 10:14 A.M., Nurse Practitioner (NP) #1 said the nursing staff had not made her aware that the Resident did not have his/her antiviral medication. She said the Resident is at risk for viral infection and could lead to complications with the lung transplant and possible hospitalization. She further said if staff notified her of the issues with pharmacy she would have reached out to the lung transplant surgeon to find an alternative treatment. She also said no one asked her to fill out a prior authorization form from pharmacy.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0761
(Tag F0761)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. During a medication pass on [DATE] at 9:21 A.M., on the Andover unit cart one. The surveyor observed a large while pill in a ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. During a medication pass on [DATE] at 9:21 A.M., on the Andover unit cart one. The surveyor observed a large while pill in a cup in the top drawer of the medication cart. The medication cup did not have a label or name to identify what the medication.
During an interview on [DATE] at 9:23 A.M., Nurse #5 said medications are to be stored in their original containers and she was not able to identify what the large white pill was.
During an interview on [DATE] at 2:22 P.M., the Director of Nursing said medications should not be free floating in the medications carts without identification. She further said all medications should be in their original pharmacy packages or manufactures.
2. On [DATE] at 10:35 A.M., the surveyor observed the following in the Andover Unit Medication Cart 2:
- Two Incruse Ellipta inhalers opened and undated.
- Two Ventolin inhalers opened and undated.
- 127 loose pills of various shapes, sizes in colors.
During an interview on [DATE] at 10:40 A.M., Nurse #10 said the medication cart should be clean with no loose medication. Nurse #10 said it is usually the night nurse's responsibility to clean it out but all nurses are expected to keep it clean. Nurse #10 was unsure if certain medications needed to be dated once opened.
During an interview on [DATE] at 11:05 A.M., Nurse #1 said the expectation is for night shift to clean out the medication carts once a month. Nurse #1 said she would not expect to see that many loose medications in the medication cart. Nurse #1 said medications like inhalers should be dated once opened.
During an interview on [DATE] at 11:19 A.M., the Director of Nursing said the expectation is for every nurse to look over the medication cart at the beginning of the shift for cleanliness and all nursing staff are responsible for the medication cart.
Based on observation, interview and policy review the facility failed to ensure that 1. one of two medication carts was locked and secured on the [NAME] unit and 2. Medication carts were kept clean and opened medications dated/labeled per manufacturers guidelines on the Andover Unit Cart 2. and 3. Medications were stored in the original, labeled containers received from the pharmacy.
Findings include:
Review of facility policy titled Medication Storage, revision date 10/2022 included the following:
-All medications will be stored in a locked cabinet, cart of medication room that is accessible only to authorized personnel.
-Medications will be stored in an orderly, organized manner in a clean area.
-Medications will be stored in the original, labeled containers received from the pharmacy.
-Expired, discontinued and/or contaminated medications will be removed from the medication storage areas and disposed of in accordance with facility policy.
1. On [DATE] at 8:49 A.M., the surveyor observed a medication cart on the [NAME] unit hallway unlocked and unsupervised. No staff were present.
During an interview on [DATE] at 8:51 A.M., Nurse #1 said the medication cart should always be locked if the nurse is not present.
During an interview on [DATE] at 10:01 A.M., the Director of Nurses (DON) said that she expects the medication carts locked at all times unless a nurse is present at the cart.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Food Safety
(Tag F0812)
Could have caused harm · This affected multiple residents
Based on observation, policy review and interview the facility failed to 1) properly store food items to prevent the risk of foodborne illness and 2) follow proper food handling practices to prevent t...
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Based on observation, policy review and interview the facility failed to 1) properly store food items to prevent the risk of foodborne illness and 2) follow proper food handling practices to prevent the risk of foodborne illness and contamination.
Findings include:
Review of the facility policy titled General Food Preparation and Handling, undated, indicated the following:
*Food Storage: Foods are received, checked and stored properly as soon as they are delivered.
*Food will be prepared and served with clean tongs, scoops, forks, spoons, spatulas or other suitable implements to avoid manual contact of prepared foods. Any utensil or serving dish must be thoroughly cleaned and sanitized prior to use.
*Use tongs or other serving utensils to serve breads or other items. Never touch food directly with bare hands.
*Leftovers must be dated, labeled, covered and in a refrigerator. Use leftovers within 3 days or discard.
1) During the initial walkthrough of the kitchen on 9/6/23 at 7:15 A.M., the surveyor made the following observations:
*A container of chicken salad with a preparation date of 8/28 and a discard date of 8/31
*A container of hot dogs, opened and not labeled or dated.
*A container of diced potatoes labeled 9/1.
*A container of congealed chicken, dated as 8/29 with a use by date of 9/2.
*A container of sliced deli meat with a use by date of 8/30.
*Numerous boxes directly on the floor in the freezer, a frozen pie was also directly on the floor.
*Personal food was observed in a reach-in refrigerator.
*Boxes of food products were directly on the floor in the dry storage room.
During an interview on 9/7/23 at 11:48 A.M., the Foodservice Director said all items should be labeled with the name of item, the date prepared and expired date. She said food should not be stored for more than three days, nothing should be stored directly on the floor and staff's personal food should not be stored with resident food.
2) During the follow up visit to the kitchen on 9/7/23 at 11:50 A.M., the surveyor observed the following during the lunch service tray line:
*The cook removed her gloves, did not perform hand hygiene, grabbed the bottom of a set of tongs (where the food touches) with her bare hands and then grabbed a baked potato from the oven. The same set of tongs were then used to grab chicken from a different oven.
*At 11:59 A.M., the cook removed her gloves, did not perform hand hygiene and grabbed the bottom of another pair of tongs (where the food touches) and then grabbed a baked potato from the oven.
During an interview on 9/7/23 at 2:02 P.M., the Foodservice Director said her expectations are for the cook not to use her bare hands to grab tongs where food will be in contact with.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0943
(Tag F0943)
Could have caused harm · This affected most or all residents
Based on document review and interview, for 9 out of 9 sampled employee personnel files the facility failed to provide annual abuse training for their staff, as required and per facility policy. Speci...
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Based on document review and interview, for 9 out of 9 sampled employee personnel files the facility failed to provide annual abuse training for their staff, as required and per facility policy. Specifically, the facility failed to provide in-servicing that included resident abuse prohibition training.
Findings include:
Review of the facility policy titled Abuse review date 10/23/22 included the following:
Training:
-Facility personnel will be trained on hire at orientation, bi-annually and as needed on an on going basis
Prevention:
-The facility will provide staff on orientation, annually and as determined, information on how and to whom they may report concerns, incidents, and grievances without fear of retribution.
Identification:
-Instruct all staff to report immediately, without fear of reprisal, any knowledge or suspicion of suspected abuse, neglect, mistreatment, and/or misappropriation of property.
-Identify events, such as suspicious bruising of residents, occurrences, patterns, and trends, that may indicate abuse, neglect and/or mistreatment.
During an interview on 9/8/23 at 12:30 P.M., The Director of Nursing (DON) and Human Resources (HR) Representative said the facility attempted to locate staff training records for three requested employees and could not find any proof that the required in-service training had been done by staff.
During an interview on 9/8/23 at 12:51 P.M., HR representative said she only does the HR side of the training and said the Staff Development Coordinator (SDC) is responsible for Abuse training and other nursing training. HR said they just hired a new SDC and said they have been without a SDC for some time.
Five additional Certified Nursing Assistant (CNA) employee personnel files and one additional Nurse file were requested and given to the surveyors. Review of the files failed to indicate annual abuse training was completed.
During an interview on 9/8/23 at 1:36 P.M., Certified Nurse Aide #3 (CNA) said she thinks the last time she had abuse training was three years ago.
During an interview on 9/8/23 at 1:37 P.M., Nurse #2 said the last time he can remember having any training including abuse training was about two years ago.
During an interview on 9/8/23 at 1:40 P.M., Nurse #8 said she had training in 2020 and said she has had none since.
During an interview on 9/8/23 at 1:41 P.M., Activities Assistant #1 said the last time she had abuse training or any training's was in 2020.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0947
(Tag F0947)
Could have caused harm · This affected most or all residents
Based on record review and interview, the facility failed to ensure that 5 of 5 staff reviewed received 12 hours of mandatory in-service training in a year.
Findings include:
Review of 5 Certified Nu...
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Based on record review and interview, the facility failed to ensure that 5 of 5 staff reviewed received 12 hours of mandatory in-service training in a year.
Findings include:
Review of 5 Certified Nursing Assistants (CNA) employee records indicated that 5 out of 5 employees did not complete the mandatory 12 hours of education required.
During an interview on 9/8/23 at 12:30 P.M., The Director of Nursing and the Human Resources Representative said the facility attempted to locate staff training records and could not find any proof that the required in-service training had been done by staff.
During interviews on 9/8/23 between 1:36 P.M., and 1:44 P.M., CNA #3, CNA #4, and CNA #6 said they have not received any in-service education in the past 2 years.
During an interview on 9/8/23 at 2:00 P.M., The Director of Nursing (DON) said she was unsure what the yearly in-service requirements were for the CNA's, but said she would find out.
During an interview on 9/8/23 at 2:04 P.M., The Director of Nursing said that each CNA is required to complete 12 hours of mandatory in-service training each year with additional hours if needed in any area.
Feb 2023
2 deficiencies
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Comprehensive Care Plan
(Tag F0656)
Could have caused harm · This affected 1 resident
Based on records reviewed and interviews, for two of four sampled residents (Resident #2 and Resident #4), the Facility failed to ensure staff consistently implemented and followed interventions ident...
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Based on records reviewed and interviews, for two of four sampled residents (Resident #2 and Resident #4), the Facility failed to ensure staff consistently implemented and followed interventions identified in their comprehensive plans of care related to assessments and prevention of skin breakdown.
Findings include
The Facility Policy, titled, Comprehensive Care Plan, dated 01/28/22, indicated the services provided or arranged by the Facility, as outlined by the comprehensive care plan would be provided by qualified persons in accordance with each resident's written plan of care.
The Facility Policy, titled, Pressure Injury Prevention Program, dated 02/18/22, indicated the Facility would provide care, treatment and services to promote prevention of pressure injuries, and implement individualized, comprehensive plan of care interventions to reduce or remove underlying risk factors, and nursing staff would observe the resident for reddened or blanched areas.
1) Resident #2 was admitted to the Facility in August 2022, diagnoses included polyneuropathy (simultaneous malfunction of many peripheral nerves throughout the body), left pubis fracture, right pubis fracture, lumbar fracture, falls, malnutrition, anemia, and alcohol abuse.
Resident #2's Skin Care Plan, dated, 08/28/22, indicated nursing staff would complete weekly skin condition checks.
Resident #2's physician's order, dated 10/29/22, indicated nursing to complete weekly skin checks every Thursday on the evening shift.
Review of Resident #2's Treatment Administration Record (TAR), dated January 2023 and February 2023, (up to the date of this survey, 02/22/23), indicated there was no documentation to support any weekly skin checks were completed by nursing, during this referenced time period.
Further review of Resident #2's medical record indicated the last weekly skin check performed by nursing was dated 11/24/22, and the Facility was unable to provide any additional documentation to show skin assessments were completed.
2) Resident #4 was admitted to the Facility in January 2023, diagnoses included left femur fracture with surgical intervention, falls, diabetes, obesity, and chronic kidney disease.
The Norton Scale for Predicting Risk of Pressure Ulcers, dated 01/08/23, indicated Resident #4 was at high risk for skin breakdown.
Resident #4's Skin Care Plan, dated, 01/08/23, indicated nursing staff would complete weekly skin condition checks.
Review of Resident #4's medical record indicated that although he/she was identified by nursing as being at risk or skin breakdown, there was no documentation to support nursing obtained or transcribed a physician order for weekly skin checks, or that nursing completed weekly skin condition checks.
During interview on 02/22/23 at 1:42 P.M., The Director of Nurses (DON) said weekly skin condition checks should be included in the physician's orders and completed weekly.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0658
(Tag F0658)
Could have caused harm · This affected 1 resident
Based on records reviewed and interviews, for one of four sampled residents, (Resident #4), the Facility failed to ensure staff provided care and services met professional standards of nursing practic...
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Based on records reviewed and interviews, for one of four sampled residents, (Resident #4), the Facility failed to ensure staff provided care and services met professional standards of nursing practice, when his/her left knee surgical wound dehisced (opened), and the physician's order for treatment was not transcribed by nursing, was not added to his/her Treatment Administration Records (TAR) and the treatment and assessment of the wound were not documented.
Findings include:
The Facility policy, titled Physician Visits and Medical Orders, dated 02/18/22, indicated medical orders would reflect changes in care and changes in treatment, and members of the interdisciplinary team would provide care, services, and treatment according to the most recent medical orders and laws, regulations, and standards of practice.
Resident #4 was admitted to the Facility in January 2023, diagnoses included left femur (thigh bone) fracture with surgical intervention, falls, diabetes, obesity, and chronic kidney disease.
Review of Facility's Wound Treatment Auditing Line List Report, dated February 2023, indicated Resident #4 had a wound on his/her left knee, and a treatment was ordered for Santyl (used to help healing skin ulcers), Calcium Alginate (typically applied to diabetic wounds, venous wounds, full-thickness burns, split-thickness graft donor sites, pressure ulcers, cavity wounds, and chronic ulcers), and a border dressing.
The Nurse Progress Note, dated 02/20/23, indicated Resident #4's left knee surgical wound was open, the Nurse Practitioner was notified, and instructed nursing to make an appointment with his/her orthopedic physician.
Review of Resident #4's medical record indicated there was no documentation on 2/20/23 (or after that) to support nursing obtained measurements of the wound, transcribed physician's orders for treatment of the wound, or that wound care treatment was administered.
Further review of Resident #4's medical record indicated there was no documentation to support he/she had a follow up appointment with the orthopedic physician for his/her left knee surgical wound.
During interview on 02/22/23 at 4:40 P.M., Nurse Supervisor #1 said that on 02/21/23 she and the Director of Nurses (DON) assessed Resident #4's left knee incision, emailed a picture of it to the Nurse Practitioner, and the DON spoke to the wound doctor and obtained an order for treatment. Nurse Supervisor #1 said the DON verbally told her the treatment was Santyl, calcium alginate, and a border dressing, which she applied.
Nurse Supervisor #1 said she thought the DON documented and entered the treatment order into Resident #4's medical record. Nurse Supervisor #1 said she did not review Resident #4's medical record to ensure the new treatment was transcribed onto his/her TAR, and said she did not complete documentation on Resident #4's TAR after she completed the wound care treatment to his/her left knee.
During interview on 02/22/23 at 3:41 P.M., the Director of Nurses (DON) said that on 02/21/23 she and Nurse Supervisor #1 assessed Resident #4's left knee incision and she obtained the treatment order from the wound doctor. The DON said she wrote measurements down and gave them to Nurse Supervisor #1, verbally told her the treatment order, and thought Nurse Supervisor #1 would document the treatment and assessment.
The DON said nursing staff were expected to document any resident change in condition, symptoms, communication with a physician or nurse practitioner, new orders, any treatment provided, and ongoing observations in the medical record. The DON said Resident #4's wound assessment and treatment order should have been in his/her medical record, but were not.
Aug 2022
12 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0657
(Tag F0657)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review and policy review, the facility failed to update the plan of care after a choking episode for ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review and policy review, the facility failed to update the plan of care after a choking episode for 1 Resident (#4) out of a total sample of 27 residents.
Findings include:
Review of facility policy titled 'Comprehensive Care Plan', reviewed 1/28/22, indicated the following:
-The facility shall provide an individualized, interdisciplinary plan of care for all residents that shall be appropriate to the resident's needs, strengths, results of diagnostic testing limitation and goals.
- All staff using the computerized plan of care shall be responsible for interdisciplinary collaborations to establish goals and appropriate interventions, as well as ongoing evaluations and revisions.
Resident #4 was admitted to the facility in April 2022 with diagnoses including macular degeneration, Barrett's esophagus (a change to the cells lining the esophagus) and gastroesophageal reflux disease (a digestive disease in which stomach acid or bile irritates the lining of the esophagus).
Review of Resident #4's Minimum Data Set Assessment (MDS) dated [DATE], indicated the Resident was cognitively intact and scored a 15 out of 15 on the Brief Interview for Mental Status (BIMS). The MDS further indicated the Resident had no behaviors, did not reject care and required assistance with care activities.
During an interview on 8/11/22, at 11:24 A.M., Resident #4 said he/she did choke on his/her pills about a month ago and said he/she was given all of his/her pills and a Tums was in the cup with the pills and he/she didn't know it was in the same cup. Resident #4 said he/she usually takes all of his/her pills at once and when he/she did that he/she started to choke on the Tums. Resident #4 said the nurse that gave him/her the medications didn't give him/her the Heimlich maneuver but called another nurse to help and that nurse performed the Heimlich maneuver and he/she was able to cough up the Tums and another pill.
Review of Resident #4's medical record indicated the following:
-A nurses note dated 7/10/22, at 1:01 P.M.: Resident receiving pills at 11 A.M. while sitting up on the bed. Resident began choking on a Tums (a large chewable tablet used to treat heartburn) that he/she mistakenly swallowed without chewing. Attempted Heimlich maneuver x 2, Resident spitting out water, but pill remained stuck in his/her throat, unable to dislodge. Requested assist from another nurse and Heimlich performed with success, a Tums and a pill were spit out. Nurse Practitioner notified
-A Nurse Practitioner progress note dated 7/11/22, at 11:35 A.M.: Choking and hypoxia (a decrease in oxygen).Resident had a recent choking episode over the weekend due to him/her being given too many pills along with a Tums that he/she was not told to chew and his/her vision is poor.
Further review of Resident #4's medical record failed to indicate any care plans related to the choking event were implemented.
On 8/11/22, at 12:29 P.M., the Administrator acknowledged there was no care plan update after the Resident choked on his/her medications.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0658
(Tag F0658)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to obtain a physician's order for a topical treatment for...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to obtain a physician's order for a topical treatment for 1 Resident (#87) out of a total sample of 27 Residents.
Findings include:
Review of the Code of Massachusetts Regulations Section 9.03- Standards of Conduct for Nurses, current through 8/5/22, indicated a nurse licensed by the Board shall not administer any prescription drug or non-prescription drug to any person in the course of nursing practice except as directed by an authorized prescriber.
Review of facility policy titled 'Med Admin- Topical', effective 11/2019, indicated the following:
*Purpose: The purpose of this procedure is to provide guidelines for the safe administration of topical medications.
*Preparation: Verify that there is a physician's medication order for this procedure.
Resident #87 was admitted to the facility in July 2022 with diagnoses including anoxic brain damage, (a brain injury caused by a lack of oxygen to the brain), aphasia (loss of ability to understand or express speech) and cognitive communication deficit.
Review of Resident #87's Minimum Data Set Assessment (MDS) dated [DATE], indicated the Resident was moderately cognitively impaired and scored a 10 out of 15 on the Brief Interview for Mental Status (BIMS). The MDS further indicated the Resident had no behaviors, did not reject care, was incontinent of bowel and bladder, required extensive assistance with care activities and was at risk for developing pressure ulcers/injuries.
On 8/09/22, at 7:55 A.M., the surveyor observed Resident #87 in bed. He/she appeared thin and said he/she had some back pain.
Review of Resident #87's medical record indicated the following:
-An admission nursing evaluation dated 7/19/22, which indicated the Resident had a Stage 1 pressure injury ( intact skin with non-blanchable redness of a localized area usually over a bony prominence) on his/her coccyx measuring 6 centimeters (cm) x 6 cm.
-Norton Pressure Ulcer scales (a tool used to assess the risk for pressure ulcer) dated 7/19/22, and 7/26/22, which indicated the Resident was a high risk for developing pressure ulcers.
- A physician's order dated 8/3/22: Change Allevyn dressing (a foam adhesive dressing used on shallow, granulating wounds) on coccyx every shift and as needed if soiled.
Further review of Resident #87's clinical record failed to indicate any additional treatment orders.
During an interview on 8/10/22, at 12:28 P.M., Nurse #3 said that he was very familiar with Resident #87. Nurse #3 said when the Resident was admitted to the facility he/she had a Stage 1 pressure injury on his/her coccyx and the skin was intact but a dark red. Nurse #3 said that sometime after Resident #87 was admitted , the area opened up. Nurse #3 said there is an order for daily wound care which includes Calmoseptine (a medication used to protect skin) and a dressing.
On 8/11/22 at 9:55 A.M., the surveyor observed Nurse #3 perform wound care for Resident #87. Resident #87 was lying in bed and his/her coccyx had an open wound on the left side. Nurse #3 said he was also going to apply topical medication patches to the Resident before he did the dressing change. Nurse #3 washed his hands, applied gloves, removed a marker from his pocket. Nurse #3 then labeled the topical patches for the Resident's back with the date and applied the patches to the Resident's back. Nurse #3 then used a paper measuring tape to measure Resident #87's wound. Nurse #3 then picked up a single use plastic cup with a thick white cream inside of it and said that it was Calmoseptine. Nurse #3 scooped the cream onto his gloved hands and applied the cream directly onto Resident #87's open wound. Nurse #3 then applied an Allevyn dressing on top of the open area.
During an interview on 8/11/22 at 10:50 A.M., Nurse #3 said there does not need to be an order for Calmoseptine and that he doesn't normally use any type of applicator for topical treatments.
During an interview on 8/11/22 at 1:45 P.M., the Infection Control Nurse said an order for any topical treatment is required, including Calmoseptine.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Pressure Ulcer Prevention
(Tag F0686)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review and policy review, the facility 1) failed to develop and implement a comprehensiv...
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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 1) failed to develop and implement a comprehensive care plan for pressure ulcers resulting in the worsening of a pressure ulcer for 1 Resident (#87) and 2) failed to ensure 1 Resident (#68) was seen by the wound care physician in accordance with physician orders, out of a total sample of 27 residents.
Findings include:
Review of facility policy titled 'Pressure Ulcer (Injury) Prevention Program', reviewed 2/18/22, indicated the following:
*Definition:
-The National Pressure Ulcer Advisory Panel (NPUAP) defines a pressure ulcer (injury) as, localized damage to the skin and/or underlying soft tissue usually over a bony prominence or related to a medical or other device. The injury can present as intact skin or an open ulcer and may be painful. The injury occurs as a result of intense and/or prolonged pressure or pressure in combination with shear. The tolerance of soft tissue for pressure and shear may also be affected by microclimate, nutrition, perfusion, co-morbidities and condition of the soft tissue.
*Stage 1:
-Non-blanchable erythema (discoloration of the skin that does not turn white when pressed) of intact skin is the heralding lesion of skin ulceration. Other indicators of Stage 1 may include: pain, areas of warmth or coolness as compared to surrounding tissue, and firm or soft areas.
*Stage 2:
-Partial thickness skin loss involves the dermis (the inner layer of the two main layers of skin). The ulcer is superficially open with a red-pink wound bed. No slough or bruising (bruising indicates suspected deep tissue injury). The ulcer may also present as an intact or open serum-filled blister
*Risk factors that may have an impact on the development, treatment and/or healing of pressure ulcers include:
-Pressure points and tissue tolerance
-Friction and/or shearing force
-Undernutrition, malnutrition, and hydration deficits
-Moisture and the impact of moisture on the skin
-Exposure of skin to urinary and fecal incontinence
-Impaired/ decreased mobility and decreased functional ability
*Policy:
-Pointe Group Care shall have a system in place that assures observations are timely and appropriate; interventions are implemented, monitored, and revised as appropriate; and changes in condition are recognized, evaluated, reported to the resident's attending practitioner and other healthcare professionals (i.e. wound nurse) as appropriate.
-This facility shall provide care, treatment and services to: promote the prevention of pressure ulcer (injury) development; promote the healing of pressure ulcers (injuries) that are present; prevent development of additional pressure ulcers.
-This facility's pressure ulcer (injury) prevention and treatment program shall include:
*Identifying residents at risk for developing pressure ulcers (injuries)
*Identifying the presence of pressure ulcers (injuries) at the time of admission
*Identifying and evaluating the risk factors and changes in the resident's condition
*Identifying and evaluating risk factors that can be removed or modified
*Implementing individualized, comprehensive plan of care (interventions) to attempt to stabilize, reduce or remove underlying risk factors
Procedure:
-Daily monitoring of Pressure Ulcer (Injury) shall include:
*With each dressing change, or at least weekly, the pressure ulcer (injury) wound shall be assessed and documented: date, location of ulcer and staging, size (perpendicular measurement of the greatest extent of length and width of the ulceration), depth of the pressure ulcer (injury) wound, presence, location and extent of any undermining or tunneling/ sinus tract
Based upon the assessment and resident's clinical condition, choices and identified needs, the resident's plan of care shall include interventions to:
-Redistribute pressure
-Minimize the resident's skin exposure to moisture
-Keep the resident's skin clean
-Provide appropriate pressure redistributing support services
-Provide non-irritating surfaces
Preventive interventions for all residents at risk:
-Use pressure redistribution devices, i.e. gels, air fluidized mattresses, low air mattresses, 4-inch convoluted foam pads, when appropriate
-Place a pillow(s) under the resident's lower leg(s), suspending the heel(s), to decrease the pressure placed on the resident's heels.
Documentation:
-Document interventions used to prevent the development of pressure ulcers.
-Note any change in the condition or size of the ulcer (injury) and any elevation of skin temperature in the Nurse's Notes and skin assessment (electronic or written) documentation.
1) For Resident #87, the failed to develop and implement a comprehensive care plan for pressure ulcers resulting in the worsening of a pressure ulcer.
Resident #87 was admitted to the facility in July 2022 with diagnoses including anoxic brain damage, (a brain injury caused by a lack of oxygen to the brain), aphasia (loss of ability to understand or express speech) and cognitive communication deficit.
Review of Resident #87's Minimum Data Set Assessment (MDS) dated [DATE] indicated the Resident was moderately cognitively impaired and scored a 10 out of 15 on the Brief Interview for Mental Status (BIMS). The MDS further indicated the Resident had no behaviors, did not reject care, was incontinent of bowel and bladder, required extensive assistance with care activities and was at risk for developing pressure ulcers/injuries.
On 8/9/22 at 7:55 A.M., the surveyor observed Resident #87 in bed. He/she appeared thin and said he/she had some back pain.
During an interview on 8/10/22 at 12:28 P.M., Nurse #3 said that he was very familiar with Resident #87. Nurse #3 said when the Resident was admitted to the facility he/she had a Stage 1 pressure injury on his/her coccyx and the skin was intact but a dark red. Nurse #3 said that sometime after Resident #87 was admitted , the area opened up. Nurse #3 said there is an order for daily wound care which includes Calmoseptine (a medication used to protect skin) and a dressing. Nurse #3 said there should be measurements of the wound. and was unable to say when the area opened up.
Review of Resident #87's medical record indicated the following:
-An admission nursing evaluation dated 7/19/22 which indicated the Resident had a Stage 1 pressure injury (intact skin with non-blanchable redness of a localized area usually over a bony prominence) on his/her coccyx measuring 6 centimeters (cm) x 6 cm.
-Norton Pressure Ulcer scales (a tool used to assess the risk for pressure ulcer) dated 7/19/22 and 7/26/22 which indicated the Resident was a high risk for developing pressure ulcers.
- A physician's order dated 8/3/22: Change Allevyn dressing (a foam adhesive dressing used on shallow, granulating wounds) on coccyx every shift and as needed if soiled.
-A care plan for actual skin found on admission. Pressure/non-pressure. Pressure ulcer coccyx, abrasions chest with two interventions: follow MD orders for treatment; notify MD/NP of skin issues found on admission.
-An August 2022 positioning sheet which failed to indicate the Resident was repositioned during the 3:00 P.M.-11:00 P.M. shifts on 8/4, 8/5, 8/6 and 8/9 and on the 11:00 P.M.- 7:00 A.M. shift on 8/7/22.
Further review of Resident #87's clinical record failed to indicate any documentation of the wound size after 7/19/22, failed to indicate when the Stage 1 pressure ulcer opened up, what size it was and when/if the MD/NP had been notified and failed to indicate any additional interventions for pressure relief.
On 8/11/22 at 9:55 A.M., the surveyor observed Nurse #3 perform wound care for Resident #87. Resident #87 was lying in bed and his/her coccyx had an open wound on the left side of his/coccyx.
During an interview following the wound care observation on 8/11/22 at 10:04 A.M., Nurse #3 said the open wound was 3.5 centimeters (cm) x 1.4 cm and that it is still a Stage 1 pressure ulcer even though the area is now open and the skin is not intact. Nurse #3 said when Resident #87 was admitted his/her skin was intact but dark red and was unable to say when the open area developed and said there had been no measurements after admission until today. Nurse #3 said the Resident does not have any specific pressure reducing interventions in place aside from the standard cushion that came on his/her wheelchair. Nurse #3 said care plans should be initiated upon admission if a resident has a pressure injury or is assessed to be at risk and that some interventions that might work are air mattresses. Nurse #3 was unsure of who was responsible for creating the comprehensive care plans and said it used to be the Unit Manager, but they no longer had Unit Managers.
During an interview on 8/11/22 at 10:06 A.M., the Director of Rehab said Resident #87 has a tilt in space wheelchair. She said the Resident was assessed to have core strength issues so a tilt in space is used and said the chair can recline back to assist residents with core strength issues and could potentially provide pressure relief. The Director of Rehab said the cushion on the wheelchair was the standard cushion.
During an interview on 8/11/22 at 1:45 P.M., the Infection Control Nurse said that once the skin has opened up on a Stage 1 pressure ulcer, it is no longer a Stage 1 pressure ulcer and a shallow, open area would be a Stage 2 pressure ulcer. The Infection Control Nurse said there should have been documentation regarding the new open area on Resident #87's coccyx. The Infection Control Nurse said that upon admission, each resident should be assessed for actual skin breakdown and potential for skin breakdown and should have individualized care plans created based on the assessments. The Infection Control Nurse was unable to say what individualized interventions were in place for Resident #87 and acknowledged the care plan only contained 2 general interventions. The Infection Control Nurse was unable to say what level the standard facility mattresses were rated at for pressure relief.
2. For Resident #68, the facility failed to ensure he/she was seen by the wound care physician in accordance with orders.
Resident #68 was admitted to the facility in July 2022 with diagnoses including failure to thrive, diabetes mellitus and a pressure ulcer.
Review of Resident #68's Minimum Data Set Assessment (MDS) dated [DATE] indicated the Resident was cognitively intact and scored a 15 out of 15 on the Brief Interview for Mental Status (BIMS). The MDS further indicated the Resident had no behaviors, did not reject care, required assistance with care activities, had a pressure ulcer present upon admission and is at risk for developing pressure ulcers/injuries.
On 8/9/22 at 8:38 A.M., the surveyor observed Resident #68 sleeping in his/her bed. The Resident was lying on a standard mattress and his/her heels were directly on the mattress.
On 8/11/22 at 9:44 A.M., the surveyor observed Resident #68 sleeping in his/her bed on a standard mattress and his/her heels were directly on the mattress.
Review of Resident #68's medical record indicated the following:
-An admission nursing evaluation dated 7/1/22 which indicated the Resident had an unstageable pressure ulcer (full thickness tissue loss in which the base of the ulcer is covered by slough {yellow, tan, gray, green or brown stringy texture} and/or eschar {tan, brown or black necrotic tissue} in the wound bed) measuring 3 cm (centimeters) x 4 cm.
-An order dated 7/15/22: Consult with wound doctor for right heel.
Further review of Resident #68's medical record failed to indicate any visit with the wound doctor.
During an interview on 8/11/22 at 10:10 A.M., Nurse #3 and the Director of Rehab said there is a wound doctor who comes to the facility weekly. Nurse #3 was unable to say how residents would be added to the list to be seen after an order was entered.
During an interview on 8/11/22 at 10:21 A.M., the Administrator said there is a wound doctor that comes out weekly and said the previous Director of Nursing would be the one to communicate with the wound doctor which residents needed to be seen based on orders. The Administrator said the former Director of Nursing had been out for about a month and was unable to say if anyone had been checking orders to ensure residents who needed to see the wound doctor were seen.
Review of facility provided list of wound doctor visits for July and August 2022 failed to indicate Resident #68 was seen by the wound doctor as ordered.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0688
(Tag F0688)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews and record review, the facility failed to ensure that 1 Resident (#66) received treatment/servi...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews and record review, the facility failed to ensure that 1 Resident (#66) received treatment/services, equipment, supplies and/or assistance to prevent a decline in range of motion (range of motion refers to degree of movement of a specific joint) out of a total of 27 sampled Residents.
Finding Included:
Review of the facility policy titled, Clinical Quality Program: Orthotics, dated 2022 indicated the following:
*Common conditions that may cause symptoms: history of CVA (cerebral vascular accident), Diabetes Mellitus and cardiovascular disease.
*Considerations: What is the goal in orthotic use? support joint to reduce pain, reduce edema or joint inflammation, and promote function.
Resident #66 was admitted to the facility in April 2022, with diagnoses that included peripheral vascular disease, Diabetes Mellitus Type 1 with foot and skin ulcers, atherosclerotic heart disease of native coronary artery disease and history of cerebral infarction.
Review of Resident #66's Minimum Data Set Assessment (MDS) dated [DATE], indicated that the Resident was cognitively intact and scored a 13 out of 15 on the Brief Interview for Mental Status (BIMS). The MDS further indicated the Resident was dependent on staff for all activities of daily living.
On 8/9/22, at 8:25 A.M., the surveyor observed Resident #66 lying in bed with his/her arms by his/her side. Resident #66's hands were fisted and holding onto balls in his/her palms. Resident #66 said his/her son placed them in his/her hands last night to help keep both hands open.
Review of Resident #66's medical record, indicated the following:
* A physician's order dated 4/7/22 for Occupational Therapy (OT) to evaluate and treat as indicated.
* An OT evaluation completed, and plan of care established 4/11/22. No bilateral hand/finger range of motion deficits were indicated on evaluation.
* An OT discharge documentation on 6/21/22 indicated no bilateral hand range of motion deficits.
* A social service note dated 7/14/22, indicated a care plan meeting occurred in which Resident #66's quarterly status was discussed with the interdisciplinary team where it was determined that there were no changes in his/her status and Resident #66's care plan remained appropriate.
During an interview with Occupational Therapist #1 on 8/11/22 at 10:35 A.M., she said that Resident #66 range of motion was within his/her functional limits and did not need splints when he/she was evaluated and discharged from OT services in June 2022.
During a follow up interview on 8/11/22, at 11:47 A.M., Occupational Therapist #1 said that if range of motion is within functional limits she would not have recommended splinting for positioning. The surveyor then observed Occupational Therapist #1 assess Resident #66's bilateral hand and finger range of motion. Occupational Therapist #1 performed range of motion to the Residents hands/fingers, and she reported that Resident #66 is presenting with decreased range of motion in both hands since he/she was discharged from OT services. Occupational Therapists #1 was asked what the communication process is if the Resident is demonstrating a decrease in hand function due to decreased hand/finger range of motion. She said if Resident #66 is demonstrating a decline in hand function due to decreased range of motion, the nursing staff communicates with the Occupational Therapist and the resident would be reassessed.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Accident Prevention
(Tag F0689)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review and policy review, the facility 1) failed to thoroughly investigate a choking episode for 1 Re...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review and policy review, the facility 1) failed to thoroughly investigate a choking episode for 1 Resident (#4), 2) failed to investigate a burn of unknown origin for 1 Resident (#87) and 3) failed to update the plan of care after a fall for 1 Resident (#3) out of a total sample of 27 residents.
Findings include:
1. For Resident #4, the facility failed to thoroughly investigate a choking event.
Review of facility policy titled 'Accident Investigation and Analysis', reviewed 1/28/22, indicated the following:
-All accidents and incidents shall be investigated by the department manager.
-Once the accident sequence is set in motion, little can be done to control the degree of severity. For this reason, all accidents and near misses shall be investigated.
-In investigating accidents, the following areas shall be focused on:
a. How was the injury or damage incurred, exactly what happened and where?
b. Under what circumstances did the accident occur, in other words, why?
c. Once the details have been reconstructed, what can be done to prevent a similar accident from recurring?
- Prevention of recurrence is always the most important goal of an investigation .Prevention of future, similar occurrence is accomplished through correcting procedures and conditions, as well as through training
-All accidents should be investigated to some extent.
Resident #4 was admitted to the facility in April 2022 with diagnoses including macular degeneration, Barrett's esophagus (a change to the cells lining the esophagus) and gastroesophageal reflux disease (a digestive disease in which stomach acid or bile irritates the lining of the esophagus).
Review of Resident #4's Minimum Data Set Assessment (MDS) dated [DATE], indicated the Resident was cognitively intact and scored a 15 out of 15 on the Brief Interview for Mental Status (BIMS). The MDS further indicated the Resident had no behaviors, did not reject care and required assistance with care activities.
Review of Resident #4's medical record indicated the following:
-A nurses note dated 7/10/22, at 1:01 P.M.: Resident receiving pills at 11 A.M. while sitting up on the bed. Resident began choking on a Tums (a large chewable tablet used to treat heartburn) that he/she mistakenly swallowed without chewing. Attempted Heimlich maneuver x 2, Resident spitting out water, but pill remained stuck in his/her throat, unable to dislodge. Requested assist from another nurse and Heimlich performed with success, a Tums and a pill were spit out. Nurse Practitioner notified .
-A Nurse Practitioner progress note dated 7/11/22, at 11:35 A.M.: Note text- choking and hypoxia (a decrease in oxygen). Resident had a recent choking episode over the weekend due to him/her being given too many pills along with a Tums that he/she was not told to chew and his/her vision is poor .
On 8/9/22 at 3:00 P.M., the surveyor asked the Administrator for all incidents for Resident #4 for the last year.
Review of facility provided incident reports for Resident #4 failed to indicate an investigation for the choking event.
During an interview on 8/11/22, at 11:24 A.M., Resident #4 said he/she did choke on his/her pills about a month ago and said he/she was given all of his/her pills and a Tums was in the cup with the pills and he/she didn't know it was in the same cup. Resident #4 said he/she usually takes all of his/her pills at once and the Tums is given in a separate cup. Resident #4 said he/she tried to swallow everything that was in the cup and when he/she did that he/she started to choke on the Tums. Resident #4 said the nurse that gave him/her the medications didn't give him/her the Heimlich maneuver but called another nurse to help and that nurse performed the Heimlich maneuver and he/she was able to cough up the Tums and another pill.
During an interview on 8/11/22, at 9:20 A.M., the Administrator and Infection Control Nurse said their understanding was that the the previous Director of Nursing, who documented the choking event, had started an investigation and they would look for it.
During an interview on 8/11/22, at 10:42 A.M., the Administrator said she was still looking for an investigation and hadn't found it.
During an interview on 8/11/22, at 11:31 A.M., the Administrator said she was still unable to locate any investigation or statements and said the nurse that documented the choking episode had been out since that day and did not return. The Administrator was unable to say if anyone continued the investigation after the nurse was out, was unable to say if any statements were obtained and said her understanding was that the Resident was not cognitively intact and could not be interviewed. The Administrator acknowledged the Resident was documented as being cognitively intact and that the surveyor was able to interview him/her.
On 8/11/22, at 12:29 P.M., the Administrator provided the surveyor with a folder containing the following:
-An internal investigation document dated 7/10/22, written by the former Director of Nursing which indicated Resident #4 was sitting in bed receiving his/her pills and mistakenly swallowed a Tums instead of chewing it and began choking. Resident spitting out water and could barely speak and was making wet, gurgling noises and Heimlich maneuver was attempted x 2 with no success. Requested assist from the other nurse on duty and he performed the Heimlich maneuver again with success, resident spit out a Tums pill and another pill.
-A typed statement dated 7/10/22, signed by Nurse #3 which indicated he responded to the Resident's room when he heard the former Director of Nursing calling for help and the Resident was in bed sitting up and the former Director of Nursing was standing next to the Resident and said she needed help getting the resident up. Nurse #3 assisted the Resident to stand up and he stood behind the Resident, tilted his/her neck back and asked him/her to give a big cough, which he/she did and dislodged his/her medications. This statement conflicts with nursing notes and the Resident interview indicating he/she required the Heimlich maneuver for the choking event.
During an interview at that time, the Administrator was unable to say where the folder with the documents had been. The Administrator acknowledged there were no other statements and acknowledged there were multiple notes indicating the Resident required the Heimlich maneuver.
2. For Resident #87, the facility failed to investigate a burn of unknown origin.
Review of facility policy titled 'Abuse, Neglect, Misappropriation Policy', dated as reviewed 1/28/22, indicated the following:
-The facility will thoroughly investigate, under the direction of the Administrator, all injuries of unknown source to determine if abuse or neglect was involved.
-An injury will be classified as an Injury of Unknown Source when both of the following conditions are met:
a. The source of the injury was not observed by any person or the source of the injury could not be explained by the resident: and
b. The injury is suspicious because of the extent of the injury or location of the injury (e.g. the injury is located in an area not generally vulnerable to trauma) or the number of injuries observed at one particular point in time or the incidence of injuries over time.
Review of facility policy titled 'Accident Investigation and Analysis', dated as reviewed 1/28/22, indicated the following:
-All accidents and incidents shall be investigated by the department manager.
-Once the accident sequence is set in motion, little can be done to control the degree of severity. For this reason, all accidents and near misses shall be investigated.
-In investigating accidents, the following areas shall be focused on:
a. How was the injury or damage incurred, exactly what happened and where?
b. Under what circumstances did the accident occur, in other words, why?
c. Once the details have been reconstructed, what can be done to prevent a similar accident from recurring?
- Prevention of recurrence is always the most important goal of an investigation .Prevention of future, similar occurrence is accomplished through correcting procedures and conditions, as well as through training
-All accidents should be investigated to some extent.
Resident #87 was admitted to the facility in July 2022 with diagnoses including anoxic brain damage (a brain injury caused by a lack of oxygen to the brain), aphasia and cognitive communication deficit.
Review of Resident #87's Minimum Data Set Assessment (MDS) dated [DATE], indicated the Resident was moderately cognitively impaired and scored a 10 out of 15 on the Brief Interview for Mental Status (BIMS). The MDS further indicated the Resident had no behaviors, did not reject care and required extensive assistance with a one person physical assist for eating and care activities.
On 8/9/22, at 3:20 P.M., the surveyor observed Resident #87 in his/her room. Resident #87 had reddened areas to his/her left hand. The Resident was unable to say what had happened to his/her hand.
Review of Resident #87's medical record indicated the following:
-A care plan initiated 7/19/22, for an Activities of Daily Living (ADL) self care deficit related to cognitive impairment, pain and weakness which indicated the Resident is dependent for care activities and requires supervision with eating.
-A Nurse Practitioner note dated 8/3/22, for left hand rash/burn: Asked to see Resident for a rash noted along left thumb extending to palm of hand with unknown etiology. Left hand with reddened areas from index finger and thumb around to palm of hand, appears consistent with burn. Assessment: superficial burn of multiple sites of left hand. Discussed with staff and unknown etiology, appears consistent with burn and Resident is fed. Staff to further investigate and will add Bacitracin twice a day.
-An order dated 8/3/22, and discontinued 8/4/22, for Bacitracin (a topical antibiotic) to left hand ?burn- three times a day for 5 days left hand burn.
-An order dated 8/4/22, for Bacitracin ointment 500 unit/gram apply to blistered areas for rash topically every shift for 5 days blistered areas to left thumb and first finger. Leave open to air.
Further review of Resident #87's medical record failed to indicate any investigation had been done for the Resident's burn of unknown origin.
On 8/9/22, the surveyor asked for any investigations for Resident #87 since admission.
On 8/10/22, at 8:54 A.M., the Administrator said there were no investigations for Resident #87. The Administrator said she was made aware of a reddened area on the Resident's hand, but thought there had been clarification from a different provider that it might not have been a burn. The Administrator said there were no specific policies regarding a burn of unknown origin but typically an investigation will include obtaining statements.
During an interview on 8/10/22, at 11:56 A.M., the Nurse Practitioner (NP #1) said Nurse #3 on the unit alerted her to the reddened area on Resident #87's hand. NP #1 said the Resident couldn't tell her what happened and said the Resident is dependent on staff for assistance. NP #1 then said it was an unusual presentation and the reddened areas were on the left index finger and thumb and extended towards the palmar surface. NP#1 then said it looked like a superficial 1st degree burn to her and that was her assessment of it. She said maybe the Resident grabbed a hot cup and was burned by liquids spilling over. The Nurse Practitioner said she put an order in for Bacitracin for a burn.
During an interview on 8/10/22, at 12:25 P.M., Nurse #3 said that he was made aware of the skin issue by a Certified Nursing Assistant (CNA) and notified the Nurse Practitioner. Nurse #3 said he thinks the Nurse Practitioner came out to see the Resident the next day. Nurse #3 said the area was reddened and the Nurse Practitioner said she thought it looked like a burn. Nurse #3 said the reddened area seemed to match up to the area that would have been affected if the Resident was holding a cup and hot liquid spilled over. Nurse #3 said that Social Services and the Administrator were made aware of the burn.
During an interview on 8/10/22, at 2:15 P.M., Certified Nursing Assistant (CNA) #1 said she noticed the area on Resident #87's hand. She said the area was reddened and it looked like a blister was present. She said she notified the nurse immediately.
3. For Resident #3 the facility failed to ensure the revision of fall care plan interventions as needed to prevent falls.
Review of the Facility's Fall Prevention policy, dated 1/28/22, indicated:
*A post-fall huddle shall be performed after all resident falls. The following shall be reviewed during the huddle; What happened? How did it happen? What may have contributed? When was the resident last observed by staff? Were appropriate interventions in place?
*Specific considerations as to why the fall might have occurred including; but not limited to how similar outcomes can be avoided, how the care plan will change.
Resident #3 was admitted to the facility in April 2022 with diagnosis including fall with fracture, dementia and psychotic disorder.
Review of his/her most recent Minimum Data Set Assessment (MDS) dated [DATE], indicated he/she is severely cognitively impaired and requires one person physical assistance with walking in his/her room and on the nursing unit. The MDS also indicated that Resident #3 was not steady while moving, standing or turning and required assistance from another person with stabilization.
On 8/9/22, at approximately 9:15 A.M. the surveyor observed Resident #3 resting in bed. The bed was in a low position close to the floor.
Review of Resident #3's Fall care plan, dated 4/22/22, indicated that Resident #3 is at risk for injuries related to fall history and indicated the following interventions to prevent falls: low/platform bed, call light within reach, adequate glare free lighting, area free of clutter, remind resident and reinforce safety awareness, lock brakes on bed/chair before transferring, educate resident to request assistance prior to ambulation, appropriate footwear.
Review of Resident #3's Activities of Daily Living (ADL) care plan, dated 4/22/22, indicated that Resident #3 requires assistance with ADL's and mobility, but failed to indicate what level of assistance he/she required.
Review of Resident #3's incident reports indicated Resident #3 had sustained 3 falls since his/her admission to the facility:
a) 4/23/22: 7:20 A.M., Resident #3 was found on the floor by staff. Resident #3 reported that he/she was coming from the bathroom and was going back to bed. There were no updates to his/her care plan in response to the fall.
b) 4/27/22: 2:00 P.M., Resident #3 fell in hallway in front of nurses station. Resident #3 had attempted to stand up lost balance and fell into the wall, landing on right side. There were no updates to his/her care plan in response to the fall.
c) 5/6/22: 2:15 P.M., Resident #3 attempted fell after standing up from his/her wheelchair in front of the nurses station. There were no updates to his/her care plan in response to the fall.
During an interview with the Infection Preventionist/Corporate Nurse on 8/10/22, at 11:05 A.M., she said that after a Resident falls, the expectation is for staff to evaluate the cause of the fall and update the plan of care.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Incontinence Care
(Tag F0690)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview, the facility failed to ensure a catheter bag was place appropriately to preve...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview, the facility failed to ensure a catheter bag was place appropriately to prevent complications for 1 Resident (Resident #40) out of a total of 27 sampled Residents.
Findings include:
Resident #40 was admitted to the facility in June 2022 with diagnoses including diabetes, hyperlipidemia and Alzheimer's disease.
Review of his/her most recent Minimum Data Set assessment dated [DATE], indicated he/she is moderately cognitively impaired and utilizes assistance with bathing and dressing.
On 8/9/22, at 7:39 A.M. and 8/10/22, at 8:01 A.M., the surveyor observed Resident #40 resting in bed with his/her Foley catheter bag hanging on the side of bed in a privacy bag. The catheter bag was placed on the bed rail near the head of the bed above his/her bladder which allowed urine to settle in the tubing, (which was visible) and not drain properly into the bag.
Review of the facility's Indwelling Urinary Catheter Insertion and Maintenance policy, dated 2/3/22, indicated; maintain unobstructed urine flow by keeping the collection bag below the level of the bladder at all times.
During an interview 8/10/22, at approximately 10:45 A.M., Nurse #5 said she observed Resident #40's Foley bag placement and said it should not be placed above his/her bladder.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0692
(Tag F0692)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview, the facility failed to identify and address a significant weight loss for 1 s...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview, the facility failed to identify and address a significant weight loss for 1 sampled Resident (#23) out of a total of 27 sampled Residents.
Findings include:
Review of the Facility's Weight Policy indicated:
*Each resident should be weighed on admission or readmission, weekly for the first 4 week after admission and at least monthly thereafter to help identify and document trends such as insidious weight loss.
*Weights may be ordered more frequently if there is a significant change in condition, food intake has declined or persisted, or there is other evidence of altered nutritional status or fluid and electrolyte imbalance.
*Any significant change in weight compared to the previous weight should be re-checked and visually verified for accuracy by the nurse on duty before being documented in the medical record.
*The dietician, physician and responsible party should be notified of significant weight changes.
Resident #23 was admitted to the facility in June 2021 with diagnosis including Alzheimer's and arthritis.
Review of Resident #23's most recent Minimum Data Set assessment dated [DATE], indicated he/she is severely cognitively impaired and requires physical assistance with bathing, dressing and eating.
On 8/10/22, at 12:16 P.M. the surveyor observed Resident #23 ambulating in his/her room. Resident #23 was thin and frail.
Review of Resident #23's physician's orders indicated an order for weekly weights every Monday initiated 7/5/21.
Review of Resident #23's weights indicated:
5/12/22: 143.4 lbs (pounds)
5/19/22: 142.2 lbs
6/1/22: 144 lbs
6/23/22: 140 lbs
6/30/22: 144 lbs
No weights were documented for July, and no documentation that Resident #23 refused to be weighed.
8/2/22: 132.8 lbs (a significant weight loss of 7.36% of his/her total body weight in 3 months)
Review of Resident #23's clinical record indicated he/she had last been assessed the Dietitian on 5/25/22; prior to the documented weight loss. The assessment indicated Resident #23's weight was stable and he/she has a history of weight loss.
Review of Resident #23's Nutritional care plan goal as of 8/2/22, indicated a goal weight between 140 lbs-150 lbs with interventions including; ensure 3 x daily, magic cup at lunch and fortified cereal at breakfast.
During an interview on 8/10/22, at 2:40 P.M., the Dietitian said that she was aware of Resident #23's documented weight of 132.8 lbs on 8/2/22, and was wanting him/her to be re-weighed to confirm. The Dietitian said that it has been difficult to obtain weights on the units and that she would expect a re-weigh to be obtained within 24 hours of a documented significant weight loss.
During a follow up interview on 8/11/22, at approximately 8:45 A.M., the Dietician said that Resident #23 had been re-weighed on 8/10/22 at 134.4 lbs. Dietitian #1 said that this weight confirmed Resident #23's weight loss and Resident #23 would be receiving fortified food at all meals in response.
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 interview, record review and policy review, the facility failed to ensure orders for a central line were complete for 1 Resident (#394) out of a total sample of 27 residents.
Findings include...
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Based on interview, record review and policy review, the facility failed to ensure orders for a central line were complete for 1 Resident (#394) out of a total sample of 27 residents.
Findings include:
Review of facility policy titled 'PICC Line Flushing', effective 11/2019, indicated the following:
*Policy: Flushing is performed to ensure and maintain cannula patency and to prevent the mixing of incompatible medications/ solutions.
*Procedure: A physician's order is required to flush a PICC (Peripherally inserted central catheter) catheter. The order must include the flushing agent, the amount, and the frequency.
Resident #394 was admitted to the facility in August 2022 with diagnoses including sepsis, leukemia and depression.
On 8/9/22, at 7:38 A.M., the surveyor observed Resident #394 lying in bed. He/she appeared frail and had skin tears on his/her right arm and discolored areas on all four extremities. Resident #394 said he/she has had the skin issues since before he/she was admitted .
Review of Resident #394's Nursing Evaluation dated 8/5/22, indicated the Resident currently has a central line (a centrally inserted tube that is placed in a vein for long term therapy) with three lumen (the part of the catheter used to give intravenous treatments or take blood) in the right front shoulder.
Review of Resident #394's medical record indicated the following physician's orders dated 8/9/22, (3 days after Resident #394 was assessed as having a central line in place):
-Tunneled valve maintenance: flush each lumen with 10 ML (milliliters) every day. Triple lumen central line every evening shift for central line maintenance. The order failed to include what flushing agent should be used to flush each lumen.
Review of Resident #394's August 2022 Medication Administration Record (TAR) indicated the following:
-Tunneled valved maintenance: flush each lumen with 10 ML every day was signed off as being completed 8/9/22 and 8/10/22
During an interview on 8/11/22, at 7:45 A.M., Nurse #3 said the flushing order should include the solution. He said the Resident's line is being flushed with normal saline.
During an interview on 8/11/22, at 8:07 A.M., the Infection Control nurse said upon admission a central line should have a dressing change and be assessed with measurements. She said there are order sets that are put in and that will include what should be done and what will be used to flush a line.
During an interview on 8/11/22, at 8:20 A.M., Nurse #4 said she was the nurse who did the admission for Resident #394. Nurse #4 said the Resident was admitted with a central line to his/her upper chest and said the central line was not being used for any current treatment. Nurse #4 said there was a dressing in place upon admission and the dressing was not changed. Nurse #4 said there should have been flushing orders put in place upon admission and she thought that she put the orders in the same day.
During an interview on 8/11/22, at 9:22 A.M., the MDS nurse said flushing orders need to include what solution should be used to flush the line.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
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 maintain infection control practices during wound care...
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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 maintain infection control practices during wound care for 1 Resident (#87) out of a total sample of 27 residents.
Findings include:
Review of facility policy titled 'Med Admin- Topical', effective 11/2019, indicated the following:
- Apply medication: paste, cream, ointment, or lotion:
a. Open the container and place the tube upside down on the table surface.
b. Apply clean gloves.
c. Remove tongue blade (a flat, thin, wooden blade with smoothed and rounded ends) from sterile wrapper.
d. Place medication on the tongue blade and transfer to gloved hands.
e. Warm the medication in gloved hands and apply gently to the skin in the direction of hair growth.
f. Repeat as necessary to cover the entire area, using a new tongue blade for each application.
g. Remove gloves. Wash and dry hands thoroughly.
Resident #87 was admitted to the facility in July 2022 with diagnoses including anoxic brain damage, (a brain injury caused by a lack of oxygen to the brain), aphasia (loss of ability to understand or express speech) and cognitive communication deficit.
Review of Resident #87's Minimum Data Set Assessment (MDS) dated [DATE], indicated the Resident was moderately cognitively impaired and scored a 10 out of 15 on the Brief Interview for Mental Status (BIMS). The MDS further indicated the Resident had no behaviors, did not reject care, was incontinent of bowel and bladder, required extensive assistance with care activities and was at risk for developing pressure ulcers/injuries.
On 8/9/22, at 7:55 A.M., the surveyor observed Resident #87 in bed. He/she appeared thin and said he/she had some back pain.
Review of Resident #87's medical record indicated the following:
-An nursing evaluation dated 7/19/22, which indicated the Resident had a Stage 1 pressure injury ( intact skin with non-blanchable redness of a localized area usually over a bony prominence) on his/her coccyx measuring 6 centimeters (cm) x 6 cm.
- A physician's order dated 8/3/22: Change Allevyn dressing (a foam adhesive dressing used on shallow, granulating wounds) on coccyx every shift and as needed if soiled.
During an interview on 8/10/22, at 12:28 P.M., Nurse #3 said that he was very familiar with Resident #87. Nurse #3 said when the Resident was admitted to the facility he/she had a Stage 1 pressure injury on his/her coccyx and the skin was intact but a dark red. Nurse #3 said that sometime after Resident #87 was admitted , the area opened up. Nurse #3 said there is an order for daily wound care which includes Calmoseptine (a medication used as a moisture barrier to protect skin) and a dressing.
On 8/11/22, at 9:55 A.M., the surveyor observed Nurse #3 perform wound care for Resident #87. Resident #87 was lying in bed and his/her coccyx had an open wound on the left side. Nurse #3 said he was also going to apply topical medication patches to Resident #87 before he did the dressing change. Nurse #3 washed his hands, applied gloves, removed a marker from his pocket and dropped the cap on the floor of the Resident's room. Nurse #3 labeled the topical patches, for the Resident's back, with the date and then picked the marker cap up off the floor with his gloved hands, potentially contaminating them, and applied the patches to the Resident's back with his contaminated gloves. Nurse #3 then used a paper measuring tape with his contaminated gloved hands to measure Resident #87's wound. Nurse #3 then picked up a single use plastic cup with a thick white cream inside of it and said that it was Calmoseptine. Nurse #3 scooped the cream onto his contaminated gloved hands and applied the cream directly onto Resident #87's open wound with his contaminated gloved hands, potentially contaminating the wound. Nurse #3 then opened an Allevyn dressing with the contaminated gloved hands, contaminating it, and applied the contaminated Allevyn dressing on top of the open wound, potentially contaminating it.
During an interview on 8/11/22, at 10:50 A.M., Nurse #3 said that he doesn't normally use any type of applicator for topical treatments. Nurse #3 acknowledged he did not change his contaminated gloves before applying the cream or the dressing directly to Resident #87's open wound.
During an interview on 8/11/22, at 1:45 P.M., the Infection Control Nurse said that the nurse should have changed his gloves after picking an item off the floor, before applying the cream to the Resident's wound.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Comprehensive Care Plan
(Tag F0656)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4. For Resident #66 the facility failed to implement the plan of care for use of adaptive eating utensils and red plate during m...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4. For Resident #66 the facility failed to implement the plan of care for use of adaptive eating utensils and red plate during meals.
Resident #66 was admitted to the facility in April 2022, with diagnoses that included peripheral vascular disease, Diabetes Mellitus Type 1 with foot and skin ulcers, atherosclerotic heart disease of native coronary artery disease and history of cerebral infarction.
Review of Resident #66's Minimum Data Set Assessment (MDS) dated [DATE] indicated the Resident was cognitively intact and scored a 13 out of 15 on the Brief Interview for Mental Status (BIMS). The MDS further indicated the Resident was dependent of staff for all activities of daily living.
Restorative Activities of Daily Living (ADL) Services Policy states:
*Residents shall receive assistance with activities of daily living (ADL's) every shift as appropriate.
* ADL's include bathing, grooming, dressing, and eating.
Review of Resident #66's care plan, last revised on 7/14/22, indicated the intervention: he/she is to use red plate, black built up handled angled spoon and white built-up handled angled fork for all meals.
On 08/09/22 at 08:40 A.M., the surveyor observed Certified Nursing Assistant (CNA) #4 feeding resident seated at bedside.
On 08/11/22 at 08:54 A.M., the surveyor observed CNA #4 feeding Resident #66 seated at bedside.
During an interview with CNA #4 on 08/11/22 at 09:06 A.M., when asked if Resident #66 can use the adaptive utensils for self-feeding, CNA #4 said that the he/she tried a little after he/she worked with therapy, but it really didn't work. CNA #4 also said that Resident #66 wasn't interested in using them, so we feed he/she all their meals. The surveyor asked CNA #4 if she had asked Resident #66 if he/she would like to try and use the adaptive utensils as they are on his/her tray every meal. She said she did not.
During an interview with Occupational Therapist #1 on 8/11/22 at 10:35 A.M., she said she was not aware Resident #66 was not using his adaptive utensils during meals. Asked what the process is for getting the adaptive utensils for all meals and communication if the resident is having difficulties. She said the process is a diet slip is submitted to the kitchen for all adaptive eating equipment to come up with each meal tray. She trains the charge nurse and staff on use of adaptive utensils for self-feeding with the individual resident. If the resident is having difficulties or unable to use assistive eating utensils, nursing communicates with Occupational Therapist and any care plan changes or revisions are completed by nursing.
2. For Resident #68, the facility failed to ensure weights were obtained in accordance with physician orders and facility policy.
Review of facility policy titled 'Weight Policy', reviewed 2/15/22 indicated the following:
-Each resident should be weighed on admission or readmission (to establish a baseline weight), weekly for the first 4 weeks after admission and at least monthly thereafter to help identify and document trends such as insidious weight loss.
Resident #68 was admitted to the facility in July 2022 with diagnoses including failure to thrive, diabetes mellitus and a pressure ulcer.
Review of Resident #68's Minimum Data Set assessment dated [DATE] indicated the Resident was cognitively intact and scored a 15 out of 15 on the Brief Interview for Mental Status (BIMS). The MDS further indicated the Resident had no behaviors, did not reject care, and required assistance with care activities.
On 8/9/22 at 10:30 A.M., the surveyor observed Resident #68 lying in bed. He/she was pleasant and appeared thin.
Review of Resident #68's medical record indicated a physician's order dated 7/1/22: weight every week for 4 weeks on Tuesday.
Review of Resident #68's recorded weights indicated the following:
*7/1/22: there were two separate entries indicating weights of 175.4 lbs (pounds) and 175.2 lbs.
Further review of Resident #68's medical record failed to indicate any additional weights had been documented after 7/1/22.
During an interview on 8/9/22 at 2:23 P.M., Certified Nursing Assistant (CNA) #1 said CNAs will record weights on a paper log and then the nurse will enter them into the resident's electronic health record (EHR).
Review of CNA paper logs for July and August 2022 failed to indicate any additional weights for Resident #68.
During an interview on 8/10/22 at 11:52 A.M., Nurse #3 said weights are documented in the EHR. Nurse #3 reviewed Resident #68's order and weights and said weekly weights were not done and should have been done as ordered.
During an interview on 8/10/22 at 2:50 P.M., the Dietitian said the facility policy for weight management is to weigh residents upon admission and then weekly for 4 weeks. She said if the weight is stable after 4 weeks the frequency will change to monthly. The Dietitian said that there are staffing challenges and it has been harder to get weights for residents. The Dietitian acknowledged there were no weights obtained after Resident #68's weight on 7/1/22.
3. For Resident #394, the facility failed to develop and implement a plan of care for a central line until 3 days after admission.
Review of facility policy titled 'Comprehensive Care Plan', reviewed 1/28/22, indicated the following:
-A baseline care plan shall be developed and implemented for each resident that includes the instructions needed to proved effective and person-centered care of the resident that meets professional standards of quality care.
-The baseline care plan shall:
* Be developed within 48 hours of a resident's admission
* Include the minimum healthcare information necessary to properly care for a resident including, but not limited to: initial goals based on admission orders; physician orders; dietary orders; therapy services; social services
-A comprehensive care plan may be developed and implemented in place of the baseline care plan if the comprehensive care plan is: developed within 48 hours of the resident's admission; addresses issues identified in the initial assessment process.
Resident #394 was admitted to the facility in August 2022 with diagnoses including sepsis, leukemia and depression.
On 8/9/22 at 7:38 A.M., the surveyor observed Resident #394 lying in bed. He/she appeared frail and had skin tears on his/her right arm and discolored areas on all four extremities.
Review of Resident #394's admission Nursing Evaluation dated 8/5/22 indicated the Resident currently has a central line (a centrally inserted tube that is placed in a vein for long term therapy) with three lumen (the part of the catheter used to give intravenous treatments or take blood) in the right front shoulder.
Review of Resident's medical record indicated the following physician's orders dated 8/9/22 (3 days after Resident #394 was assessed as having a central line in place):
-Tunneled valve maintenance: flush each lumen with 10 ml (milliliters) every day. Triple lumen central line every evening shift for central line maintenance. The order failed to include what flushing agent should be used to flush each lumen.
-Tunneled: change needleless connector on admission, every week & as needed, and after blood draws.
-Tunneled: change transparent dressing on admission, every week & as needed.
-Tunneled: measure external catheter length on admission, with each dressing change & as needed.
During an interview on 8/11/22 at 8:07 A.M., the Infection Control nurse said upon admission a central line should have a dressing change done and be assessed with measurements. She said there are order sets that should be put in upon admission and that will include what care should be done and what should be used to flush.
During an interview on 8/11/22 at 8:20 A.M., Nurse #4 said she was the nurse who did the admission for Resident #394. Nurse #4 said the Resident was admitted with a central line to his/her upper chest and said the central line was not being used for any current treatment but should be flushed. Nurse #4 said there was a dressing in place upon admission and the dressing was not changed. Nurse #4 said there were no measurements done for the central line and said there should have been orders put in upon admission and she thought that she put the orders in the same day.
During an interview on 8/11/22 at 9:22 A.M., the MDS nurse said she was made aware that Resident #394 was admitted with a central line on 8/6/22. The MDS nurse said there was no documentation in the Resident's hospital paperwork that was received by the facility regarding central line placement confirmation, type of device and the ports. The MDS nurse said she needed verification of placement before any orders regarding central line care and to flush the line could be put in and acknowledged the orders were put in on 8/9/22, which was three days after admission.
During a follow up interview on 8/11/22 at 9:44 A.M., the MDS nurse said while waiting for the hospital paperwork, the staff could have notified the provider and requested an x-ray to confirm placement.
Based on observation, record review and interview, the facility failed to follow physician's orders and care plans for 4 Residents (#23, #66, #68, #394,) out of a total of 27 sampled Residents.
Findings include:
1. For Resident #23, the facility failed to obtain weekly weights per his/her physician's orders.
Resident #23 was admitted to the facility in June 2021 with diagnoses including Alzheimer's and arthritis.
Review of Resident #23's most recent Minimum Data Set Assessment indicated he/she is severely cognitively impaired and requires physical assistance with bathing, dressing and eating.
On 8/10/22 at 12:16 P.M. the surveyor observed Resident #23 ambulating in his/her room. Resident #23 was thin and frail.
Review of Resident #23's physician's orders indicated an order for weekly weights every Monday initiated 7/5/21.
Review of Resident #23's weights indicated:
05/12/22: 143.4 lbs (pounds)
05/19/22: 142.2 lbs
06/01/22: 144 lbs
06/23/22: 140 lbs
06/30/22: 144 lbs
No weights were documented for July 2022 and no documentation that Resident #23 refused to be weighed.
8/2/22: 132.8 lbs
During an interview with the Dietitian on 8/10/22 at 2:40 P.M., she said that it has been difficult to obtain weights on the unit due to staffing issues.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0725
(Tag F0725)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview, the facility failed to ensure staffing levels were appropriate to meet the ne...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview, the facility failed to ensure staffing levels were appropriate to meet the needs of Residents on 2 of 3 units.
Findings include:
Review of the Facility assessment dated [DATE], indicated: All staffing is primarily based on the daily census on each unit. Each Resident's preference for schedule, waking times, naps, bathing, bedtime, etc. is reflected in their individual plan of care. Our current staffing patterns allow for these needs to be met on an individual basis. Staffing patterns are increased based on acuity and behavior, example being if a Resident needs 1:1 attention for a period of time, or need for 2 staff members to handle a transfer, such as with a Resident that requires a Hoyer lift ( a device utilized to physically lift someone out of bed requiring 2 people).
At the time of the survey, the Andover Unit housed 16 total Residents. Of those Residents, 2 required 2 person assistance for activities of daily living (ADL) care, 9 were totally dependent with ADL care, and 4 required the use of a Hoyer lift to get out of bed.
The Concord unit housed 40 Residents. Of those Residents, 22 required 2 personal assistants with ADL care, 34 were totally dependent and 9 utilized a Hoyer lift to get out of bed.
On 8/9/22, on the Concord Unit, there were 2 Certified Nurses Aides (CNA's) working on the unit caring for 39 Residents. The CNA's were going room to room attempting to provide care for every resident in a timely manner.
At 9:54 A.M. A resident was calling out from his/her bedroom help me, help me, I have to go to the bathroom. Nurse #6 entered and told the resident that someone would be in to assist him/her. Nurse #6 went to find the CNA's to assist the resident when she was stopped by Nurse #1. Nurse #1 said that they were busy caring for another resident and they needed to take care of him/her first.
At 10:15 A.M. The surveyor interviewed CNA #2 and CNA #3. CNA #2 and CNA #3 said that they were the only 2 CNA's working on the unit as two others scheduled had called out for the day. CNA #2 and CNA #3 said that there are supposed to be 4 CNA's providing care to the resident's on the unit, but there are times where there are only 2 CNA's due to call outs or general staffing issues. They said that the staffing issues can make their job difficult but that they do the best they can. CNA #2 and CNA #3 said that they will still provide showers to the resident's on the unit, and the Nurses on the unit do step in and help with providing physical care to the residents.
At approximately 11:15 A.M., the surveyor observed Nurse #1 passing medications. Earlier in the morning the surveyor observed her assisting with serving the breakfast meal. Nurse #1 was interrupted numerous times by staff and residents for various reasons.
Review of the medication administration record (MAR) on 8/9/22, at 11:30 A.M., for sampled Residents on the Concord Unit indicated the following:
Resident #40 had not received his/her scheduled 9:00 A.M. medications including: Lexapro (an antidepressant) 10 MG for Alzheimer's disease, Meantime HCL ER 28 MG for Alzheimer's disease, and Acetaminophen 500 MG for pain.
Resident #25 had not received his/her scheduled 9:00 A.M. medications including: Amlodipine Beslyate tablet 2.5 MG for hypertension, Gabapentin capsule 100 MG for type 2 diabetes mellitus, and Acetaminophen 1000 MG.
Resident #81 had not received his/her scheduled 8:00 A.M. and 9:00 A.M. medications including: Zyprexa (an antipsychotic) 2.5 MG for agitation related to Dementia, Oxycodone tablet 5 MG for pain, Allopurinol tablet 100 MG for gout, Amlodipine Beyslate tablet 2.5 MG, Bumetanide tablet 2 MG given for edema, Sertraline HCI tablet 50 MG for Dementia, Ibuprofen tablet 200 MG given for pain and Acetaminophen tablet 325 MG.
Resident #62 had not received his/her scheduled 8:00 A.M. and 9:00 A.M., medications including: Divalporex Sodium Capsule 125 MG for anxiety, Acetaminophen 325 MG for osteoporosis, citalopram hydrobromide 10 MG for anxiety Trazodone HCI 50 MG for anxiety, and Apixaban tablet 2.5 MG given for Atrial Fibrillation.
Resident # 82 had not received his/her scheduled for 8:00 A,M., and 9:00 A.M. medications including: Amlodipine Besylate 5 MG for hypertension.
During an interview on 8/9/22, at 1:20 P.M., Nurse #1 said she comes in to work at 8 A.M., she does not focus on the medication pass. Nurse #1 said she is pulled away from the medication cart to help with dining, feeding and supervision, until 9:30 A.M., or 10:00 A.M., because the unit is short-staffed. Nurse #1 also said she then starts to pass medication between 9:30 A.M., and 10:00 A. M., but on days like yesterday and today when there are only have 2 CNA's, it is worse because she started her medication pass later. Nurse #1 said that on usual days they have 4 CNAs, but even then, 4 CNAs are not very helpful. Nurse #1 said that residents should always get their medications on time, but with the staffing issues, she is not able to give their medication in a timely manner.
On 8/10/22, at 8:00 A.M. the surveyor arrived on the unit. Staff informed the surveyor that there were 3 CNA's assigned to the unit.
On 8/10/22, at 8:10 A.M., Nurse #1 was observed getting report from Nurse #7 who worked 11 A.M.- 8:00 A.M., Nurse #1 was observed locking the medication cart after getting the report and going directly into the dining room to help with breakfast dining, supervision and feeding.
During initial interviews with residents on the Andover Unit, multiple residents reported that there were not enough staff available to provide care. Residents reported not being able to get out of bed for the day if there were not staff available to assist, waiting for hours to receive care, be toileted or showered and also reports of not getting their medications on time.
During the Medication Pass on 8/10/22, medications were administered to residents late by Nurse #3 on the Andover Unit. During an interview on 8/10/22, at 11:42 A.M., Nurse #3 said that he is usually the only nurse on the unit to give medications and treatments to 16-18 residents. Nurse #3 said staffing is difficult and he tries his hardest to get the medications administered on time.
During an interview on 8/10/22, at 2:00 P.M., CNA #1 said that she usually works on the Andover Unit and recently there have been issues with staffing. CNA #1 said that there used to be more agency staff, but she had not seen them in awhile. CNA #1 said she is usually the only CNA on the unit and there is usually only 1 nurse working out of two medication carts. CNA #1 said that the Andover Unit is hectic and the resident's on the unit require a high level of care. CNA #1 said that of the 16 Residents on the unit, 11 are totally dependent for assistance with ADL's, 5 require a Hoyer lift transfer, and 90% are incontinent. She said that she currently still had one more resident she needed to provide a shower for. CNA #1 said that she works 5-6 days a week and although her shift is supposed to end at 3:00 P.M., she said she never leaves on time and is often asked to stay late or work a double. CNA #1 said that there are no breaks and she does the best she can to give the best care she can. CNA #1 said that the nurse on the unit will often assist, but that can impact his ability to give medications and/or treatments. CNA #1 said that sometimes other staff come to the unit to help pass meal trays or give ancillary assistance with things that are not direct care, but it is not consistent.
During an interview on 8/10/22, at 11:39 A.M., the Business Office Manager said that she was assisting with scheduling as the scheduler was out. She said that staffing was based on the census of the building and acuity. She said that she was not aware of any staffing issues and the following were the current staffing needs for the units:
Andover Unit: (sub acute care) All shifts: 1 nurse; 2 CNA's.
[NAME] & Concord Units: (long term/dementia care) 7:00 A.M. - 3:00 P.M., (morning shift) & 3:00 P.M. - 11:00 P.M. (evening shift): 2 nurses; 4 CNAs. 11:00 P.M. - 7:00 A.M. (night shift) 1 nurse; 2 CNAs.
Review of the staffing schedules for the past 21 days (7/19/22 - 8/9/22) indicated that the Concord Unit had less than 4 CNA's working during all morning and evening shifts and on 3 days, (7/22/22, 7/25/22 and 7/30/22), there was 1 nurse working the morning shift.
The Andover Unit staffing schedules indicated that there had been two CNA's scheduled to work 6 morning shifts in July 2022, but none since 7/29/22. Additionally, on 7/25/22, a nurse was assigned to work as a CNA and on 8/8/22, 2 occupational therapists were working as CNA's on the Andover Unit.
During an interview on 8/11/22, at 7:47 A.M., Occupational Therapist #2 said that on 8/8/22; (the day before survey started) after morning meeting, he had been asked to fill in on the Andover Unit as the facility was unable to schedule a CNA for that shift. Occupational Therapist #2 said that this was the second time he had been asked to do so and once or twice a month staffing CNA's is an issue. He said that there used to be 2 CNA's consistently working on the Andover Unit, but now there is only 1.
During an interview on 8/11/22, at 12:48 P.M., the Administrator said that the facility was trying to fill empty staffing positions. The Administrator said that they used agency, but agency staffing was not always reliable. The Administrator said that she was aware of the staffing concerns for 8/8/22, and that ancillary staff had been called to the Andover Unit to provide additional support and she had reached out to the state agency for assistance through the rapid response team.
The facility failed to ensure sufficient staffing was provided to meet the needs of the Residents on the Andover and Concord Units.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Unnecessary Medications
(Tag F0759)
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 it was free of a medication erro...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review and policy review, the facility failed to ensure it was free of a medication error rate of five percent or greater. Three of 4 licensed nurses observed on 3 of 3 Resident care units made 9 errors in 29 opportunities resulting in a medication error rate of 31.03%. These errors impacted 5 of 7 Residents observed.
Findings include:
Review of facility policy titled 'Medication Administration' reviewed 2/4/22, indicated the following:
-The individual administering a medication shall be aware of the following information concerning each medication before administration:
*Appropriate timing of medication administration
During an observation of a medication pass on the Concord Unit on 8/10/22, at 9:33 A.M., Nurse #1 administered the following medications to Resident #73:
-Divalproex Sodium (a medication used to treat seizures)125 milligrams (mg) 2 capsules
-Trazodone (a medication used to treat depression) 12.5 mg 3 tabs
Review of Resident #73's current physician orders indicated the following:
-Depakote Sprinkles (Divalproex Sodium) 125 mg- give 2 capsules by mouth two times a day at 8:00 A.M. and 8:00 P.M.
-Trazodone- give 37.5 mg by mouth three times a day at 8:00 A.M., 1:00 P.M., 8:00 P.M.
Both medications were administered 1 hour and 33 minutes after the ordered time.
During an observation of a medication pass on 8/10/22, at 9:38 A.M., Nurse #1 administered medications including the following to Resident #59:
-Midodrine (a medication used to treat low blood pressure) 2.5 mg 1 tab
Review of Resident #59's current physician orders indicated the following:
-Midodrine 2.5 mg two times a day at 8:00 A.M. and 2:00 P.M.
The medication was administered 1 hour and 38 minutes after the ordered time.
During an observation of a medication pass on 8/10/22, at 9:44 A.M., Nurse #1 administered medications including the following to Resident #28:
-Acetaminophen (a pain reliever) 500 mg 1 tab
-Prednisone (a steroid) 5 mg 1 tab
Review of Resident #28's current physician orders indicated the following:
-Acetaminophen 500 mg 1 tab by mouth two times a day at 8:00 A.M. and 8:00 P.M.
-Prednisone 5 mg 1 tab by mouth at 8:00 A.M.
The medications were administered 1 hour and 44 minutes after the ordered time.
During an interview on 8/10/22, at 11:31, Nurse #1 said the nurse administering the medications should be checking that it's the right name, medication, dose, strength and time. Nurse #1 said there is a one hour window before and after the ordered time to administer medications and acknowledged the medications were given late. Nurse #1 said timing is difficult on her unit and many medications are given late. Nurse #1 said until there is more staff to assist with meals in the morning it will be difficult to get the medications administered on time. Nurse #1 said at a minimum there are 7 residents who are totally dependent for meals and 5 staff (2 nurses and 3 Certified Nursing Assistants) and said one staff member must supervise the dining room and the other staff will assist the totally dependent residents before starting to administer medications.
During an observation of a medication pass on the [NAME] Unit on 8/10/22, at 9:56 A.M., Nurse #2 administered medications including the following to Resident #53:
-Acetaminophen 325 mg 2 tabs
Review of Resident #53's current physician orders indicated the following:-Acetaminophen 325 mg by mouth three times daily at 8:00 A.M., 1:00 P.M., 8:00 P.M.
The medication was administered 1 hour and 56 minutes after the ordered time.
During an interview on 8/10/22, at 11:37 A.M., Nurse #2 said there is generally an hour window before and after an order is written to administer it. Nurse #2 acknowledged he administered Resident #53's Acetaminophen late.
During an observation of a medication pass on the Andover Unit on 8/10/22, at 10:16 A.M., Nurse # 3 administered medications including the following to Resident #91:
-Apixaban (an anticoagulant) 2.5 mg 1 tablet
-Metoprolol Tartrate (a blood pressure medication) 12.5 mg 1 tablet
-Acetaminophen 500 mg 2 tablets
Review of Resident #91's current physician orders indicated the following:
-Apixaban 2.5 mg by mouth twice daily at 9:00 A.M. and 9:00 P.M.
-Metoprolol Tartrate 12.5 mg by mouth twice daily at 9:00 A.M. and 9:00 P.M.
-Acetaminophen 500 mg by mouth three times a day at 9:00 A.M., 2:00 P.M. and 9:00 P.M.
During an interview on 8/10/22, at 11:42 A.M., Nurse #3 acknowledged the late administration of the medications. Nurse #3 said that he is usually the only nurse on the unit to give medications and treatments to 16-18 residents. Nurse #3 said staffing is difficult and he tries his hardest to get the medications administered on time.
During an interview on 8/10/22, at 4:04 P.M., the Infection Control nurse said that nurses have a one hour window before and after a medication is ordered to administer it.
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 major safety red flags. No abuse findings, life-threatening violations, or SFF status.
- • No fines on record. Clean compliance history, better than most Massachusetts facilities.
Concerns
- • 58 deficiencies on record. Higher than average. Multiple issues found across inspections.
- • Grade D (40/100). Below average facility with significant concerns.
Bottom line: Trust Score of 40/100 indicates significant concerns. Thoroughly evaluate alternatives.
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About This Facility
What is Willow Brook Rehabilitation And Healthcare Center's CMS Rating?
CMS assigns WILLOW BROOK REHABILITATION AND HEALTHCARE CENTER an overall rating of 1 out of 5 stars, which is considered much below average nationally. Within Massachusetts, this rating places the facility higher than 0% of the state's 100 nursing homes. A rating at this level reflects concerns identified through health inspections, staffing assessments, or quality measures that families should carefully consider.
How is Willow Brook Rehabilitation And Healthcare Center Staffed?
CMS rates WILLOW BROOK REHABILITATION AND HEALTHCARE CENTER's staffing level at 1 out of 5 stars, which is much below average compared to other nursing homes. Staff turnover is 52%, compared to the Massachusetts average of 46%. RN turnover specifically is 71%, which is notably high. RNs provide skilled clinical oversight, so turnover in this role can affect medical care quality.
What Have Inspectors Found at Willow Brook Rehabilitation And Healthcare Center?
State health inspectors documented 58 deficiencies at WILLOW BROOK REHABILITATION AND HEALTHCARE CENTER during 2022 to 2025. These included: 56 with potential for harm and 2 minor or isolated issues. While no single deficiency reached the most serious levels, the total volume warrants attention from prospective families.
Who Owns and Operates Willow Brook Rehabilitation And Healthcare Center?
WILLOW BROOK REHABILITATION AND HEALTHCARE 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 MARQUIS HEALTH SERVICES, a chain that manages multiple nursing homes. With 142 certified beds and approximately 126 residents (about 89% occupancy), it is a mid-sized facility located in WILMINGTON, Massachusetts.
How Does Willow Brook Rehabilitation And Healthcare Center Compare to Other Massachusetts Nursing Homes?
Compared to the 100 nursing homes in Massachusetts, WILLOW BROOK REHABILITATION AND HEALTHCARE CENTER's overall rating (1 stars) is below the state average of 2.9, staff turnover (52%) is near the state average of 46%, and health inspection rating (2 stars) is below the national benchmark.
What Should Families Ask When Visiting Willow Brook Rehabilitation And Healthcare Center?
Based on this facility's data, families visiting should ask: "Can you walk me through typical staffing levels on day, evening, and night shifts?" "Can I visit during a mealtime to observe dining assistance and food quality?" "How do you handle medical emergencies, and what is your hospital transfer rate?" "Can I speak with family members of current residents about their experience?" These questions are particularly relevant given the below-average staffing rating.
Is Willow Brook Rehabilitation And Healthcare Center Safe?
Based on CMS inspection data, WILLOW BROOK REHABILITATION AND HEALTHCARE 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 1-star overall rating and ranks #100 of 100 nursing homes in Massachusetts. While no facility is perfect, families should still ask about staff-to-resident ratios and recent inspection results during their visit.
Do Nurses at Willow Brook Rehabilitation And Healthcare Center Stick Around?
WILLOW BROOK REHABILITATION AND HEALTHCARE CENTER has a staff turnover rate of 52%, which is 6 percentage points above the Massachusetts average of 46%. Moderate turnover is common in nursing homes, but families should still ask about staff tenure and how the facility maintains care continuity when employees leave.
Was Willow Brook Rehabilitation And Healthcare Center Ever Fined?
WILLOW BROOK REHABILITATION AND HEALTHCARE 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 Willow Brook Rehabilitation And Healthcare Center on Any Federal Watch List?
WILLOW BROOK REHABILITATION AND HEALTHCARE 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.