The Shores Of Worthington
For profit - Corporation
69 Beds
EPHRAM LAHASKY
Data: November 2025
3 Immediate Jeopardy citations
Trust Grade
0/100
#329 of 337 in MN
Last Inspection: March 2025
Within standard 12-15 month inspection cycle. Federal law requires annual inspections.
Overview
The Shores of Worthington has received a Trust Grade of F, indicating poor performance with significant concerns. They rank #329 out of 337 nursing homes in Minnesota, placing them in the bottom half of facilities in the state, and #2 out of 2 in Nobles County, meaning there is only one other local option that is better. The facility's situation is worsening, with issues increasing from 9 in 2024 to 28 in 2025. While staffing is a relative strength with a rating of 4 out of 5 stars and RN coverage better than 78% of facilities, the turnover rate of 54% is concerning, exceeding the state average. Additionally, the home has been fined $47,643, which is higher than 88% of Minnesota facilities, indicating repeated compliance problems. Specific incidents of concern include an outbreak of RSV affecting 13 residents due to inadequate infection control measures, resulting in hospitalizations; a resident fell and sustained spinal fractures due to improper use of a mechanical lift; and a resident with cognitive impairments was able to leave the facility unsupervised, leading to a dangerous situation. Overall, while there are some strengths in staffing, the numerous critical incidents and poor overall ratings suggest families should carefully consider their options.
- Trust Score
- F
- In Minnesota
- #329/337
- Safety Record
- High Risk
- Inspections
- Getting Worse
- Staff Stability ⚠ Watch
- 54% turnover. Above average. Higher turnover means staff may not know residents' routines.
- Penalties ⚠ Watch
- $47,643 in fines. Higher than 89% of Minnesota facilities, suggesting repeated compliance issues.
- Skilled Nurses ✓ Good
- Each resident gets 66 minutes of Registered Nurse (RN) attention daily — more than 97% of Minnesota nursing homes. RNs are the most trained staff who catch health problems before they become serious.
- Violations ⚠ Watch
- 56 deficiencies on record. Higher than average. Multiple issues found across inspections.
0/100
Bottom 3%
Review needed
9 → 28 violations
★☆☆☆☆
1.0
Overall Rating
★★★★☆
4.0
Staff Levels
★★☆☆☆
2.0
Care Quality
★☆☆☆☆
1.0
Inspection Score
↔
Stable
2024: 9 issues
2025: 28 issues
The Good
-
4-Star Staffing Rating · Above-average nurse staffing levels
-
Full Sprinkler Coverage · Fire safety systems throughout facility
-
No fines on record
Facility shows strength in staffing levels, fire safety.
The Bad
1-Star Overall Rating
Below Minnesota average (3.2)
Significant quality concerns identified by CMS
Staff Turnover: 54%
Near Minnesota avg (46%)
Higher turnover may affect care consistency
Federal Fines: $47,643
Above median ($33,413)
Moderate penalties - review what triggered them
Chain: EPHRAM LAHASKY
Part of a multi-facility chain
Ask about local staffing decisions and management
The Ugly 56 deficiencies on record
3 life-threatening 1 actual harm
Apr 2025
4 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
Quality of Care
(Tag F0684)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to comprehensively assess and treat impaired skin integri...
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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 comprehensively assess and treat impaired skin integrity for 1of 1 residents (R3) who had acute dermatitis.
Findings include:
R3's face sheet dated 4/15/25, identified diagnoses of type two diabetes, obesity.
R3's admission Minimum Data Set (MDS) dated [DATE], identified no cognitive deficits. Frequent incontinence of bladder and bowel.
R3's care plan dated 3/25/25, identified R3 required extensive assistance with person hygiene and toilet use. R3's care plan dated 3/31/25, identified risk for impaired skin integrity and to monitor for moisture, apply barrier product as needed. A goal dated 4/4/25 included, skin integrity would be evaluated. Corresponding intervention directed staff to evaluate skin integrity.
R3's hospital discharge orders dated 3/18/25, identified an order for bacitracin-neomycin-polymyxin 5-400-5000 milligrams (mg) unit ointment and apply 1 application twice daily to rash until clear. Clotrimazole 1% cream apply topically three times per day as needed, no diagnosis indicated. Hydrocortisone butyrate 0.1% cream apply one application topically three times per day as needed for rash. Triamcinolone acetonide 0.1% cream apply topically to affected areas twice daily as needed for atopic dermatitis. Interdry AG textile to opposing skin folds for prevention or treatment of irritated skin. Change every five days or if soiled. Leave a two inch tail outside of each end of affected area to wick away moisture.
R3's physician orders dated 3/18/25 identified the aforementioned physician orders according to the hospital discharge summary.
Review of R3's medication administration record (MAR) for March and April 2025, identified the treatment orders but there was no indication R3's skin care treatments were applied.
The admission skin assessment dated [DATE] did not identify an issues with R3's skin.
R3's progress note dated 3/18/25 at 1:29 p.m., identified the note as a nurse to nurse report from hospital. Under folds increased moisture and redness.
R3's progress note dated 3/19/25 at 12:22 p.m., indicated R3's rash had healed.
R3's skilled evaluation progress note dated 4/9/25 at 11:43 p.m., identified no skin issues on abdomen or groin area.
During an observation on 4/10/25 at 7:46 a.m., R3 was in bed. Nursing assistant (NA)-A filled basin with water and applied gloves to provide morning cares. NA-A removed R3's brief. R3's abdomen was reddened across the whole apron fold and groin area was very red on both sides. NA-A stated R3's abdomen looked a little sore/red across the whole abdominal fold and was very red in the groin area on the creases. NA-A then dried the areas she had just cleaned and applied a new incontinent brief. NA-A left the R3's room and returned to the room with an antifungal cream and an antifungal powder. NA-A stated she would use the antifungal cream as the area was not moist but leave the powder in the room also; she the applied antifungal cream to abdominal fold and groin creases. NA-A left the room, walked to registered nurse (RN)-A and notified RN-A that R3 was ready for a breakfast tray. NA-A did not mention R3's reddened folds.
During an observation and interview on 4/10/25 at 12:20 p.m., registered nurse infection preventionist (IP)-A stated skin should be checked at a minimum weekly during a bath. NA's should be doing a daily check during morning and evening cares. A notable change should be reported to the nurse. IP-A explained R3 had been admitted from the hospital, the hospital had reported to the facility R3 had redness under folds and moisture, but the facility did not see that when he admitted . When the initial assessment was completed, the staff verify skin conditions, and the facility charting did not show concerns in that area. IP-A went to R3's room and put gloves on. IP-A lowered pants and lifted abdominal fold and stated that the areas were definitely red and moist. R3 indicated he had a history of problems in that area. This facility was not providing enough hygiene. The facility where he resided at prior and would be returning to had given him showers four times a week, had three times a week in a bath with jets, and used a medicated spray to manage the skin issues. This facility could not provide him with bathing due to his condition. IP-A stated the issue should have been reported to the nurse, medical doctor notified. The area needed to have the moisture removed to decrease redness. If this goes untreated it could lead to sores/infection. IP-A felt that a powder and Interdry would be a good treatment for the areas. Education should be done on cleaning and drying the folds as well.
During an interview on 4/10/25 at 2:35 p.m., RN-A stated she looked at R3's skin after NA-A said to look at it because it was very sore. RN-A got busy and behind in work, IP-A also told her about R3's skin, and thought a fax was started to send to the physician. This was the first time it was reported to her that R3 had a red groin. RN-A explained skin issues would be documented under the skin section of the daily skilled charting notes. RN-A reviewed the record and identified there was nothing documented pertaining to the condition. RN-A relied on the NA's to tell her if a resident had new skin issues so that the area would be assessed.
During an interview on 4/10/25 at 2:53 p.m., director of nursing (DON) stated the floor nurses have had education on what to look for with skin concerns. DON would expect the NA's to notify the floor nurse of a skin concern and the nurse would examine and determine next steps. DON was unsure if antifungal could be given as a standing order but typically would call or send a fax to the physician for orders. If care and treatment were provided improperly or not at all, nothing good could come of it. Improper treatment of wounds could lead to worsening wound(s) and if medications were given incorrectly, that could lead to a negative outcome.
During an interview on 4/11/25 at 2:24 p.m., DON and IP-A stated there have been discrepancies between what the hospital reports and what the resident actually has when they enter the building regarding wounds and dressings. It was absolutely not appropriate and out of the scope of practice for an NA to choose what product to apply on a resident.
The facility Wound Care procedure dated 9/29/21, identified to begin by verifying the physician order for the procedure. Document in the medical record: type of wound care given, all assessment data, etc. Report other information in accordance with facility policy and professional standards of practice.
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
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, and record review the facility failed to monitor and complete comprehensive skin assessments, e...
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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 monitor and complete comprehensive skin assessments, evaluate the effectiveness of interventions, and provide physician ordered treatments as prescribed to prevent or negate the risk of deterioration or new ulcer development for 1 of 3 residents (R1) who was at risk for pressure ulcers and had a history of pressure ulcers.
Findings include:
R1's face sheet dated 4/9/25, identified diagnoses of obesity.
R1's quarterly Minimum Data Set (MDS) dated [DATE], identified no cognitive impairment. R1 was dependent with cares on lower body. Had an indwelling urinary catheter, always incontinent of bowels. R1 had frequent pain rated 10/10 with 10 as the worst pain ever experienced. R1 had a stage III pressure ulcer which indicated full thickness tissue loss. R1 had behaviors both verbal and physical directed at others, and rejected cares frequently.
R1's wound evaluation dated 3/6/25, identified the stage III pressure ulcer to right ischial tuberosity was healed.
R1's care plan dated 3/23/25, identified behavior management with interventions to attempt alternative time to provide care refused, monitor for signs and symptoms of infection. Pressure ulcer care dated 10/11/24, identified educate resident about proper skin care to prevent skin breakdown, encourage to frequently shift weight, provide skin care per facility guidelines, provide wound care per treatment order. Refused to sleep in bed and sleeps in the recliner per choice.
R1's Braden scale for predicting pressure ulcer risk dated 4/8/25, identified a score of 13 which indicated moderate risk for pressure ulcers.
R1's physician order dated 11/25/24, include the order to apply a mixture of calmoseptime external ointment mixed with collagen fibers to bilateral buttocks topically two times per day. R1's corresponding treatment administration record (TAR) between 3/6/25 through 4/10/25 identified the calmoseptime with collegene was marked as completed, however R1's record between 3/6/25 through 4/10/25 did not include corresponding assessments and monitoring of the area for which the treatment was being applied.
During an observation on 4/10/25 at 10:49 a.m., nursing assistant (NA)-A, NA-B, and registered nurse (RN)-A entered R1's room to provide cares all wearing a gown, mask, and gloves. R1 demonstrated yelling behaviors toward all three staff during the episode of care. NA-A detached the tabs of the brief. Bowel movement present. NA-A sprayed peri-wash to the dried on bowel movement. RN-A began wiping bowel movement from both buttocks with wet wipes using her right hand. R1 stated his rectal area was very sore and to be careful. R1's bottom was noted to have many small, opened, red areas with bloody discharge on the right buttock and the left buttock had a heart shaped reddened area. RN-A stated they had some cream for that and squeezed a large amount of calmoseptime cream onto her right glove and rubbed it on bilateral buttocks pressure areas. RN-A did not mix the cream with collagen sprinkles nor measure the areas on R1's bottom. R1 began to scream and yelled ouch and I told you it was sore down there! NA-A took calmoseptime cream and squeezed some on right glove and put on creases of perineal region. NA-A removed gloves and asked NA-B to get her a new pair. NA-A put new gloves on. After transferring back to the recliner NA-A, NA-B, and RN-A removed gloves and washed hands in sink.
During an interview on 4/10/25 at 11:17 a.m., RN-A stated the areas on R1's buttocks are moisture related sores. The treatment was to apply calmoseptime to the areas. A medical doctor had not looked at the areas but the DON would complete the assessments. In a subsequent interview on 4/10/25 at 2:35 p.m., RN-A stated she notified DON that R1's buttocks needed to be evaluated due to a change in the wounds. RN-A verified that collagen sprinkles were not used during wound treatment. RN-A was not comfortable with wounds and staging and would refer to DON on determining what treatment would be best and what stage a pressure injury would be considered. R1 is hard because when he yells it creates a rushed environment and steps get missed.
R1's late entry progress note dated 4/10/25 created at 5:39 p.m. for 11:17 a.m., identified buttocks changed in appearance and current orders are for calmoseptime. Notified director of nursing (DON) and resident agreed to lay down after supper for wound picture. Corresponding wound assessments dated 4/10/25 at 6:15 p.m., by DON identified stage III (resolved stage III) pressure injury to right ischial tuberosity measured area: <0.1 centimeters (CM), length: 0.22cm and width: 0.31 cm, no depth was identified. Left ischial tuberosity stage III (resolved stage III) pressure injury area 5.87cm, length 2.42cm, width 2.96cm, no depth was identified. Wound orders updated to apply to both buttocks: cleanse with Vashe wound cleanser, apply collagen to open areas, cover with silicone bordered foam. Change every 3 days and as needed.
During an interview on 4/10/25 at 2:11 p.m., RN-B stated moisture associated skin breakdown occurs when there is excessive moisture in an area. Once there is an area that has broken down it is more susceptible to breakdown. R1 is very adamant if he does not want to do something and the staff have to really try and coax him. RN-B would notify DON, and medical doctor if a change in wounds was noted. RN-B verified she was the nurse working with R1 on 4/9/25 and signed off that calmoseptime and collagen treatment had been completed. RN-B could not recall what condition the buttocks were in on 4/9/25 and did not remember looking at the wounds.
During an interview on 4/10/25 at 12:20 p.m., infection preventionist (IP)-A stated the DON completed weekly wound rounds on residents. Skin should be checked a minimum of weekly on bath days by the nurses. NA's should observe skin daily with cares and report changes to the nurse. Charting daily on the condition of wounds/wound dressing if the dressing is not scheduled to be changed is the expectation. R1 typically allowed the staff to transfer him from recliner to bed once a day. Every shift the staff encourage him to change positions. R1's current wound treatment was not appropriate for to treat R1's skin. The facility had wound training with a product specific company early in 2025 and they provided the facility with laminated cards for the NA's to direct what creams or lotions to use with specific skin issues. The DON has encouraged the nurses to come to her or the assistant director of nursing (ADON) if they were unsure about a wound.
During an interview on 4/10/25 at 2:53 p.m., DON stated she observed wounds on residents weekly. RN-A informed DON to look at R1's buttocks as she was not confident in staging pressure ulcers. DON explained RN-A should have applied the treatment as ordered. Improper pericare could lead to infection and improper wound care could lead to worsening of wounds, both of which are negative outcomes.
The facility Pressure Ulcers/Skin Breakdown - Clinical Protocol dated 7/12/22, identified nursing staff and physician will assess and document an individuals significant risk factors for developing pressure ulcers. The physician will order pertinent wound treatments and help identify medical interventions related to wound management.
The facility Wound Care procedure dated 9/29/21, identified to begin by verifying the physician order for the procedure. Document in the medical record: type of wound care given, all assessment data, etc. Report other information in accordance with facility policy and professional standards of practice.
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
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, interview, and record review the facility failed to ensure appropriate care and services were provided to ...
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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 ensure appropriate care and services were provided to prevent urinary tract infections to the extent possible for 1 of 2 residents (R1) who had an indwelling urinary catheter.
Findings include:
R1's face sheet dated 4/15/25, identified diagnoses of overactive bladder (urgent need to urinate), atrophy of testes (shrinkage of one or both testes), benign prostatic hyperplasia (enlarged prostate) with lower urinary tract symptoms (frequent/urgent need to urinate).
R1's quarterly Minimum Data Set (MDS) dated [DATE], identified no cognitive impairment. R1 was dependent with cares on lower body. Had an indwelling urinary catheter, always incontinent of bowels. R1 had behaviors both verbal and physical directed at others and rejected cares frequently.
R1's care plan dated 4/4/25, identified risk for urinary retention with foley catheter to be replaced monthly and as needed. Interventions included to evaluate for urinary complaints. R1 insisted that the catheter be placed. Monitor for abdominal distention and signs/symptoms of UTI. Evaluate for pain, urinary complaints, urine characteristics and cognitive changes.
R1's physician order dated 8/30/24, identified an order for a urinary catheter 16 french 10 cubic centimeters (CC) balloon be placed, changed monthly with a diagnosis of urinary incontinence.
R1's progress note dated 12/5/25, identified R1 returned from emergency department with a diagnosis of acute cystitis (inflammation of bladder often caused by bacteria) with hematuria (blood in urine). Start ciprofloxacin (antibiotic) twice daily for days. Maintain foley catheter with a 24 french 10 cc balloon.
R1's physician order dated 1/5/25, included an order for 24 french catheter with 10 cc balloon.
During an interview on 4/10/25 at 12:20 p.m., infection preventionist (IP)-A stated she was unable to find specific culture results for the UTI but that R1 went to the emergency department for treatment on 12/5/25.
R1's progress note dated 3/6/25, identified urine analysis and urine culture (UA/UC) results from 3/5/25 were positive for a UTI. Will treat with Keflex (antibiotic).
During an interview on 4/10/25 at 12:20 p.m., IP-A stated the UC growth showed ecoli and enterococcis faccaeilis. Reviewed that these bacteria spread from direct or indirect contact with healthcare workers hands.
R1's progress note dated 3/7/25, identified foley catheter changed, urine dark with sediment, when pulled out tubing tip was full of mucous. Located a 20 french with 30cc balloon, 24 french was not available as ordered by the physician on 1/5/25.
R1's progress note dated 4/4/25, identified UA/UC was ordered due to R1 having coke colored urine with blood present, and hallucinations.
R1's progress note dated 4/5/25, identified UA was collected and ready to be sent to the lab. R1's record did not include the lab results.
R1's progress note dated 4/7/25, indicated a physician order for Macrobid (antibiotic) two times a day for seven days started. Repeat UA in seven days.
During an interview on 4/10/25 at 12:20 p.m., IP-A stated the bacteria that grew from the UC from 4/5/25, had multiple morphotypes present. IP-A went onto the computer and looked up what mulitiple morphotypes could be caused by and stated this bacteria can also be spread by direct or indirect contact with healthcare workers hands.
During an observation on 4/10/25 at 10:49 a.m., nursing assistant (NA)-A, NA-B, and registered nurse (RN)-A entered R1's room to provide cares all wearing a gown, mask, and gloves. R1 had yelling behaviors directed at staff throughout the episode of care. NA-A detached the tabs of the brief. Bowel movement present. NA-A wiped with her right hand in penile area and NA-B sprayed periwash on the dried stool dried on to and adheared to R1's bottom area. As NA-B cleaned the stool in an upward motion across R1's scrotum and by the catheter R1 yelled that it hurt. NA-A then took a wet washcloth and wiped on the groin creases and bowel movement was present on the washcloth. NA-A had NA-B rinse the washcloth in the filled water basin. NA-A took the same wash cloth from the basin and wiped the creases again. NA-A then moved to R1's penis and wiped around the catheter tip and then down the catheter tubing with the dirty washcloth. NA-A used a clean, dry towel to dry the areas. NA-A then moved the catheter tubing with her right gloved hand to move it out of the way while R1 was turned to his left side. Without changing gloves and santizing hands, NA-A took calmoseptine cream and squeezed some on right glove and put on creases of perineal region. NA-A then removed gloves and asked NA-B to get her a new pair. NA-A put new gloves on without performing hand hygiene. After transferring back to the recliner NA-A, NA-B, and RN-A removed gloves and washed hands in sink.
During an interview on 4/10/25 at 12:20 p.m., IP-A stated an investigation/analysis has not been completed nor surveillance activities such as audits in order to identify potential causal factors of R1's repeated UTI's so that interventions could be developed and implemented to prevent or reduce the risk. IP-A expected staff were to perform pericare following infection control guidelines.
During an interview on 4/10/25 at 2:53 p.m., DON stated there had not been surveillance activities that addressed catheter related infections. If staff were not providing personal cares appropriately, that could lead to infection. DON and the ADON would be, but have not started, working on providing education and competencies with staff on catheter cares and pericares.
During an interview on 4/11/25 at 11:36a.m., DON and IP-A stated the facility will increase fluids on residents with catheters. R1 preferred to drink mountain dew and was not good at drinking water. The nurses monitor for cognitive symptoms in R1 since the UTI he currently has, he was noted to have hallucinations as a symptom. Proper hand hygiene should be performed with pericares.
The facility Urinary Catheter Care dated 11/1/21, identified to maintain clean technique when handling or manipulating the catheter, tubing, or drainage bag. It is not recommended to change the indwelling catheters or bags at fixed, routine intervals and instead based on clinical indications such as infection. Observe the resident for complications associated with urinary catheters.
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
Infection Control
(Tag F0880)
Could have caused harm · This affected 1 resident
Based on observation, interview, and record review the facility failed to perform appropriate hand hygiene during cares for 4 of 4 residents (R3, R4, R5, and R10) observed for personal cares.
Findings...
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Based on observation, interview, and record review the facility failed to perform appropriate hand hygiene during cares for 4 of 4 residents (R3, R4, R5, and R10) observed for personal cares.
Findings include:
R3
R3's face sheet dated 4/15/25, identified diagnoses of intertrochanteric fracture of left femur (broken hip).
R3's care plan dated 3/25/25, identified personal hygiene required extensive assistance from staff.
During an observation on 4/10/25 at 7:46 a.m., R3 was in bed. nursing assistant (NA)-A filled basin with water and applied gloves. Cleansed top half of body and face. Had R3 turn to the side and wiped bowel movement with wipes. NA-A without performing hand hygiene, returned to the front of R3 and cleaned penis pulling down foreskin and wiping away white particles with a washcloth. NA-A then took off gloves and without performing hand hygiene left and returned to R3's room and without performing hand hygiene put new gloves on. NA-A instructed R3 to turn and washed bottom with wipe. NA-A then took the washcloth to remove the remaining stool from R3's bottom. NA-A put the washcloth in the water basin to rinse it out. NA-A then used that same washcloth from the dirty water and finished cleaning R3's bottom. While wearing the same gloves NA-A dried R3's bottom area and applied a new incontinent brief. Rinsed basin out in sink and emptied water into toilet. NA-A removed gloves and without performing hand hygiene gave R3 his call light and then washed her hands.
R4
R4's face sheet dated 4/10/25, identified moderate intellectual disabilities.
R4's care plan dated 8/20/24, identified R4 required assistance of two staff and mechanical standing lift for toileting.
During an observation on 4/10/25 at 8:23 a.m., R4 was seated on the commode (portable toilet) with the mechanical standing lift attached. NA-A and NA-B applied gloves. NA-B lifted R4 into a half standing position with the machine while NA-A cleaned bowel movement from R4's bottom area. R4 stated that it was sore. NA-A stated she would put ointment on when finished wiping. NA-A moved to R4's front and wiped peri area with the same gloved hand used to wipe the backside. NA-A removed the glove after wiping, grabbed a tube of preventative ointment and applied to rectal area. Removed other glove and pulled up R4's pants and incontinent product. NA-A applied another set of gloves to clean commode. Removed gloves when finished. Both NA's washed hands at R4's sink.
R5
R5's face sheet dated 4/10/25, identified fracture of upper and lower end of right fibula (broken calf bone), and fracture of medial malleolus of right tibia (the bump on the side of the ankle).
R5's care plan dated 4/8/25, identified R5 required assistance of two staff and mechanical lift for transfers.
During an observation on 4/10/25 at 8:10 a.m., NA-A applied enhanced barrier precautions (EBP gown, gloves, mask) and entered room. NA-B was inside R5's room and opened the door. NA-B stepped out of the room and applied EBP. R5 was in the room attached to mechanical lift on the commode. NA-A and NA-B transferred R5 from the commode to the bed and removed the mechanical lift. NA-A wiped R5's bottom. Applied pants on R5's legs and incontinent product by rolling R5 side to side. Re-attached mechanical lift to R5. Transferred R5 to wheelchair and adjusted R5's shirt and boosted back in the wheelchair to R5's comfort. Gave R5 the call light and placed overhead table in front of wheelchair. Removed EBP and sanitized hands.
R10
R10's face sheet dated 4/15/25, identified diagnoses of parkinsonism (difficulties with movement).
R10's care plan dated 2/17/25, identified R10 required extensive assistance with personal hygiene.
During an observation on 4/10/25 at 7:06 a.m., R10 was laying in bed. NA-C filled water in a basin.Applied gloves. Asked R10 to remove dentures so they could be brushed, removed and put in container to soak during cares. Washed face and abdominal region with soap and water after removing gown. After drying R10, applied a shirt. Opened brief and cleansed peri area. Grabbed another washcloth and cleaned backside. Put on a new incontinent product. Removed gloves and put a new pair on. Put a few gloves in her pocket. Put pants on. Had R10 sit on the edge of bed, put on socks, put walker in front of him. Transferred to wheelchair. Removed gloves and sanitized hands.
During an interview on 4/10/25 at 8:36 a.m., NA-B stated that handwashing is done between residents.
During an interview on 4/10/25 at 9:45 a.m., NA-C stated handwashing is done in the morning, on breaks, if bowel movements are bad and messy, otherwise hand sanitizer after exiting rooms. NA-C was unaware about handwashing between removing and applying new gloves.
During an interview on 4/10/25 at 9:53 a.m., NA-A stated handwashing is used after coming in contact with a resident or leaving the room. It should be done between glove changes, I forgot.
During an interview on 4/10/25 at 2:35 p.m., registered nurse (RN)-A stated hand sanitizing is done throughout the day, in between glove changes. Wash hands before and after cares.
During an interview on 4/11/25 at 9:47 a.m., licensed practical nurse (LPN)-A stated management monitors, teaches, and reinforces hand hygiene and the importance of handwashing between pericare.
During an interview on 4/10/25 at 12:20 p.m., registered nurse infection preventionist (IP)-A stated the staff should wash or sanitize hands after glove removal and should change gloves and sanitize or handwash after cleaning the peri area whether front or back. Staff should not clean bowels and use the same gloved hand or cleaning utensil to clean the front side.
During an interview on 4/10/25 at 2:53 p.m., director of nursing (DON) stated they [management] observe a ton of handwashing, applying and removing gloves that are a month or two old. Nothing good can come of improper peri care, it could lead to an infection. Hand washing and/or sanitizing should be done more often than it is apparently. We have been pushing staff to wash hands when removing gloves and use the sink, it is available in every room. If cleaning something dirty, remove gloves, wash/sanitize hands, put on new gloves, it is not worth it to cross-contaminate.
The facility policy Perineal Care dated 2/8/22, identified the procedure was to provide cleanliness to the resident, prevent infections and skin irritation. For a female resident wash perineal area, wiping front to back. Wash the rectal area wiping from the base of the labia towards and extending over the buttocks. For a male resident wash perineal area starting with urethra and working outward. Wash rectal area thoroughly including under the scrotum, the anus, and buttocks.
Mar 2025
23 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0578
(Tag F0578)
Could have caused harm · This affected 1 resident
Based on interview and document review, the facility failed to ensure the physician signed a Provider Order for Life-Sustaining Treatment (POLST) order for 1 of 15 residents (R37) following admission....
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Based on interview and document review, the facility failed to ensure the physician signed a Provider Order for Life-Sustaining Treatment (POLST) order for 1 of 15 residents (R37) following admission.
Findings include:
R37's 1/15/25, admission Minimum Data Set (MDS) identified R37 was cognitively alert and required substantial/maximal assistance with activities of daily living (ADLs). R37 had a diagnoses of malnutrition, anxiety, diabetes and cirrhosis.
R37's 1/08/25 POLST, identified R37 was to be full code. There was no mention on the consent R37's wishes were communicated to the primary physician and was not signed within 30 days of admisson on rounds.
Interview on 2/26/25 at 8:40 a.m., with Registered nurse (RN)-B identified residents POLST would be obtained during admissions with social service department and was to be signed by the primary physician and was to be updated on the resident medical record to ensure it matched admission orders and the resident had not changed or wished to change their status upon admission.
Interview on 2/26/25 at 8:46 a.m., with director of nursing (DON) identified her expectation of POLST choices were to be addressed and documented when a resident was admitted to the facility by the physician. She voiced agreement that facility had failed to follow their policy, and the signed document had not been completed since R37's admission to the facility.
Interview on 2/27/25 and 2:40 p.m., with admission coordinator identified R37's POLST had not been completed and was missed during admission. She identified it was not an acceptable practice for a R37 to not have a POLST in her medical record and was not aware R37's POLST was not signed by the physician on admission.
Interview on 3/04/25 at 8:15 a.m., with medical director would expect residents code status to be determined and confirmed upon admission.
Review of the October 2022 Advance Directive Policy identified the facility would obtain resident status on the POLST upon admission. The director of nursing or designee would notify the provider of advance directives or changes to the advance directive so that appropriate orders would be documented on a residents' medical record and plan of care. The facility would place residents advance directive document in an accessible location in the medical record.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Comprehensive Assessments
(Tag F0636)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on interview and document review, the facility failed to ensure 1 of 1 resident (R41) was accurately and comprehensively ...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on interview and document review, the facility failed to ensure 1 of 1 resident (R41) was accurately and comprehensively assessed when R41 exhibited behaviors or refusal of all cares, medication, treatment and evaluation.
Findings include:
Review of the Resident Assessment Instrument (RAI) 3.0 manual identified The RAI process has multiple regulatory requirements. Federal regulations require the assessment accurately reflects the resident's status, a registered nurse conducts or coordinates each assessment with the appropriate participation of health professionals, and the assessment process includes direct observation, as well as communication with the resident and direct care staff on all shifts. In addition, an accurate assessment requires collecting information from multiple sources. Those sources must include the resident and direct care staff on all shifts, and should also include the resident's medical record, physician, and family, guardian, and/or other legally authorized representative, or significant other as appropriate or acceptable. It is important to note here that information obtained should cover the same observation period as specified by the Minimum Data Set (MDS) items on the assessment, and should be validated for accuracy (what the resident's actual status was during that observation period) by the interdisciplinary team (IDT) completing the assessment.
R41's face sheet identified he was admitted to the facility in September 2024. R41 had a recent hospital stay 11/4/24 through 11/6/24 and had diagnoses of hypoparathyroidism (parathyroid glands do not produce enough parathyroid hormone and treated with medication), history of a lumbar spinal fracture, right leg fracture, right artificial hip, hypothyroidism (thyroid gland does not produce enough thyroid hormone), generalized anxiety disorder, and multiple fractures of ribs.
R41's 11/25/24, quarterly Minimum Data Set identified R41 was admitted to the facility (from the now closed sister facility) in September 2024. The MDS identified in section:
1) C: R41 was reported to answer cognitive questions to identify his mental status.
2) D: in the field D0100 Should Resident Mood Interview be Conducted the answer was checked yes however; no responses were given. D0500: Staff assessment of Resident Mood was blank. D0700: Social isolation was marked never.
3) E: Behavior: E0100 identified R41 had delusions. No behaviors were noted for physical, Verbal, or Other. Rejection of care was noted to only occur 1 to 3 days during the look-back period. E1100: Change in Behavior or Other Symptoms was left blank when asked how the residents current behavior status, care rejection, or wandering compared to his prior assessment.
4) F: Preferences for Customary Routine and Activities was not filled out.
5) H: Bladder and Bowel: H0300 identified R41 was occasionally incontinent.
6) J: Health Conditions: J0200 Should Pain Assessment Interview be Conducted? Answer is yes. J0300 Pain Assessment Interview/Pain Presence: Unable to answer was checked. J0800: Indicators of Pain or Possible Pain in the last 5 days: None of these signs observed or documented.
7) K: Swallowing/Nutritional Status: K0100 Swallowing Disorder/Signs and symptoms of possible swallowing disorder is related to observations of swallowing or reports of complaints of swallowing: None of the above was marked. K0200 Weight was documented as 191 pounds (lbs.). K0300 and K0310 mention weight loss and gain. Both are marked no or unknown.
8) L0200: oral/Dental Status: L0200 describes visualization of the mouth. No questions were answered.
9) M: Skin Conditions: M0100 Determination of Pressure Ulcer Risk: identified a formal assessment instrument or tool such as a [NAME] score and clinical assessment were checked as completed. M150 identified R41 was at risk for pressure ulcers. M0210: Unhealed pressure ulcers: Does the resident have 1 or more unhealed pressure ulcers at Stage 1 or higher? Answer was marked no.
10) P: Restraints: P0200 Alarms: subsection E: Wander/elopement alarm was marked with a 2 and noted to be used daily.
Notes associated with the 2/25/25, MDS assessment in progress identified on 2/19/25, R41's:
1) Fall risk was evaluated. Staff documented he had no falls in the past 3 months. R41 was noted to have intermittent confusion. R41 was ambulatory and continent of bowel and bladder. Systolic blood pressure noted there was no drop between lying and standing. R41 was listed as having adequate vision and reportedly had no change of condition in the last 14 days. R41 had no hospitalizations in the last 30 days. His gait/balance was recorded as normal. R41 was noted to have taken 1-2 medications currently or within the last 7 days and had a fall score of 6.
2) Lift/Transfer Evaluation portion was completed. R41 was noted to be independent for cares and dressing. He was noted to not leave his room or have any locomotion on or off the unit. There was no indication how staff determined he was able to carry out tasks independently and/or safely.
3) Abnormal Involuntary Movement Scale (AIMS) (used to determine ill effects of anti-psychotic medications) identified R41 was noted to have no concerns with muscles of facial expression, no symptoms or effects affecting the peri-oral area (areas around the mouth), no abnormal movements of his tongue, and no abnormal movements with his upper or lower extremities.
It is unknown how the facility had determined supporting facts for the assessment, since R1 had no vitals taken since admission or shortly thereafter, or how staff could determine he remained continent or had adequate vision without performing an assessment due to R41's numerous documented refusals.
4) Elopement evaluation was documented. R41 had a history of wandering at home and had no wandering in the facility noted.
Notes associated with the 2/25/25, MDS in progress identified on 2/20/25, R41's:
1) Brief Interview for Mental Status (BIMS) was performed. Staff noted :Resident was unable to complete the interview and refused to answer questions. He Sits shaking his head no.
2) PHQ-9 score was evaluated. R41 was noted to answer No or had no response at all.
3) Social Services quarterly psychosocial quarterly note identified R41 continued to reside in a private room in the facility due to behaviors. Continues to refuse to communicate with staff. States You leave when approached to talk. Refuses most cares and medication. He refused his COVID screening and was placed on isolation, however staff noted he did not leave his room. FM-A calls often and states there isn't anything you can do to change his behavior. The social worker noted he was uncooperative with all assessments. He continued to talk about My father. Staff were unable to determine if the comment was related to religion or was part of a delusion.
Notes associated with the 2/25/25, MDS in progress identified on 2/23/25, a Restorative Nursing Screener/GG Evaluation note was made. His ambulation was noted to not be able to be assessed. His self-care portion identified staff noted R41 was independent with eating, toileting, showering or bathing, and personal hygiene, but also identified R41 had refused the assessment.
Notes associated with the 2/25/25, MDS in progress identified on 2/25/25, R41's OBRA Interim note was documented. Staff noted his functional limitations and range of motion (ROM) assessment identified he had no impairment. His Mobility and Ambulation portions in the note were documented as Not attempted. R41's Long Term Care Evaluation progress note (documented by the MDS nurse (RN-E)), identified the reason for the evaluation was a quarterly MDS assessment that was currently in progress. RN-E documented no falls since his last assessment occurred and no skin changes occurred. Vitals were listed as blood pressure (BP) 168/101 millimeters of mercury (mm/hg) obtained on 2/25/25 at 5:38 p.m. while R41 was seated, using his left arm. His oxygen saturation level (SpO2) was listed at 93% on room air. A vitals note was made Resident refused assessment. Vitals are from admission. I had to put something to close the assessment.
R41's progress notes identified in September 2024, on:
1) 9/9/25, a clinical admission note was made. R41 was currently experiencing unwanted behaviors, chronic refusal of cares, bathing, allow his clothing to be changed, and refusing staff to obtain vitals stating my father , my father, my father takes care of me. My father tells me what to do and he says no touch. R41 was occasionally incontinent upon admission assessment, and some physical assessment data was documented.
2) 9/14//24, R41 refused to eat his breakfast and lunch. He was reported to have not eaten the day before. R41 told staff he was fasting for a month because God told him to. Staff noted they had expressed concerns to the physician's (MD) office and received an order to administer Haldol (powerful antipsychotic used to treat acute psychological behaviors usually reserved when there is an immediate threat to patient safety) The MD noted if there was no improvement with R41's behavior, he would need to go to behavioral health again. The facility notified R41's family (FM)-A. FM-A stated there is nothing you can do if he will not take medications, he will have to go back to behavioral health R41 was noted to kick out at the nurse when staff attempted to give him his Haldol injection.
Further review of R41's progress notes identified staff documented numerous refusals of all cares or assessment.
R41's September 2024 through February 2025 vital signs report identified vitals were obtained on 9/9/24. Of those vitals, R41 had 1 weight measurement on 9/9/24 of 191 lbs. No other weights were documented as obtained. R41 BP on 9/9/24 was listed at 168/101 mm/hg and his oxygen saturation (SpO2) was documented as 93%. On 2/25/25, the same date as the MDS note listed above, R41's BP and SpO2 readings were documented as the exact same as September 2024. No other vitals were obtained for R41 throughout his stay from September 2024 through March 2025.
R41's bathing history was reviewed for the previous 30 days prior to the survey. At no time during February was R41 bathed.
R41's assessment data history from September 2024 through March 2025 was obtained. R41 had only 3 assessments noted as completed. Those assessments were a [NAME] pressure ulcer risk assessment. One upon admission, one at R41's 11/21/24 quarterly assessment, and then R41's currently in progress 2/19/25, MDS assessment. No other assessments were documented for R41 from September 2024 through March 2025.
R41's personal hygiene task for the last 30 days prior to survey was viewed. R41 was noted by staff to be completely independent with personal hygiene. It is unclear how staff determined this to be accurate and true.
R41's behavior history task, documented by staff identified staff had checked R41 exhibited no behaviors of any kind.
R41's March 2025. Medication and Treatment records (MAR/TAR) identified R41 had not received medications or treatments. Corresponding progress notes made by nursing staff in the medical record identified R41 refused all medications and cares.
Interview on 3/03/25 at 11:28 a.m., with laundry aide (LA)-A identified LA-A had never washed any clothing for R41. She has never done R41's laundry since his admission. She assumed maybe his family washed his clothing.
Observation on 3/3/25 at 11:30 a.m., of R41's room identified his door was open partially. R41 was observed to be standing in his room. Staff attempted to speak from the door. R41 waived his arm at staff to leave. No direct observations of R41 were able to be obtained.
Interview on 3/03/25 at 11:35 a.m., with RN-E related to R41 identified RN-E stated R41 refuses everything. When R41 was first admitted to the facility he would take his medication. Soon after he began refusing treatment or allowing staff into his room. R41 would tell staff god tells him he can't take his medication or that he doesn't need them. Some staff may be able to enter his room, but it is rare . it depends on the nurse aide. R41 always says get out!. Facility staff have spoken to FM-A and the MD. Essentially he isn't a risk for harm to himself or others He refuses medications that include antipsychotics. Staff are At a point with him .he is good living here . [staff] offer everything. When asked how RN-E or others assisting with the MDS assessments were able to perform assessments such as skin, she stated Staff cannot do skin assessments. She turns in MDS data based on what is able to be captured. Through the facility electronic program, designed to submit information to the Centers for Medicare and Medicaid (CMS) for payment, RN-E noted she had to put something in to the vitals section, or it would not allow her to close it within their system. RN-E stated her assessment data was based off what staff told her about R41, however did note that staff are not able to physically assess or often speak to R41 as he refuses staff entry most all days into his room when they try to either speak to him or provide any care at all, except to deliver meals. R41 allows that. RN-E agreed she is signing the MDS assessments to be accurate and true and acknowledged she is unable to accurately perform a comprehensive assessment on R41 and enters data in, so submissions are made.
Interview on 3/03/25 at 4:26 p.m., with RN-A identified she was familiar with R41 and had even cared for him at the sister facility before it closed. RN-A stated R41 refuses everything. There are very limited staff who can interact with R41. He strikes out, kicks, and has verbal behaviors. R41 will not leave his room. She thinks R41 is continent or bowel and bladder, but acknowledged without being able to assess R41, there would be no way to know. Staff provide no cares or treatments for R41. RN-A was unaware if he even allowed linens to be changed on his bed or his clothing washed. RN-A had not seen R41's skin since he was administered Haldol in September 2024. RN-A was unaware staff were documenting R41 as having no behaviors, however, she related that to not being allowed to enter R41's room or provide any cares. RN-A recalled she has been unable to perform any assessments, give medication, or provide cares to R41 since September 2024.
Interview on 3/03/25 at 5:37 p.m., with the director of nursing (DON) identified RN-E is responsible for MDS data collection and assessment. She was aware R41 refused all cares, assessments, or treatments. When asked how staff can accurately and comprehensively assess R41, she noted they cannot.
Interview on 3/4/25 at 8:16 a.m., with the medical director (MD)-A identified he was unaware of R41's refusal of all cares. He would expect to be notified as he agreed R41 isn't capable of making an informed decision related to his health and safety. He was unaware R41 received no skilled nursing care, had only 2 baths, refused all meds, and had no laundry done. He was also unaware staff were unable to comprehensively assess R41. He agreed the assessment data included on the MDS would be false if staff could not actually assess R41.
Review of the 2001, MDS/RAI Coordinator job description identified the purpose of that position is to conduct and coordinate the development and completion of resident assessment in accordance with the requirements of the state and the policies and goals of the facility. Part of the duties included to evaluate each resident's condition and pertinent medical data to determine the need for special assessment activities or the need to revise or amend the plan of care and to ensure all members of the assessment team are aware of the importance of completeness and accuracy in their assessment functions and be aware of penalties including civil money penalties for false certification.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Assessment Accuracy
(Tag F0641)
Could have caused harm · This affected 1 resident
Based on interview and record review, the facility failed to accurately and thoroughly assess 1 of 1 resident (R40) for a history of trauma related to a diagnosis of Post-Traumatic Stress Syndrome (PT...
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Based on interview and record review, the facility failed to accurately and thoroughly assess 1 of 1 resident (R40) for a history of trauma related to a diagnosis of Post-Traumatic Stress Syndrome (PTSD).
Findings include:
R40's 1/4/25, quarterly Minimum Data Set (MDS) assessment identified her cognition was severely impaired, she felt down, depressed or hopeless 2-6 days a week, and she displayed verbal behaviors directed towards others such as screaming, threatening, or cursing 1-3 days a week. R40 had a diagnosis of PTSD, anxiety, and a psychotic disorder. She was dependent on staff for all activities of daily living (ADL's).
R40's 9/11/24, PTSD Resident Screening assessment identified the first question was: Sometimes things happen to people that are unusually or especially frightening, horrible, or traumatic. For example: a serious accident or fire, a physical or sexual assault or abuse, an earthquake or flood, a war, seeing someone be killed or seriously injured, having a loved one die through homicide or suicide. R40 answered no. The facility assessment indicated if the answer is no, the assessor should stop there and not ask any of the additional questions. There was no indication the facility reached out to the emergency contact or family to try and identify the cause of the PTSD so the facility could be made aware potentially of any potential triggers and plan for that.
Review of R40's care plan identified she becomes both physically and verbally aggressive during bathing and staff should administer medications as prescribed, encourage resident to verbalize cause of aggression, utilize diversion techniques, and allow personal space. The care plan made no mention that R40 had a history of an unknown traumatic event leading to a diagnosis of PTSD.
Interview on 2/27/25, at 2:24 p.m., with social service designee (SSD)-B identified that she completed the trauma assessment with R40, she reported they had several challenges while transferring more than 30 residents into their facility from their sister facility that had closed. She could not recall specifically if she had reached out to the staff from the previous facility or to the family for information regarding R40's diagnosis of PTSD. She agreed they did not include anything on the care plan and was unable to find any documentation of anything that had been done to assess for triggers or appropriate care related to the diagnosis of PTSD.
A policy was requested; however, none was provided by the end of the survey period.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0642
(Tag F0642)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on interview and document review, the facility failed to ensure 1 of 1 resident (R41) was accurately and comprehensively ...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on interview and document review, the facility failed to ensure 1 of 1 resident (R41) was accurately and comprehensively assessed as certified when it was R41 exhibited behaviors and refusal of all cares, medication, treatment and evaluation.
Findings include:
Review of the Resident Assessment Instrument (RAI) 3.0 manual identified The RAI process has multiple regulatory requirements. Federal regulations require the assessment accurately reflects the resident's status, a registered nurse conducts or coordinates each assessment with the appropriate participation of health professionals, and the assessment process includes direct observation, as well as communication with the resident and direct care staff on all shifts. In addition, an accurate assessment requires collecting information from multiple sources. Those sources must include the resident and direct care staff on all shifts, and should also include the resident's medical record, physician, and family, guardian, and/or other legally authorized representative, or significant other as appropriate or acceptable. It is important to note here that information obtained should cover the same observation period as specified by the Minimum Data Set (MDS) items on the assessment, and should be validated for accuracy (what the resident's actual status was during that observation period) by the interdisciplinary team (IDT) completing the assessment.
R41's face sheet identified he was admitted to the facility in September 2024. R41 had a recent hospital stay 11/4/24 through 11/6/24 and had diagnoses of hypoparathyroidism (parathyroid glands do not produce enough parathyroid hormone and treated with medication), history of a lumbar spinal fracture, right leg fracture, right artificial hip, hypothyroidism (thyroid gland does not produce enough thyroid hormone), generalized anxiety disorder, and multiple fractures of ribs.
R41's 11/25/24, quarterly Minimum Data Set identified R41 was admitted to the facility (from the now closed sister facility) in September 2024. The MDS identified in section:
1) C: R41 was reported to answer cognitive questions to identify his mental status.
2) D: in the field D0100 Should Resident Mood Interview be Conducted the answer was checked yes however; no responses were given. D0500: Staff assessment of Resident Mood was blank. D0700: Social isolation was marked never.
3) E: Behavior: E0100 identified R41 had delusions. No behaviors were noted for physical, Verbal, or Other. Rejection of care was noted to only occur 1 to 3 days during the look-back period. E1100: Change in Behavior or Other Symptoms was left blank when asked how the residents current behavior status, care rejection, or wandering compared to his prior assessment.
4) F: Preferences for Customary Routine and Activities was not filled out.
5) H: Bladder and Bowel: H0300 identified R41 was occasionally incontinent.
6) J: Health Conditions: J0200 Should Pain Assessment Interview be Conducted? Answer is yes. J0300 Pain Assessment Interview/Pain Presence: Unable to answer was checked. J0800: Indicators of Pain or Possible Pain in the last 5 days: None of these signs observed or documented.
7) K: Swallowing/Nutritional Status: K0100 Swallowing Disorder/Signs and symptoms of possible swallowing disorder is related to observations of swallowing or reports of complaints of swallowing: None of the above was marked. K0200 Weight was documented as 191 pounds (lbs.). K0300 and K0310 mention weight loss and gain. Both are marked no or unknown.
8) L0200: oral/Dental Status: L0200 describes visualization of the mouth. No questions were answered.
9) M: Skin Conditions: M0100 Determination of Pressure Ulcer Risk: identified a formal assessment instrument or tool such as a [NAME] score and clinical assessment were checked as completed. M150 identified R41 was at risk for pressure ulcers. M0210: Unhealed pressure ulcers: Does the resident have 1 or more unhealed pressure ulcers at Stage 1 or higher? Answer was marked no.
10) P: Restraints: P0200 Alarms: subsection E: Wander/elopement alarm was marked with a 2 and noted to be used daily.
Notes associated with the 2/25/25, MDS assessment in progress identified on 2/19/25, R41's:
1) Fall risk was evaluated. Staff documented he had no falls in the past 3 months. R41 was noted to have intermittent confusion. R41 was ambulatory and continent of bowel and bladder. Systolic blood pressure noted there was no drop between lying and standing. R41 was listed as having adequate vision and reportedly had no change of condition in the last 14 days. R41 had no hospitalizations in the last 30 days. His gait/balance was recorded as normal. R41 was noted to have taken 1-2 medications currently or within the last 7 days and had a fall score of 6.
2) Lift/Transfer Evaluation portion was completed. R41 was noted to be independent for cares and dressing. He was noted to not leave his room or have any locomotion on or off the unit. There was no indication how staff determined he was able to carry out tasks independently and/or safely.
3) Abnormal Involuntary Movement Scale (AIMS) (used to determine ill effects of anti-psychotic medications) identified R41 was noted to have no concerns with muscles of facial expression, no symptoms or effects affecting the peri-oral area (areas around the mouth), no abnormal movements of his tongue, and no abnormal movements with his upper or lower extremities.
It is unknown how the facility had determined supporting facts for the assessment, since R1 had no vitals taken since admission or shortly thereafter, or how staff could determine he remained continent or had adequate vision without performing an assessment due to R41's numerous documented refusals.
4) Elopement evaluation was documented. R41 had a history of wandering at home and had no wandering in the facility noted.
Notes associated with the 2/25/25, MDS in progress identified on 2/20/25, R41's:
1) Brief Interview for Mental Status (BIMS) was performed. Staff noted :Resident was unable to complete the interview and refused to answer questions. He Sits shaking his head no.
2) PHQ-9 score was evaluated. R41 was noted to answer No or had no response at all.
3) Social Services quarterly psychosocial quarterly note identified R41 continued to reside in a private room in the facility due to behaviors. Continues to refuse to communicate with staff. States You leave when approached to talk. Refuses most cares and medication. He refused his COVID screening and was placed on isolation, however staff noted he did not leave his room. FM-A calls often and states there isn't anything you can do to change his behavior. The social worker noted he was uncooperative with all assessments. He continued to talk about My father. Staff were unable to determine if the comment was related to religion or was part of a delusion.
Notes associated with the 2/25/25, MDS in progress identified on 2/23/25, a Restorative Nursing Screener/GG Evaluation note was made. His ambulation was noted to not be able to be assessed. His self-care portion identified staff noted R41 was independent with eating, toileting, showering or bathing, and personal hygiene, but also identified R41 had refused the assessment.
Notes associated with the 2/25/25, MDS in progress identified on 2/25/25, R41's OBRA Interim note was documented. Staff noted his functional limitations and range of motion (ROM) assessment identified he had no impairment. His Mobility and Ambulation portions in the note were documented as Not attempted. R41's Long Term Care Evaluation progress note (documented by the MDS nurse (RN-E)), identified the reason for the evaluation was a quarterly MDS assessment that was currently in progress. RN-E documented no falls since his last assessment occurred and no skin changes occurred. Vitals were listed as blood pressure (BP) 168/101 millimeters of mercury (mm/hg) obtained on 2/25/25 at 5:38 p.m. while R41 was seated, using his left arm. His oxygen saturation level (SpO2) was listed at 93% on room air. A vitals note was made Resident refused assessment. Vitals are from admission. I had to put something to close the assessment.
R41's progress notes identified in September 2024, on:
1) 9/9/25, a clinical admission note was made. R41 was currently experiencing unwanted behaviors, chronic refusal of cares, bathing, allow his clothing to be changed, and refusing staff to obtain vitals stating my father , my father, my father takes care of me. My father tells me what to do and he says no touch. R41 was occasionally incontinent upon admission assessment, and some physical assessment data was documented.
2) 9/14//24, R41 refused to eat his breakfast and lunch. He was reported to have not eaten the day before. R41 told staff he was fasting for a month because God told him to. Staff noted they had expressed concerns to the physician's (MD) office and received an order to administer Haldol (powerful antipsychotic used to treat acute psychological behaviors usually reserved when there is an immediate threat to patient safety) The MD noted if there was no improvement with R41's behavior, he would need to go to behavioral health again. The facility notified R41's family (FM)-A. FM-A stated there is nothing you can do if he will not take medications, he will have to go back to behavioral health R41 was noted to kick out at the nurse when staff attempted to give him his Haldol injection.
Further review of R41's progress notes identified staff documented numerous refusals of all cares or assessment.
R41's September 2024 through February 2025 vital signs report identified vitals were obtained on 9/9/24. Of those vitals, R41 had 1 weight measurement on 9/9/24 of 191 lbs. No other weights were documented as obtained. R41 BP on 9/9/24 was listed at 168/101 mm/hg and his oxygen saturation (SpO2) was documented as 93%. On 2/25/25, the same date as the MDS note listed above, R41's BP and SpO2 readings were documented as the exact same as September 2024. No other vitals were obtained for R41 throughout his stay from September 2024 through March 2025.
R41's bathing history was reviewed for the previous 30 days prior to the survey. At no time during February was R41 bathed.
R41's assessment data history from September 2024 through March 2025 was obtained. R41 had only 3 assessments noted as completed. Those assessments were a [NAME] pressure ulcer risk assessment. One upon admission, one at R41's 11/21/24 quarterly assessment, and then R41's currently in progress 2/19/25, MDS assessment. No other assessments were documented for R41 from September 2024 through March 2025.
R41's personal hygiene task for the last 30 days prior to survey was viewed. R41 was noted by staff to be completely independent with personal hygiene. It is unclear how staff determined this to be accurate and true.
R41's behavior history task, documented by staff identified staff had checked R41 exhibited no behaviors of any kind.
R41's March 2025. Medication and Treatment records (MAR/TAR) identified R41 had not received medications or treatments. Corresponding progress notes made by nursing staff in the medical record identified R41 refused all medications and cares.
Interview on 3/03/25 at 11:28 a.m., with laundry aide (LA)-A identified LA-A had never washed any clothing for R41. She has never done R41's laundry since his admission. She assumed maybe his family washed his clothing.
Observation on 3/3/25 at 11:30 a.m., of R41's room identified his door was open partially. R41 was observed to be standing in his room. Staff attempted to speak from the door. R41 waived his arm at staff to leave. No direct observations of R41 were able to be obtained.
Interview on 3/03/25 at 11:35 a.m., with RN-E related to R41 identified RN-E stated R41 refuses everything. When R41 was first admitted to the facility he would take his medication. Soon after he began refusing treatment or allowing staff into his room. R41 would tell staff god tells him he can't take his medication or that he doesn't need them. Some staff may be able to enter his room, but it is rare . it depends on the nurse aide. R41 always says get out!. Facility staff have spoken to FM-A and the MD. Essentially he isn't a risk for harm to himself or others He refuses medications that include antipsychotics. Staff are At a point with him .he is good living here . [staff] offer everything. When asked how RN-E or others assisting with the MDS assessments were able to perform assessments such as skin, she stated Staff cannot do skin assessments. She turns in MDS data based on what is able to be captured. Through the facility electronic program, designed to submit information to the Centers for Medicare and Medicaid (CMS) for payment, RN-E noted she had to put something in to the vitals section, or it would not allow her to close it within their system. RN-E stated her assessment data was based off what staff told her about R41, however did note that staff are not able to physically assess or often speak to R41 as he refuses staff entry most all days into his room when they try to either speak to him or provide any care at all, except to deliver meals. R41 allows that. RN-E agreed she is signing the MDS assessments to be accurate and true and acknowledged she is unable to accurately perform a comprehensive assessment on R41 and enters data in, so submissions are made.
Interview on 3/03/25 at 4:26 p.m., with RN-A identified she was familiar with R41 and had even cared for him at the sister facility before it closed. RN-A stated R41 refuses everything. There are very limited staff who can interact with R41. He strikes out, kicks, and has verbal behaviors. R41 will not leave his room. She thinks R41 is continent or bowel and bladder, but acknowledged without being able to assess R41, there would be no way to know. Staff provide no cares or treatments for R41. RN-A was unaware if he even allowed linens to be changed on his bed or his clothing washed. RN-A had not seen R41's skin since he was administered Haldol in September 2024. RN-A was unaware staff were documenting R41 as having no behaviors, however, she related that to not being allowed to enter R41's room or provide any cares. RN-A recalled she has been unable to perform any assessments, give medication, or provide cares to R41 since September 2024.
Interview on 3/03/25 at 5:37 p.m., with the director of nursing (DON) identified RN-E is responsible for MDS data collection and assessment. She was aware R41 refused all cares, assessments, or treatments. When asked how staff can accurately and comprehensively assess R41, she noted they cannot.
Interview on 3/4/25 at 8:16 a.m., with the medical director (MD)-A identified he was unaware of R41's refusal of all cares. He would expect to be notified as he agreed R41 isn't capable of making an informed decision related to his health and safety. He was unaware R41 received no skilled nursing care, had only 2 baths, refused all meds, and had no laundry done. He was also unaware staff were unable to comprehensively assess R41. He agreed the assessment data included on the MDS would be false if staff could not actually assess R41.
Review of the 2001, MDS/RAI Coordinator job description identified the purpose of that position is to conduct and coordinate the development and completion of resident assessment in accordance with the requirements of the state and the policies and goals of the facility. Part of the duties included to evaluate each resident's condition and pertinent medical data to determine the need for special assessment activities or the need to revise or amend the plan of care and to ensure all members of the assessment team are aware of the importance of completeness and accuracy in their assessment functions and be aware of penalties including civil money penalties for false certification.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
PASARR Coordination
(Tag F0644)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and document review, the facility failed to notify the State Mental Health Authority ([NAME] Cou...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and document review, the facility failed to notify the State Mental Health Authority ([NAME] County) for 1 of 1 resident with a diagnosis of major neurocognitive disorder with known behaviors and inpatient psychiatric stay 3 months prior to admission.
Findings include:
R41's face sheet identified he was admitted to the facility in September 2024. R41 had diagnoses recorded of hypoparathyroidism (parathyroid glands do not produce enough parathyroid hormone and treated with medication), history of a lumbar spinal fracture, right leg fracture, right artificial hip, hypothyroidism (thyroid gland does not produce enough thyroid hormone), generalized anxiety disorder, and multiple fractures of ribs.
R141's previous Preadmission Assessment Screening and Resident Review (PASARR) Level I was done previously at the now closed sister facility on 5/23/24, prior to R41's transfer to the facility. The questions answered at that time were:
1) Has this person had any of the following: A mental illness as a primary diagnosis for hospitalization within the past 2 years? Answer: No. Does this person have a diagnosis or symptoms of mental illness that has significantly interfered with functioning in life activities within the last 6 months? Answer: no. In the ADL's section Behavior was noted to require no intervention at that time.
R41's 11/25/24, quarterly Minimum Data Set (MDS) identified R41 was admitted to the facility (from the now closed sister facility) in September 2024. R1 was noted to have delusions with no behaviors identified.
R41's progress notes identified on:
1) 9/9/25, a clinical admission note was made. R41 was currently experiencing unwanted behaviors, chronic refusal of cares, bathing, allow his clothing to be changed, and refusing staff to obtain vitals stating my father , my father, my father takes care of me. My father tells me what to do and he says no touch. R41 was occasionally incontinent upon admission assessment, and some physical assessment data was documented.
2) 9/14//24, R41 refused to eat his breakfast and lunch. He was reported to have not eaten the day before. R41 told staff he was fasting for a month because God told him to. Staff noted they had expressed concerns to the physician's (MD) office and received an order to administer Haldol (powerful antipsychotic used to treat acute psychological behaviors usually reserved when there is an immediate threat to patient safety) The MD noted if there was no improvement with R41's behavior, he would need to go to behavioral health again. The facility notified R41's family (FM)-A. FM-A stated there is nothing you can do if he will not take medications, he will have to go back to behavioral health R41 was noted to kick out at the nurse when staff attempted to give him his Haldol injection.
3) 9/16/25 at 2:09 p.m., a call was placed to the primary care physician (PCP) nurse regarding R41's worsening and refusals of cares, medications, and meals. R41 had not allowed staff to touch him. R41 advised staff he was fasting for the entire month of September 2024. Staff expressed their concerns and asked for orders and suggestion. R41's PCP faxed back an order for staff to administer Haldol intramuscularly (IM) 5 milligrams (mg) every 4 hours x 2 doses. If no improvement, the order directed staff to send R41 to behavioral health again. R41's family member (FM)-A was called and stated to staff there was nothing they could do if he wouldn't take his medications .he would have to go back to the behavioral unit. FM-A gave permission for staff to administer the medication.
4) 9/16/24 at 2:47 p.m., staff attempted to enter R41 to speak with him about fasting. R41 began to scream at staff to get out of his room. The nurse attempted to educate R41 on the need for the injection and began screaming AHHHHHHHHHH NO injection!. R41 told staff he would not eat and is fasting for the month. He refused to allow staff to assess him and told staff to get out. The IM Haldol was given.
5) 9/17/24 at 10:12 a.m., staff noted R41 was in his room seated in his recliner. Staff offered food. R41 replied his food was poisoned. When staff attempted to interact with him, he raised his voice and told them not to touch him. He was upset staff gave him 2 injections (the previous day). The nurse tried to reiterate why R41 received the injections due to his delusions. R41 repeated more delusions such as I have intel. Another call was placed to R41's PCP. The PCP advised staff to proceed with a transfer to behavioral health.
6) 9/16/24 at 5:24 p.m., a call was placed for a non-emergent ambulance. EMS staff asked R41 questions and reported NO, I am normal .go away!. EMS identified R41 knew his name, and his location and had refused transfer. EMS told staff due to his ability to answer those questions, They were unable to take R41 to behavioral health as he was oriented correctly. EMS left without the resident due to his refusal for transfer. R41's PCP was updated. Numerous notes were made after 9/16/24, related to R41's ongoing refusal of all cares.
7) 10/1/24 at 10:47 a.m., staff noted they had called FM-A about R41's refusals of medication. Staff suggested discontinuing all medication as they felt it caused more behaviors. FM-A said lets do it. There was no indication staff had first checked with R41's PCP, behavioral health, or the medical director at that time on how they could best provide care and services to R41 prior to requesting family approval to discontinue medication.
8) 10/21/24, R41 was seen in house by contracted behavioral health services. A fax back after the visit was received with orders to administer Abilify (antipsychotic medication) IM and continue to try and give oral medications as he allowed. They also received a new order for as needed lorazepam (anti-anxiety medication) IM for agitation and severe anxiety and follow up every 14 days. Staff were instructed to contact the clinic with any concerns.
9) 10/21/24 at 11:25 p.m., a note was placed identifying R41 was seen in house by his PCP. No new orders were given. R41 refuses to take all medication. R41 was noted to be in his room all day and getting up only to use his bathroom. Staff noted no delusional behaviors.
10) 10/22/25 at 9:15 p.m., staff noted they had received electronically signed progress notes form the PCP. Staff noted they were unable to assess R41 or obtain vital signs. Per the PCP, they will return in 2 months to recheck.
Further review of the progress notes repeated the same inability of staff to provide care and services to R41.
Review of a R41's physician progress notes identified on:
1) 10/22/24, the PCP noted diagnoses of agitation, depression, catatonia (group of symptoms that usually involve a lack of movement and communication, and can include agitation, confusion, and restlessness), chronic anemia (low iron), high blood pressure, liver disease, enlarged prostrate, mild persistent asthma, high cholesterol, and chronic obstructive pulmonary disease (COPD). R41's PCP noted he was followed by psychiatry. R41 refused everything including vital signs, examination and appeared to be quiet in his recliner. He was apparently in no pain but again refused to be touched or examined. The PCP noted it was a difficult assessment because patient refused talking to us and refused to be examined. The PCP directed staff to continue with his blood pressure medication (Amlodipine) if he accepted. Depression with catatonia, and combative behavior were identified with orders directing staff to continue Haldol every 6 hours as needed. No end date was given. Staff were instructed to give his lorazepam at bedtime, mirtazapine and Abilify (anti-depressant) and continue with escitalopram (another anti-depressant) and continue with his inhaler related to COPD as tolerated and accepted by R41. The PCP noted R41 was a difficult patient to take care of as he consistently refuses care .will return in 2 months to recheck should he allow us to examine him and check vitals.
2) The nurse practitioner (NP) documented R41 was refusing all cares. Will continue current medications as patient allows
3) 11/19/24, the PCP noted additional diagnoses from the previous visit of chronic hepatitis C, allergic rhinitis, elevated fasting glucose, pre-diabetes, and bilateral knee pain. R41 was noted to refuse everything namely examination, medications, some of his food, showering .basically spends his days on the recliner. Upon examination it was noted vitals signs were not taken because R41 refused. R41 made no complaints of pain or anything but refused his exam. Nurses reported he refused most of the time his food, although he ate some snacks, refuses showers, changing his clothing, medications, being touched, examined, or having his vital signs checked. The PCP reported they would keep insisting on seeing him without much hope. Psychiatry also tried to see him at the facility but patient refuses. The PCP was not changing anything with his medications as R41 was not taking it the times offered. He would return the next scheduled visit to see if there was improvement.
4) 1/21/25, the PCP returned for a facility visit. He noted R41 continued to refuse everything namely examinations, medications, some to most food, showering, and spent his day in his recliner. R41 would become aggressive when approached. R41 once again refuse exam and no vitals were taken. Nursing reported his refusals of care. The PCP's plan was no changes to medication as R41 wasn't taking them. The PCP noted he would continue attempts to see R41 on scheduled visits. Psychiatry had tried to see R41 several times, but he is able to provide his name, DON, and because of that, the PCP felt R41 could not be called incompetent to make decisions and noted psychiatry could not force the issue, neither can we. There was no indication the PCP had reached out to the medical director for guidance and his capacity to consent to refuse evaluated related to refusals of all care, most food and medication as a potential risk for harm without receiving appropriate care of services exists.
R41's 6/3/24, inpatient psych note from the Behavioral Health Hospital (BHH) identified R41 had diagnoses of catatonia, major neurocognitive disorder, altered mental status, and hypoxemia (lack of oxygen to the brain). R41 was identified to bat continued high risk/complexity secondary to the combination of acute on chronic psychiatric diagnoses, cormorbid medical illness, and use of multiple psychotropic medication. R41 had received electroconvulsive therapy (shock therapy) as an inpatient at the hospital. R41 had improvement there both physically and mentally. He was no longer catatonic after treatments with ECT and medication management. At that time, R1 was noted to be cooperative, well groomed and well nourished. R41 had no delusions, hallucinations, or paranoia with insight fair and improving. Upon his admission, R41 was an unreliable historian, had limited judgement in decision making in every day activities, social situations, and compliance for treatment. R41 had a previous BHH stay in April 2024, due to sever deterioration in functioning and concerns for catatonia. R41 failed to have the capacity to consent for decision making upon admission due to his mental health exacerbation.
Interview on 3/03/25 at 5:37 p.m., with the director of nursing (DON) identified she was aware R41 refused all cares, assessments, or treatments. The facility was not required by State law to have updated PASARR Level 1 screening when they transferred residents from their now closed sister facility. The DON agreed staff should have had the county re-assess R41 for a Level II PASARR upon admission related to his mental health diagnosis and inpatient treatment he had 3 months prior to admission.
No PASARR II policy was provided.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0657
(Tag F0657)
Could have caused harm · This affected 1 resident
Based on observation, interview, and document review, the facility failed to revise 2 of 2 residents (R7 and R44) care plan after receiving new orders directing facility to ensure R44's legs were elev...
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Based on observation, interview, and document review, the facility failed to revise 2 of 2 residents (R7 and R44) care plan after receiving new orders directing facility to ensure R44's legs were elevated as much as possible and to reposition R7 at least every 2 hours.
Findings include:
R44's 1/28/25, admission Minimum Data Set assessment identified her cognition was moderately impaired. She required extensive assistance with her activities of daily living (ADL)'s. R44 had diagnosis of atrial fibrillation (disease of the heart characterized by irregular and often faster heartbeat), heart failure, renal insufficiency, dementia, anxiety, depression, and morbid obesity.
Interview on 2/27/25 at 9:18 a.m., with FM-H identified that R44 had seen a physician last week and at the appointment R44 had increased swelling to her lower legs. The physician placed orders to add a water pill to decrease fluid in legs, and for staff to wrap her legs or put compression stocking on daily. He reported that on 2/23/25 he went to the facility to visit and R44 did not have any leg wraps on. FM-H spoke with the charge nurse and she identified she was not aware of the new orders but would check into it.
R44's 2/19/25, physician order identified staff were to apply anti-fungal powder under abdominal folds, apply compression stockings or ace wraps to lower extremities daily, keep lower extremities elevated as much as possible, and increase Lasix to 40 milligrams (mg) twice daily for 30 days.
Observation on 3/3/25 at 9:50 a.m., R44 is seated in a wheelchair, head facing downward with eyes closed. Legs are wrapped from her feet to just below the knee in ace bandages and feet are down on the floor.
Observation on 3/3/25 at 1:42 p.m., R44 was seated in her wheelchair with feet on the floor. She wheeled herself over to the closet and stood up to look at clothes, writer alerted staff. Nursing assistant (NA)-E went to R44's room and directed her to sit back down in her chair and then left the room.
Interview on 3/3/25 at 1:47 p.m., with NA-E identified she had assisted R44 at 7:00 a.m., with morning cares and transferred her to her wheelchair. She identified that she had offered her to sit in a recliner around 10:00 a.m., but she refused. She reported the refusal to the nurse, she said the nurse told her to just try again in a little bit but reports she did not offer to sit in a recliner again. She reports that the nurse wraps her legs in the morning, the nurse would normally come in to put creams and powders on in the morning while the aids are doing morning cares, but she was not aware of anyone doing that today. She reported that normally new orders that would involve direct care staff would be passed on in shift report. It was passed on today about elevating legs but she did not hear anything about applying antifungal powder.
Observation on 3/3/25 at 1:59 p.m., following interview with NA-E, she asked R44 if she would like to sit in a recliner, R44 said yes, and NA-E transferred her to the recliner and elevated her legs.
Review of R44's undated care plan had no mention of lower extremity edema, wrapping legs daily, or elevating legs as much as possible.
Interview on 3/4/25, at 8:47 a.m., with the facilities medical director identified he would expect staff to ensure care plans are revised to reflect the direct care needs of the residents as their condition changes.
R7's 1/31/25, significant change Minimum Data Set (MDS) assessment identified her cognition was intact. R7 reported she had little interest or pleasure in doing things, she felt down and depressed, and had no energy nearly every day, she had no behaviors and did not reject care. R7 had physical impairments on both sides and was dependent on staff for ADL's. She had diagnosis of diabetes, dementia, anxiety, depression, pressure ulcer to the right buttock and right heal. R7 used antipsychotics and antidepressants on a routine basis, and was administered pain medication daily.
Continuous observation on 3/3/25, from 4:00 p.m. through 6:15 p.m.
4:00 p.m., R7 was seated in her wheelchair in the common/dining area at a table. She had pressure relieving boots on her feet the right boot extends to several inches below the knee, and the left boot was misplaced above the ankle, skin was visible below the boot. She had a cushion under her right elbow. Her legs were not elevated, her feet were on the floor and her chair did not have foot pedals. R7 had slid down in her chair and was leaning back with eyes closed.
4:19 p.m., R7 remained in her wheelchair, awake, and in the same position.
4:30 p.m., R7 remained in her wheelchair, awake, and in the same position. She stopped several staff to visit with them, however, none of the staff offered to reposition her and did not prompt her to adjust her position in her chair.
4:50 p.m., she remained in her wheelchair, in the same position. The facility social worker designee sat next to her, R7 complained that her wrist hurt.
4:58 p.m., staff offered R7 pain medication for her wrist.
5:21 p.m., a NA brought a warm pack to R7 and placed it on her wrist. She did not offer to reposition her or encourage her to adjust her position in her chair.
5:24 p.m., Facility staff brought R7 her supper meal tray. R7 told staff she wanted to eat in her room, staff returned her tray to the cart.
5:28 p.m., staff are bringing her back to her room, R7's feet are dragging on the floor. They stop after about 20 feet and another staff assists by lifting her legs up and they bring R7 back to her room wheeling backwards. They were discussing that they cannot find the foot pedals for her wheelchair.
Interview at 5:30 p.m., with nursing assistant (NA)-D reported R7 had another wheelchair that is larger, however, she does not like to use it unless she is going out for an appointment. She reports that she delivered her room tray and that it was unusual that she was out in the common area as she normally stays in her room.
Observations continue:
5:35 p.m., R7 was in her room, she remained seated in her wheelchair. She was in front of her over-bed table and had her meal tray in front of her.
5:55 p.m., staff entered R7's room, nursing assistants asked her if she was going to eat anything, R7 told staff to take her tray. nursing assistant offered other food options, R7 agreed to try some pudding. The staff left the room. The nursing assistant did not offer to reposition R7.
6:15 p.m., R7 remained in her room, seated in her wheelchair. Staff were in and out of her room several times, however, they did not offer to reposition her.
Interview on 3/3/25, at 6:15 p.m., With RN-B identified she was unsure how often R7 should be repositioned. She reviewed R7's care plan and identified she does not have scheduled repositioning. She reported she thought R7 had been up in her wheelchair since 1:00 p.m., she stated she had been out in the day room all afternoon. She identified that she would direct staff to reposition R7.
R7's 2/11/25, wound consultant note identified R7's skin to left and right heel is dark red, purple, blistered, and open. Open area to right heel medial is a stage 3, the area on the right heel is a deep tissue injury the right lateral foot is also a deep tissue injury, and the left heel is a deep tissue injury all are secondary to pressure. The wound consultant note identified that in addition to the current interventions in place staff were to implement scheduled repositioning every 2 hours.
Review of R7's undated care plan identified R7 required total assist of 2 staff for bed mobility, she had a pressure ulcer and staff should keep skin clean, monitor ulcer for signs of progression or declination, provide wound care per treatment order and encourage her to frequently shift weight. Staff should reposition R7 as she allows. The care plan made no mention of how often staff should reposition her.
The facility provided policy Pressure Injuries Overview identified an avoidable pressure ulcer may be caused by not implementing interventions that are consistent with residents needs, goals, and professional standards of practice, monitoring or evaluation of the impact of the interventions or revision of the interventions as appropriate.
The facilities 11/30/21, Care Plans, Comprehensive Person-Centered policy identified the comprehensive person-centered care plan would describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being, and incorporate risk factors associated with identified problems. Assessments of residents are ongoing, and care plans are revised as information about the residents and residents condition change.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Quality of Care
(Tag F0684)
Could have caused harm · This affected 1 resident
Based on observation, interview, and document review, the facility failed to implement physician orders for 1 of 1 resident (R44).
Findings include:
R44's 1/28/25, admission Minimum Data Set assessme...
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Based on observation, interview, and document review, the facility failed to implement physician orders for 1 of 1 resident (R44).
Findings include:
R44's 1/28/25, admission Minimum Data Set assessment identified her cognition was moderately impaired. She required extensive assistance with her activities of daily living (ADL)'s. R44 had diagnosis of atrial fibrillation (disease of the heart characterized by irregular and often faster heartbeat), heart failure, renal insufficiency, dementia, anxiety, depression, and morbid obesity.
Interview on 2/27/25 at 9:18 a.m., with FM-H identified that R44 had seen a physician last week and at the appointment R44 had increased swelling to her lower legs. The physician placed orders to add a water pill to decrease fluid in legs, and for staff to wrap her legs or put compression stocking on daily. He reported that on 2/23/25 he went to the facility to visit and R44 did not have any leg wraps on. FM-H spoke with the charge nurse, and she identified she was not aware of the new orders but would check into it.
Observation on 3/3/25 at 9:50 a.m., R44 is seated in a wheelchair, head facing downward with eyes closed. Legs are wrapped from her feet to just below the knee in ace bandages and feet are down on the floor.
R44's March 2025 medication administration record identified an order to apply ace wraps to bilateral lower extremities daily. The order entry date was 2/27/25, the order had been transcribed 8 days after it was received from the physician. Furosemide oral tablet 20 mg twice daily in addition to 20 mg for a total of 40 mg twice daily for 30 days transcribed on 2/21/25, 2 days after the order was received. R44's medication/treatment administration record lacked any direction for nursing staff to elevate lower extremities or to apply antifungal powder under abdominal folds.
Observation on 3/3/25 at 1:42 p.m., R44 was seated in her wheelchair with feet on the floor. She wheeled herself over to the closet and stood up to look at clothes, writer alerted staff. Nursing assistant (NA)-E went to R44's room and directed her to sit back down in her chair and then left the room.
Interview on 3/3/25 at 1:47 p.m., with NA-E identified she had assisted R44 at 7:00 a.m., with morning cares and transferred her to her wheelchair. She identified that she had offered her to sit in a recliner around 10:00 a.m., but she refused. She reported the refusal to the nurse, she said the nurse told her to just try again in a little bit but reports she did not offer to sit in a recliner again. She reports that the nurse wraps her legs in the morning, the nurse would normally come in to put creams and powders on in the morning while the aids are doing morning cares, but she was not aware of anyone doing that today. She reported that normally new orders that would involve direct care staff would be passed on in shift report. It was passed on today about elevating legs, but she did not hear anything about applying antifungal powder.
Interview on 3/3/25, at 11:15 a.m., with RN-B and RN-D, identified their process is to review the new order upon receiving, transcribe the order, make a nursing progress note, and place the original copy in a wall pocket behind the nurses station for the medical records person to scan into the medical record. They identified the orders received following R44's 2/19/25 appointment had been transcribed late and the original order was not yet scanned into the medical record. RN-B reported they did not currently have a medical record person, and she was told they had planned to resolve that position, she stated nursing does not have time to scan all the orders in, she further revealed that they only complete a second check on narcotic orders and admission orders.
Subsequent interview on 3/3/25, at 11:58 a.m., RN-B came to the conference room with the original order. She reported she found the order in a pile of papers that were waiting to be scanned in.
R44's 2/19/25, original physician order identified staff were to apply antifungal powder under abdominal folds, apply compression stockings or ace wraps to lower extremities daily, keep lower extremities elevated as much as possible, and increase Lasix to 40 milligrams (mg) twice daily for 30 days.
A facility policy for order transcription and implementation was requested but nothing was provided by the end of the survey period.
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 interview and document review the facility failed to assess weight loss to determine the cause for 1 of 4 residents (R8) reviewed for nutrition.
Findings include:
R8's 1/11/25, quarterly Min...
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Based on interview and document review the facility failed to assess weight loss to determine the cause for 1 of 4 residents (R8) reviewed for nutrition.
Findings include:
R8's 1/11/25, quarterly Minimum Data Set (MDS) assessment identified R8's cognition was intact. R8 was independent with eating. R8 had behaviors and refused cares. R8 was identified to have a weight loss of 5% or more in the last month or loss of 10% or more in last 6 months. R8 was identified for weight loss that was not a physician-prescribed weight -loss regimen. R8 did not have a therapeutic diet. Section L Oral/Dental Status of the assessment was not completed. R8 had pain and took scheduled pain medication. R8 had one stage 3 pressure ulcer, two unstageable pressure ulcers and tow venous ulcers.
R8's 2/26/25, Order Summary Report identified R8 was on a regular diet with regular texture. R8 was to be weighed monthly. R8 took Arginade Powder 1 packet by mouth one time a day for wound healing. There was no mention that R8 was on a supplement related to weight loss.
R8's Weight Summary report identified R8's weights as follows:
8/14/24 weight 273.0 pounds using wheelchair
9/4/24 weight 270.6 pounds using wheelchair
9/7/24 weight 245.6 using mechanical lift -with a message that there had been a 10% weight change compared to 4/5/24 of 282.4 pounds, a 7.5% weight change compared to 7/5/24 of 273.4 pounds, and a 5% weight change compared to 8/14/24 of 273.0 pounds.
9/14/24 weight 245.4 pounds using mechanical lift
9/18/24 weight 246.9 pounds using mechanical lift with message that there had been a 10% weight change compared to 4/5/24 of 282.4 pounds, a 7.5% weight change compared to 7/5/24 of 273.4 pounds, and a 5% weight change compared to 9/4/24 of 270.6 pounds.
10/7/24 weight 246.9 pounds using mechanical lift
10/9/24 weight 247.5 pounds using wheelchair
10/23/24 weight 247.0 pounds using mechanical lift
11/7/24 weight 243.8 pounds using mechanical lift
1/8/25 weight 240.2 pounds using mechanical lift
2/7/25 weight 240.0 pounds using mechanical lift
Review of nutritional progress notes identified:
10/22/24, dietician note for a follow up for weight change and skin issues. R8 was tolerating a regular diet and was independent with eating. R8 ate 25-75% of his meals and was a picky eater. Recommended Arginade supplement 1 packet for would healing. Noted weight changes and requested re-check of his weight.
1/9/25, dietary manager note R8 was on a regular diet. Have visited with R8 about his intakes and R8 will tell dietary manager to just go. Intakes were 25-75 % and resident had snacks in his room. Will continue to monitor and encourage intakes.
2/12/25, dietary manager note R8's average intake was 50-75%. Will continue to monitor.
Interview on 2/26/25 at 8:53 a.m., with the dietary manager identified R8 was weight when he allowed. She had visited with him about meals, and he will answer what he wants. She confirmed she was aware that R8 had lost at least 10% in the last 6 months as the electronic medical record point click care (PCC) flags a warning when there is a discrepancy in the weight. She reported that the dietician would review the weight loss and contact the provider with recommendations or have the nursing department do that. She was unaware if the provider had been notified of R8' s weight loss. She revealed the dietician had not assessed R8 in a while. She updated the dietician monthly and R8 did not have any weight loss the last time the dietician was at the facility. She reported that she does review weights weekly and if she identified something she would report that to the director of nursing to address. She stated that the facility had tried boost supplement with R8 but she was unsure if he drinks the supplement or not as dietary does not provide that to him nursing does.
Interview on 2/26/25 at 8:59 a.m., with director of nursing (DON) identified that the dietician reviewed residents for weight loss. The dietician would assess and make recommendation, and nursing would communicate that with the provider. The dietician only comes once a month however, if there was a concern outside of that time frame, the facility can call her. Nursing can also make recommendations to the provider.
Interview on 2/26/25 at 3:10 p.m., with registered nurse (RN)-B who confirmed that the provider had not been updated on R8's potential weight loss. She revealed that the dietary department had lacked communication about his weight loss and the facility needed to improve their communication during their interdisciplinary meetings (IDT). RN-B reviewed R8's weights and agreed that according to the charting R8 had lost about 30 pounds over last 6 months. RN-B confirmed that the discrepancy should have been investigated as there could have been multiple variables. The dietary manager should be monitoring weights and reporting to nursing who then should have notified the provider.
Interview on 3/3/25 at 4:57 p.m., with registered dietician (RD) identified she would expect to be notified if there was a resident identified with weight loss so that she could assess the resident. She revealed that the dietary manager provides her with a list of residents that need to be assessed, or that were new admission, and/or had an annual assessment due. She was unaware R8 had a weight loss and would expect that she should be able to trust that the dietary manager to be monitoring weights and would notify her with concerns. The interdisciplinary team (IDT) should be discussing concerns like weight loss at their meetings and nursing also should have notified the provider. She reported it was frustrating that it seemed like no one was addressing issues when they came up like this. She further revealed the problem that she had at times was with the contracted staff who do not seem to know the residents or just blow you off when you ask about a resident. She was told they are contracted pool staff, and they do not know. She would have expected when the discrepancy was identified in the facilities electronic record, point click care (PCC) that someone would have re-weighed the resident and investigated to see if a different scale had been used or some other variable had taken place. She confirmed that PCC does flag discrepancies with weights within the system to alert staff and at that time should have been addressed.
Interview on 3/4/25 at 8:15 a.m., with medical director identified his expectation for a resident with a significant weight loss to be assessed by the dietician or nursing staff to determine the cause of the weight loss, notify the primary provider and implement appropriate interventions as needed.
Review of 1/20/22, Weight Assessment and Intervention policy identified any weight change of 5% or more since last weight assessment the staff would re-weigh resident and if weight was verified the nursing staff would immediately notify the dietician. The dietician would then respond within 24 hours of notification. An assessment would be completed with the physician reviewing medication that could be causing the weight loss, care plan would be reviewed and revised as need with interventions.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0698
(Tag F0698)
Could have caused harm · This affected 1 resident
Based on observation, interview and document review, the facility failed to consistently monitor and assess a resident for potential complications related to dialysis treatment post treatment for 2 of...
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Based on observation, interview and document review, the facility failed to consistently monitor and assess a resident for potential complications related to dialysis treatment post treatment for 2 of 2 resident (R18 and R42) reviewed for dialysis.
Findings include:
R18's admission Record identified R18 was admitted to the facility at the end of January 2025. R18 had the following diagnoses of chronic kidney disease stage 5, anemia, type 2 diabetes mellitus, and vitamin D deficiency.
R18's 1/29/25, admission Minimum Data Set (MDS) assessment identified R18's cognition was intact. R18 had no behavior and required moderate assistance with cares. R18 took a daily anticoagulant, diuretic, and antiplatelet. R18 attended dialysis.
Observation on 2/25/25 at 7:45 a.m., R18 showed a dialysis port in her right upper chest.
R18 2/27/25, Order Summary Report identified R18 was on a renal diet and consistent carbohydrate diet. The order summary had no mention of monitoring access site for signs and symptoms of infection, no mention of location of access site, and no mention of dialysis schedule.
R18's 1/24/25, care plan identified R18 required hemodialysis related to renal failure. R18 would have interventions should she have any signs of complications from dialysis occur through the review date. Staff were to encourage her to attend dialysis. Staff to monitor her intake. Staff to monitor and report sign or symptoms of infection to her access site. Staff were not to draw blood or take a blood pressure in arm with graft. The care plan lacked identification and location of her access sight to be monitored. The care plan lacked identification of dialysis schedule or where R18 attended dialysis at.
Review of R18's pre/post dialysis evaluation assessments identified that the assessment had been completed in January 2 out of the 4 times and in February 4 out of 10 times reviewed.
R42's admission Record identified R42 was admitted to the facility in August of 2024. R42 had the following diagnoses of type 2 diabetes mellitus, end stage renal disease, cirrhosis of liver, and history of traumatic fractures.
R42's 2/19/25, quarterly MDS assessment identified R42's cognition was intact. R42 was dependent on staff for most cares. R42 had some behaviors towards others and rejection of care. R42 took insulin daily, an antidepressant and antiplatelet daily. R42 attended dialysis.
R42's undated, care plan identified nutritional status as resident will consume 75% of meals and to modify diet as appropriate according to the resident's food tolerances and preferences. R42's care plan lacked identification that R42 was on dialysis, the location of an access site, any precaution that may be needed, or for any monitoring of an access site. The care plan lacked R42's dialysis schedule or where R42 attended dialysis.
R42's 3/4/25, Order Summary Report identified R42 was on a renal diet. The order summary lacked identification of dialysis access site monitoring and lacked dialysis schedule.
Interview on 2/26/25 at 3:10 p.m., with registered nurse (RN)-B confirmed that R18 had not consistently had a pre/post dialysis assessment completed since admission. She further confirmed that R18's dialysis access was not identified on her treatment record nor her care plan. She revealed she had a right chest port and a right arm fistula and without identification of the access location the nurse would not know where to look especially the contracted staff.
Interview on 3/4/25 at 8:15 a.m., with medical director identified his expectation was that a resident on dialysis should have their access site assessed at a minimum upon returning from dialysis each time.
Review of 6/19/19, dialysis agreement identified the nursing facility was responsible for transportation, contacting the dialysis unit and/or nephrologist for dialysis related problems. Assessing the dialysis resident including access observation, vitals and weight if needed.
Review of 11/3/21, Dialysis Care External Facility policy identified the nursing staff would observe the residents access site upon return from the dialysis treatment for bleeding and/or other complications.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0742
(Tag F0742)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and document review, the facility failed to notify the medical director for 1 of 1 resident (R41) who exhibit...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and document review, the facility failed to notify the medical director for 1 of 1 resident (R41) who exhibited increased and ongoing behaviors since shortly after admission, with no mental health intervention to receive appropriate treatment and services and had questionable mental ability to refuse cares and treatment.
Findings include:
R41's face sheet identified he was admitted to the facility in September 2024. R41 had a recent hospital stay 11/4/24 through 11/6/24 and had diagnoses of hypoparathyroidism (parathyroid glands do not produce enough parathyroid hormone and treated with medication), history of a lumbar spinal fracture, right leg fracture, right artificial hip, hypothyroidism (thyroid gland does not produce enough thyroid hormone), generalized anxiety disorder, and multiple fractures of ribs.
R41's 11/25/24, quarterly Minimum Data Set (MDS) identified R41 was admitted to the facility (from the now closed sister facility) in September 2024. R1 was noted to have delusions with no behaviors identified.
R41's current, undated physician orders identified R41 had 9 medication orders listed to included higher risk medications such as Apixaban (blood clot prevention medication), mirtazapine (antidepressant), and amlodipine (high blood pressure medication).
R41's current, undated care plan identified R41 was noted to be independent with all Activities of Daily Living (ADL), and could transfer and perform personal cares independently. Staff noted in the Behavior Management focus the goals was for undesirable behaviors to be monitored and managed. Staff were to:
1) Attempt an alternate time to provide care if refused.
2) Educate R41 and his family (FM)-A of the necessity of care.
3) Ensure the safety of R41 and others.
4) Monitor for emotional factors that may contribute to new behaviors.
No other interventions were noted or documented related to how staff were to provide appropriate care to R41 with repeated refusals of medication and care.
R41's progress notes identified on:
1) 9/9/25, a clinical admission note was made. R41 was currently experiencing unwanted behaviors, chronic refusal of cares, bathing, allow his clothing to be changed, and refusing staff to obtain vitals stating my father , my father, my father takes care of me. My father tells me what to do and he says no touch. R41 was occasionally incontinent upon admission assessment, and some physical assessment data was documented.
2) 9/14//24, R41 refused to eat his breakfast and lunch. He was reported to have not eaten the day before. R41 told staff he was fasting for a month because God told him to. Staff noted they had expressed concerns to the physician's (MD) office and received an order to administer Haldol (powerful antipsychotic used to treat acute psychological behaviors usually reserved when there is an immediate threat to patient safety) The MD noted if there was no improvement with R41's behavior, he would need to go to behavioral health again. The facility notified R41's family (FM)-A. FM-A stated there is nothing you can do if he will not take medications, he will have to go back to behavioral health R41 was noted to kick out at the nurse when staff attempted to give him his Haldol injection.
3) 9/16/25 at 2:09 p.m., a call was placed to the primary care physician (PCP) nurse regarding R41's worsening and refusals of cares, medications, and meals. R41 had not allowed staff to touch him. R41 advised staff he was fasting for the entire month of September 2024. Staff expressed their concerns and asked for orders and suggestion. R41's PCP faxed back an order for staff to administer Haldol intramuscularly (IM) 5 milligrams (mg) every 4 hours x 2 doses. If no improvement, the order directed staff to send R41 to behavioral health again. R41's family member (FM)-A was called and stated to staff there was nothing they could do if he wouldn't take his medications .he would have to go back to the behavioral unit. FM-A gave permission for staff to administer the medication.
4) 9/16/24 at 2:47 p.m., staff attempted to enter R41 to speak with him about fasting. R41 began to scream at staff to get out of his room. The nurse attempted to educate R41 on the need for the injection and began screaming AHHHHHHHHHH NO injection!. R41 told staff he would not eat and is fasting for the month. He refused to allow staff to assess him and told staff to get out. The IM Haldol was given.
5) 9/17/24 at 10:12 a.m., staff noted R41 was in his room seated in his recliner. Staff offered food. R41 replied his food was poisoned. When staff attempted to interact with him, he raised his voice and told them not to touch him. He was upset staff gave him 2 injections (the previous day). The nurse tried to reiterate why R41 received the injections due to his delusions. R41 repeated more delusions such as I have intel. Another call was placed to R41's PCP. The PCP advised staff to proceed with a transfer to behavioral health.
6) 9/16/24 at 5:24 p.m., a call was placed for a non-emergent ambulance. EMS staff asked R41 questions and reported NO, I am normal .go away!. EMS identified R41 knew his name, and his location and had refused transfer. EMS told staff due to his ability to answer those questions, They were unable to take R41 to behavioral health as he was oriented correctly. EMS left without the resident due to his refusal for transfer. R41's PCP was updated. Numerous notes were made after 9/16/24, related to R41's ongoing refusal of all cares.
7) 10/1/24 at 10:47 a.m., staff noted they had called FM-A about R41's refusals of medication. Staff suggested discontinuing all medication as they felt it caused more behaviors. FM-A said lets do it. There was no indication staff had first checked with R41's PCP, behavioral health, or the medical director at that time on how they could best provide care and services to R41 prior to requesting family approval to discontinue medication.
8) 10/21/24, R41 was seen in house by contracted behavioral health services. A fax back after the visit was received with orders to administer Abilify (antipsychotic medication) IM and continue to try and give oral medications as he allowed. They also received a new order for as needed lorazepam (anti-anxiety medication) IM for agitation and severe anxiety and follow up every 14 days. Staff were instructed to contact the clinic with any concerns.
9) 10/21/24 at 11:25 p.m., a note was placed identifying R41 was seen in house by his PCP. No new orders were given. R41 refuses to take all medication. R41 was noted to be in his room all day and getting up only to use his bathroom. Staff noted no delusional behaviors.
10) 10/22/25 at 9:15 p.m., staff noted they had received electronically signed progress notes form the PCP. Staff noted they were unable to assess R41 or obtain vital signs. Per the PCP, they will return in 2 months to recheck.
Further review of the progress notes repeated the same inability of staff to provide care and services to R41.
Review of a R41's physician progress notes identified on:
1) 10/22/24, the PCP noted diagnoses of agitation, depression, catatonia (group of symptoms that usually involve a lack of movement and communication, and can include agitation, confusion, and restlessness), chronic anemia (low iron), high blood pressure, liver disease, enlarged prostrate, mild persistent asthma, high cholesterol, and chronic obstructive pulmonary disease (COPD). R41's PCP noted he was followed by psychiatry. R41 refused everything including vital signs, examination and appeared to be quiet in his recliner. He was apparently in no pain but again refused to be touched or examined. The PCP noted it was a difficult assessment because patient refused talking to us and refused to be examined. The PCP directed staff to continue with his blood pressure medication (Amlodipine) if he accepted. Depression with catatonia, and combative behavior were identified with orders directing staff to continue Haldol every 6 hours as needed. No end date was given. Staff were instructed to give his lorazepam at bedtime, mirtazapine and Abilify (anti-depressant) and continue with escitalopram (another anti-depressant) and continue with his inhaler related to COPD as tolerated and accepted by R41. The PCP noted R41 was a difficult patient to take care of as he consistently refuses care .will return in 2 months to recheck should he allow us to examine him and check vitals.
2) The nurse practitioner (NP) documented R41 was refusing all cares. Will continue current medications as patient allows
3) 11/19/24, the PCP noted additional diagnoses from the previous visit of chronic hepatitis C, allergic rhinitis, elevated fasting glucose, pre-diabetes, and bilateral knee pain. R41 was noted to refuse everything namely examination, medications, some of his food, showering .basically spends his days on the recliner. Upon examination it was noted vitals signs were not taken because R41 refused. R41 made no complaints of pain or anything but refused his exam. Nurses reported he refused most of the time his food, although he ate some snacks, refuses showers, changing his clothing, medications, being touched, examined, or having his vital signs checked. The PCP reported they would keep insisting on seeing him without much hope. Psychiatry also tried to see him at the facility but patient refuses. The PCP was not changing anything with his medications as R41 was not taking it the times offered. He would return the next scheduled visit to see if there was improvement.
4) 1/21/25, the PCP returned for a facility visit. He noted R41 continued to refuse everything namely examinations, medications, some to most food, showering, and spent his day in his recliner. R41 would become aggressive when approached. R41 once again refuse exam and no vitals were taken. Nursing reported his refusals of care. The PCP's plan was no changes to medication as R41 wasn't taking them. The PCP noted he would continue attempts to see R41 on scheduled visits. Psychiatry had tried to see R41 several times, but he is able to provide his name, DON, and because of that, the PCP felt R41 could not be called incompetent to make decisions and noted psychiatry could not force the issue, neither can we. There was no indication the PCP had reached out to the medical director for guidance and his capacity to consent to refuse evaluated related to refusals of all care, most food and medication as a potential risk for harm without receiving appropriate care of services exists.
Interview on 3/03/25 at 11:28 a.m., with laundry aide (LA)-A identified LA-A had never washed any clothing for R41. She has never done R41's laundry since his admission. She assumed maybe his family washed his clothing.
Observation on 3/3/25 at 11:30 a.m., of R41's room identified his door was open partially. R41 was observed to be standing in his room. Staff attempted to speak from the door. R41 waived his arm at staff to leave. No direct observations of R41 were able to be obtained.
Interview on 3/03/25 at 11:35 a.m., with RN-E, the MDS nurse related to R41 identified R41 refuses everything. When R41 was first admitted to the facility he would take his medication. Soon after he began refusing treatment or allowing staff into his room. R41 would tell staff god tells him he can't take his medication or that he doesn't need them. Some staff may be able to enter his room, but it is rare . it depends on the nurse aide. R41 always says get out!. Facility staff have spoken to FM-A and the MD. Essentially he isn't a risk for harm to himself or others He refuses medications that include antipsychotics. Staff are At a point with him .he is good living here . [staff] offer everything. When asked how RN-E or others assisting with the MDS assessments were able to perform assessments such as skin, she stated Staff cannot do skin assessments. She turns in MDS data based on what is able to be captured. Through the facility electronic program, designed to submit information to the Centers for Medicare and Medicaid (CMS) for payment, RN-E noted she had to put something in.
R41's 6/3/24, inpatient psych note from the Behavioral Health Hospital (BHH) identified R41 had diagnoses of catatonia, major neurocognitive disorder, altered mental status, and hypoxemia (lack of oxygen to the brain). R41 was identified to bat continued high risk/complexity secondary to the combination of acute on chronic psychiatric diagnoses, cormorbid medical illness, and use of multiple psychotropic medication. R41 had received electroconvulsive therapy (shock therapy) as an inpatient at the hospital. R41 had improvement there both physically and mentally. He was no longer catatonic after treatments with ECT and medication management. At that time, R1 was noted to be cooperative, well groomed and well nourished. R41 had no delusions, hallucinations, or paranoia with insight fair and improving. Upon his admission, R41 was an unreliable historian, had limited judgement in decision making in every day activities, social situations, and compliance for treatment. R41 had a previous BHH stay in April 2024, due to sever deterioration in functioning and concerns for catatonia. R41 failed to have the capacity to consent for decision making upon admission due to his mental health exacerbation.
R41's behavior history task, documented by staff identified staff had checked R41 exhibited no behaviors of any kind.
R41's September 2024 through February 2025 vital signs report identified vitals were obtained on 9/9/24. Of those vitals, R41 had 1 weight measurement on 9/9/24 of 191 lbs. No other weights were documented as obtained. R41 BP on 9/9/24 was listed at 168/101 mm/hg and his oxygen saturation (SpO2) was documented as 93%. On 2/25/25, the same date as the MDS note listed above, R41's BP and SpO2 readings were documented as the exact same as September 2024. No other vitals were obtained for R41 throughout his stay from September 2024 through March 2025.
R41's bathing history was reviewed for the previous 30 days prior to the survey. At no time during February was R41 bathed.
R41's assessment data history from September 2024 through March 2025 was obtained. R41 had only 3 assessments noted as completed. Those assessments were a [NAME] pressure ulcer risk assessment. One upon admission, one at R41's 11/21/24 quarterly assessment, and then R41's currently in progress 2/19/25, MDS assessment. No other assessments were documented for R41 from September 2024 through March 2025.
R41's personal hygiene task for the last 30 days prior to survey was viewed. R41 was noted by staff to be completely independent with personal hygiene. It is unclear how staff determined this to be accurate and true.
R41's March 2025. Medication and Treatment records (MAR/TAR) identified R41 had not received medications or treatments. Corresponding progress notes made by nursing staff in the medical record identified R41 refused all medications and cares.
Interview on 3/03/25 at 4:26 p.m., with RN-A identified she was familiar with R41 and had even cared for him at the sister facility before it closed. RN-A stated R41 refuses everything. There are very limited staff who can interact with R41. He strikes out, kicks, and has verbal behaviors. R41 will not leave his room. She thinks R41 is continent or bowel and bladder, but acknowledged without being able to assess R41, there would be no way to know. Staff provide no cares or treatments for R41. RN-A was unaware if he even allowed linens to be changed on his bed or his clothing washed. RN-A had not seen R41's skin since he was administered Haldol in September 2024. RN-A was unaware staff were documenting R41 as having no behaviors, however, she related that to not being allowed to enter R41's room or provide any cares. RN-A recalled she has been unable to perform any assessments, give medication, or provide cares to R41 since September 2024.
Interview on 3/03/25 at 5:37 p.m., with the director of nursing (DON) identified she was aware R41 refused all cares, assessments, or treatments. When asked how staff can accurately and comprehensively assess R41, she noted they cannot. She agreed staff are providing no skilled nursing related to R41's refusals. The DON agreed the medical director should have been notified to assist with R41 when he was not able to make safe decisions regarding his care.
Interview on 3/4/25 at 8:16 a.m., with the medical director (MD)-A identified he was unaware of R41's refusal of all cares. He would expect to be notified as he agreed R41 isn't capable of making an informed decision related to his health and safety. He was unaware R41 received no skilled nursing care, had only 2 baths since admission, refused all meds, and had no laundry done. He was also unaware staff were unable to comprehensively assess R41. He agreed the assessment data included on the MDS would be false if staff could not actually assess R41.
Review of the 10/18/21 Behavioral Health Services (BHS) policy identified BHS were to be provided as part of the interdisciplinary, person centered approach to care. Staff were to promote dignity, autonomy, privacy, socialization and safety as appropriate and were to be trained in ways to support residents. Staff were to be trained in protocols and guidelines related to mental disorders and psychosocial adjustment difficulties of residents. There was no mention what professional references staff were to use to guide decisions on what to do if current interventions were not working to ensure the health and safety of resident with poor decision making capabilities was maintained.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Medication Errors
(Tag F0758)
Could have caused harm · This affected 1 resident
Based on observation, interview, and record review, the facility failed to include an appropriate diagnosis for the use of an antipsychotic medication for 1 of 5 residents (R6) reviewed for unnecessar...
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Based on observation, interview, and record review, the facility failed to include an appropriate diagnosis for the use of an antipsychotic medication for 1 of 5 residents (R6) reviewed for unnecessary medication.
Findings include:
R6's 12/10/24, quarterly Minimum Data Set (MDS) assessment identified her cognition was severely impaired, she had no behaviors and was dependent on staff for activities of daily living (ADL)'s. R6 had diagnosis of Alzheimer's disease late onset, non-traumatic brain disorder, and adult failure to thrive. She had been administered antipsychotic medication and antidepressant medication on a routine basis.
R6's medication administration record (MAR) identified she was administered quetiapine (antipsychotic) 75 milligrams (mg) in the morning, 25 mg at noon, and 100 mg at bedtime for Alzheimer's Disease with late onset, and sertraline 50 mg daily for dementia with other behavioral disturbances.
R6's electronic medical record diagnosis list identified Alzheimer's disease with late onset, and adult failure to thrive.
R6's care plan identified she was taking psychotropic medication related to dementia and staff should monitor/record occurrences of target behaviors including violence/aggression, delusions, and audible hallucinations.
The electronic medical record lacked an appropriate diagnosis for the use of psychotic medications.
Interview on 2/27/25 at 1:27 p.m., with registered nurse (RN)-E identified she was responsible for completing the MDS, she reported she should have done a better job when pulling R6's medical information from the hospital records that had been provided to the facility. She knows there is not an appropriate diagnosis for the administration of an antipsychotic in R6's facility medical record and was not certain if R6 had a diagnosis of depression prior to admitting.
Interview on 3/3/25 at 11:24 a.m., with RN-B identified contracted licensed nurses working at the facility were unable to access hospital medical records.
Review of the facility provided Antipsychotic Medication Use policy dated 7/13/22, identified antipsychotic medication shall generally be used only for diagnosis of schizophrenia, schizoaffective disorder, schizophreniform disorder, delusional disorder, bipolar disorder, depression with psychotic features, treatment refractory major depression, psychosis in the absence of dementia, medical illnesses with psychotic symptoms and/or treatment related psychosis of mania, Tourette's disorder, Huntington's disease, hiccups, and nausea/vomiting associated with cancer or chemotherapy. Diagnosis alone do not warrant the use of antipsychotic medication. In addition to an appropriate diagnosis, antipsychotic mediations will generally only be considered if behavioral symptoms present a danger to the resident and others.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0761
(Tag F0761)
Could have caused harm · This affected 1 resident
Based on observation, interview and document review the facility failed to ensure controlled medications were reconciled according to the facility protocol to prevent potential diversion for 1 of 1 em...
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Based on observation, interview and document review the facility failed to ensure controlled medications were reconciled according to the facility protocol to prevent potential diversion for 1 of 1 emergency kits reviewed.
Findings include:
Observation and interview on 3/3/25 at 3:36 p.m., with registered nurse (RN)-C of the medication room on first floor. Observed was a refrigerator with a paddle lock on it with the key being on the nurse's key ring. Located inside the refrigerator was a clear box with 2 vials of Lorazepam 2 milligrams/milliliter (MG/ML) an antianxiety medication and a red plastic tag with the number 0501539. RN-C reported that the Lorazepam was from the emergency kit and counted each shift. The count was documented in the narcotic log located on the medication cart. Review of the narcotic logbook with RN-C found he was unable to find that the Lorazepam had been reconciled and documented. RN-C revealed that at shift change they had not checked the emergency Lorazepam from the refrigerator. RN-C confirmed that the nurses should be confirming the red plastic tag number on the box with the emergency Lorazepam each shift to monitor for diversion.
Review of the emergency kit medication list identified Lorazepam 2mg/ml quantity of 2 vials.
Interview on 3/3/25 at 3:45 p.m., with licensed practical nurse (LPN)-A confirmed that the emergency Lorazepam located in the refrigerator had not been getting reconciled. LPN-A agreed that the Lorazepam red tag number and amount should be monitored at each shift change.
Interview on 3/3/25 at 3:50 p.m., with director of nursing (DON) confirmed that the emergency Lorazepam should be monitored each shift and that the nursing staff should be documenting the red tag number and verifying the amount to monitor for diversion.
Interview on 3/4/25 at 8:15 a.m., with medical director identified his expectation was that the nursing staff would monitor controlled medication to avoid the risk of medication diversion.
Review of 3/3/25, Controlled Substances policy identified that the facility would reconcile controlled medication upon receipt, administration, disposition, and at the end of each shift. The nurse coming on duty and the nurse going off duty would reconcile the count together. Discrepancies in controlled medications would be documented and reported to the director of nursing. Investigations in all discrepancies of controlled medication would be completed. The discrepancies would be reviewed with the pharmacist and administrator to determine further action if needed. The director of nursing would periodically review policies and procedures for monitoring controlled medication to prevent diversion.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0808
(Tag F0808)
Could have caused harm · This affected 1 resident
Based on interview, and document review the facility failed to ensure 1 of 1 resident (R18) received ordered therapeutic diet to maintain or improve their nutritional status.
Findings include:
R18's ...
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Based on interview, and document review the facility failed to ensure 1 of 1 resident (R18) received ordered therapeutic diet to maintain or improve their nutritional status.
Findings include:
R18's admission Record identified R18 was admitted to the facility at the end of January 2025. R18 had the following diagnoses of chronic kidney disease stage 5, anemia, type 2 diabetes mellitus, and vitamin D deficiency.
R18's 1/29/25, admission Minimum Data Set (MDS) assessment identified R18's cognition was intact. R18 had no behavior and required moderate assistance with cares. R18 took a daily anticoagulant, diuretic, and antiplatelet. R18 attended dialysis.
Review of the 5/14/24, Centers for Disease Control (CDC), Diabetes and Kidney Disease: What to Eat?: article located at, https://www.cdc.gov/diabetes/healthy-eating/diabetes-and-kidney-disease-food.html, identified, A healthy diabetes diet looks pretty much like a healthy diet for anyone. Eat lots of fruits, veggies, healthy fats, and lean protein. Eat less salt, sugar, and foods high in refined carbs. With a chronic kidney disease (CKD) diet, you'll avoid or limit certain foods to protect your kidneys. You'll include other foods to give you energy and keep you nourished. Your specific diet will depend on whether you're in early-stage or late-stage CKD or if you're on dialysis. Depending on your kidney disease stage, you may also need to reduce the potassium, phosphorus, and protein in your diet. Many foods that are part of a typical healthy diet may not be right for a CKD diet. Your nutrition needs will change with late-stage CKD. If you're on dialysis, you may need to eat more, especially more protein. Your appetite can change because food tastes different.
R18's 1/23/25, hospital discharge orders identified renal consistent carbohydrate diet.
R18's 2/27/25, Order Summary Report identified R18 was on a renal diet and consistent carbohydrate diet.
Review of R18's diet slip from the dietary department identified diet as diabetic. There was no mention of foods to avoid or special instruction on the diet slip.
R18's 1/24/25, care plan identified R18 required hemodialysis related to renal failure. R18 had no mention of nutritional status and diet to be provided.
Interview on 2/26/25 at 3:46 p.m., with dietary aide (DA)-A who reported she was unaware of what a renal diet consisted of but could ask the cook if she knew.
Interview on 2/26/25 at 4:23 p.m., with nursing assistant (NA)-A who reported R18 was on no restrictions, and she did not care for the food offered to her, so her daughter brought her food in frequently.
Interview on 2/27/25 at 9:20 a.m., with registered nurse (RN)-D who reported R18's orders identified R18 was on a renal diet and consistent carbohydrate diet.
Interview 2/27/25 at 9:28 a.m., with cook (C)-B who identified R18 was on a diabetic diet and not on a renal diet. The kitchen did not give her anything special for a diet, she was served the same foods as everyone else but in smaller portions.
.
Interview on 2/27/25 at 12:21 p.m., with dietary manager identified upon admission she was given a diet slip for a diabetic diet for R18. She confirmed she knew R18 attended dialysis, so she received smaller portions. R18 was to also avoid potassium. R18 basically received the same diet as everyone else but smaller portions. R18 had no fluid restrictions, and her labs were followed by the hospital dietician.
Interview on 3/3/25 at 12:14 p.m., with C-B who reported she served R18 fried chicken, mashed potatoes, and sherbet for lunch. She revealed she sent the tray up to first floor between 11:45 and 12:00 noon. R18 received smaller portion sizes verse the regular size meal as she was on a diabetic diet.
Interview on 3/3/25 at 12:18 p.m., with licensed practical nurse (LPN)-A identified R18 left at 11:30 a.m., for dialysis. LPN-A reported that R18's daughter brought R18 food frequently. No dietary tray was sent up for R18 because the kitchen does not send meal trays to R18 on dialysis days as her daughter will bring her food. LPN-A was unsure how staff documented meal intakes when her daughter brings her food.
Interview on 3/3/25 at 1:51 p.m., with dietary manager identified nursing communicates diet orders by filling out a diet slip. R18's daughter brings her food in frequently as R18 wants more tradition foods related to her culture. The dietary department does not send a meal tray to R18 if they know that the daughter brought her in food.
Interview on 3/3/25 at 2:00 p.m., with RN-D identified a copy of the diet order upon admission was given to the dietary department and a dietary slip was filled out with the diet order. If there was a new dietary order from dialysis nursing would give a copy of that order to the dietary department and fill out the dietary slip.
Interview on 3/3/25 at 4:57 p.m., with registered dietician (RD) identified the dietary department should be knowledgeable about a renal diet. R18 should be on a renal diet and receive limited potatoes, and potassium rich food. R18 should be served a meal tray regardless of the daughter bringing in food for her. R18 can decline to eat the meal but should be offered the meal.
Interview on 3/4/25 at 8:15 a.m., with medical director identified his expectation was that dietary department would provide the appropriate prescribed diet as ordered.
A copy of the original physician diet order was request but not provided.
Review of undated Diet and Nutrition Care Manual for Renal Dialysis identified carbohydrates should be controlled if needed in residents with hyper or hypo glycemia, sodium should be restricted if needed to avoid excessive fluid retention, fluid intake was individualized, potassium should be adjusted to maintain a potassium level within normal range. Phosphorus should be adjusted to maintain phosphate levels in the normal range.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Medical Records
(Tag F0842)
Could have caused harm · This affected multiple residents
Based on interview and document review the facility failed to include the run/communication report from dialysis in the facility medical record for 2 of 2 residents (R18 and R42) reviewed for dialysis...
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Based on interview and document review the facility failed to include the run/communication report from dialysis in the facility medical record for 2 of 2 residents (R18 and R42) reviewed for dialysis, in addition the facility failed to transcribe physician order for 1 of 1 resident (R44) following an appointment.
Findings include:
R18's admission Record identified R18 was admitted to the facility at the end of January 2025. R18 had the following diagnoses of chronic kidney disease stage 5, anemia, type 2 diabetes mellitus, and vitamin D deficiency.
R18's 1/29/25, admission Minimum Data Set (MDS) assessment identified R18's cognition was intact. R18 had no behavior and required moderate assistance with cares. R18 took a daily anticoagulant, diuretic, and antiplatelet. R18 attended dialysis.
R18's 1/24/25, care plan identified R18 required hemodialysis related to renal failure. Staff were to encourage her to attend dialysis. The care plan lacked identification of dialysis schedule or where R18 attended dialysis.
R18's electronic medical record, point click care (PCC) identified R18 had 2 copies of her dialysis run/communication report. One report was dated 1/24/25 and the second report was dated 1/27/25. The facility electronic medical lacked all other dialysis run/communication reports from dialysis.
R42's admission Record identified R42 was admitted to the facility in August of 2024. R42 had the following diagnoses of type 2 diabetes mellitus, end stage renal disease, cirrhosis of liver, and history of traumatic fractures.
R42's 2/19/25, quarterly MDS assessment identified R42's cognition was intact. R42 was dependent on staff for most cares. R42 had some behaviors towards others and rejection of care. R42 took insulin daily, an antidepressant and antiplatelet daily. R42 attended dialysis.
R42's undated, care plan identified nutritional status as resident will consume 75% of meals and to modify diet as appropriate according to the resident's food tolerances and preferences. R42's care plan lacked identification that R42 was on dialysis, the location of an access site, any precaution that may be needed, or for any monitoring of an access site. The care plan lacked R42's dialysis schedule or where R42 attended dialysis.
R42's 3/4/25, Order Summary Report identified R42 was on a renal diet. The order summary lacked identification of dialysis access site monitoring and lacked dialysis schedule.
R42's electronic medical record PCC identified the last dialysis run/communication report was from 1/27/25 with no further reports in R42's facility medical record.
Interview on 3/3/25 at 11:24 a.m., with registered nurse (RN)-B identified contracted licensed nurses working at the facility were unable to access hospital medical records. We used to have a medical records person, that could obtain and add records from the hospital to the facility medical record, but we no longer have the position.
Review of 6/19/19, Dialysis Agreement identified communication would be shared between dialysis and the nursing home regarding the run summary, any related dialysis complications, new orders, and any changes in condition or concerns related to the vascular access site.
Review of 11/3/21, Dialysis Care External Facility policy identified shared communication between the dialysis center and the nursing home would be coordinated by the director of nursing or designee. The communication would include post weight, blood pressure and dialysis site condition. Nutritional management will be coordinated between the dialysis dietitian and the facility dietician with recommendation initiated when received.
R44's 1/28/25, admission Minimum Data Set assessment identified her cognition was moderately impaired. She required extensive assistance with her activities of daily living (ADL)'s. R44 had diagnosis of atrial fibrillation (disease of the heart characterized by irregular and often faster heartbeat), heart failure, renal insufficiency, dementia, anxiety, depression, and morbid obesity.
Interview on 2/27/25 at 9:18 a.m., with FM-H identified that R44 had seen a physician last week and at the appointment R44 had increased swelling to her lower legs. The physician placed orders to add a water pill to decrease fluid in legs, and for staff to wrap her legs or put compression stocking on daily. He reported that on 2/23/25 he went to the facility to visit and R44 did not have any leg wraps on. FM-H spoke with the charge nurse, and she identified she was not aware of the new orders but would check into it.
Observation on 3/3/25 at 9:50 a.m., R44 is seated in a wheelchair, head facing downward with eyes closed. Legs are wrapped from her feet to just below the knee in ace bandages and feet are down on the floor.
R44's March 2025 medication administration record identified an order to apply ace wraps to bilateral lower extremities daily. The order entry date was 2/27/25, the order had been transcribed 8 days after it was received from the physician. Furosemide oral tablet 20 mg twice daily in addition to 20 mg for a total of 40 mg twice daily for 30 days transcribed on 2/21/25, 2 days after the order was received. R44's medication/treatment administration record lacked any direction for nursing staff to elevate lower extremities or to apply antifungal powder under abdominal folds.
Interview on 3/3/25, at 11:15 a.m., with RN-B and RN-D, identified their process is to review the new order upon receiving, transcribe the order, make a nursing progress note, and place the original copy in a wall pocket behind the nurse's station for the medical records person to scan into the medical record. They identified the orders received following R44's 2/19/25 appointment had been transcribed late and the original order was not yet scanned into the medical record. RN-B reported they did not currently have a medical record person, and she was told they had planned to resolve that position, she stated nursing does not have time to scan all the orders in, she further revealed that they only complete a second check on narcotic orders and admission orders.
Subsequent interview on 3/3/25, at 11:58 a.m., RN-B came to the conference room with the original order. She reported she found the order in a pile of papers that were waiting to be scanned in.
R44's 2/19/25, original physician order identified staff were to apply antifungal powder under abdominal folds, apply compression stockings or ace wraps to lower extremities daily, keep lower extremities elevated as much as possible, and increase Lasix to 40 milligrams (mg) twice daily for 30 days.
Interview on 3/4/25 at 8:15 a.m., with the facility medical director identified he would expect facility staff to transcribe and implement physician orders upon receipt.
A facility policy for order transcription was requested but nothing was provided by the end of the survey period.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Comprehensive Care Plan
(Tag F0656)
Could have caused harm · This affected most or all residents
Based on interview and document review, the facility failed to ensure 9 of 15 sampled residents (R1, R5, R7, R8, R18, R20, R28, R41, and R42) care plans were developed and able to be revised as necess...
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Based on interview and document review, the facility failed to ensure 9 of 15 sampled residents (R1, R5, R7, R8, R18, R20, R28, R41, and R42) care plans were developed and able to be revised as necessary. This has the potential to affect all 56 residents.
Findings include:
R41's face sheet identified he was admitted to the facility in September 2024. R41 had a recent hospital stay 11/4/24 through 11/6/24 and had diagnoses of hypoparathyroidism (parathyroid glands do not produce enough parathyroid hormone and treated with medication), history of a lumbar spinal fracture, right leg fracture, right artificial hip, hypothyroidism (thyroid gland does not produce enough thyroid hormone), generalized anxiety disorder, and multiple fractures of ribs.
R41's 11/25/24, quarterly Minimum Data Set (MDS) identified R41 was admitted to the facility (from the now closed sister facility) in September 2024. R1 was noted to have delusions with no behaviors identified.
R41's 11/19/24, physician progress note identified the PCP noted additional diagnoses from the previous visit of chronic hepatitis C, allergic rhinitis, elevated fasting glucose, pre-diabetes, and bilateral knee pain.
R41's current, undated care plan identified R41 was noted to be independent with all Activities of Daily Living (ADL), and could transfer and perform personal cares independently. Staff noted in the Behavior Management focus the goals was for undesirable behaviors to be monitored and managed. Staff were to:
1) Attempt an alternate time to provide care if refused.
2) Educate R41 and his family (FM)-A of the necessity of care.
3) Ensure the safety of R41 and others.
4) Monitor for emotional factors that may contribute to new behaviors.
No other interventions were noted or documented related to how staff were to provide appropriate care to R41 with repeated refusals of medication and care. There was also no mention of interventions for additional diagnoses listed from the PCP.
Interview on 3/03/25 at 11:35 a.m., with RN-E, the MDS nurse identified the care plans used to be able to be individualized. Now they are canned or pre-programmed interventions. RN-E stated it was hard to individualize the care plans. RN-E agreed R41's increased behaviors were not care-planned, nor was his Hepatitis C. It does not allow for very accurate individualization of care plans.
R8's admission Record identified R8 was admitted in June of 2023 with the following diagnoses: stroke, peripheral vascular disease, overactive bladder, history of bladder infections, benign prostatic hyperplasia with urinary tract symptoms, long term use of anticoagulant, major depressive disorder, anxiety disorder, and atrial fibrillation.
R8's 1/11/25, quarterly Minimum Data Set (MDS) assessment identified R8's cognition was intact. R8 had behaviors directed towards others, had other behaviors that were not directed towards others, and rejection of care that occurred 1 to 3 days during the assessment period. R8 was dependent on staff for most cares, R8 had an indwelling Foley catheter. Re had 1 stage 3 pressure ulcer and 2 unstageable pressure ulcers. R8 had 2 venous ulcers. R8 took a daily antipsychotic, antidepressant, anticoagulant, and opioid.
R8's 2/26/25, Order Summary Report identified Xarelto 20 milligrams (mg) an (anticoagulant a blood thinner that prevents blood clots) one time a day for atrial fibrillation. R8 had a pressure ulcer on his right buttocks and sacral/lumbar region, and wounds on his bilateral lower extremities.
R8's February Medication Administration Record identified R8 refused dressing treatments to wounds on lower extremity 12 times and other wound treatments for sacral and buttocks 15 times
R8's undated, care plan identified R8 had pressure ulcers and staff were to educate on skin care to prevent skin breakdown. Staff were to encourage R8 to frequently shift weight and wear Prevalon boots while in bed or recliner. Staff were to provide wound care as ordered. There was no mention of a scheduled repositioning regimen to heal and prevent further pressure ulcers. There was no mention of what staff were to do if R8 refused wound care. R8 took Xarelto a blood thinner and there was no mention of the blood thinner on the care plan and what side effects staff should be monitoring for and reporting to the nurse.
Interview on 3/4/25 at 8:15 a.m., with medical director identified his expectation was that a resident receiving medications such as anticoagulants that the nursing staff would monitor for side effects.
Review of the 9/29/21, Wound Care policy identified that staff were to notify the supervisor if a resident refused wound care.
R18's admission Record identified R18 was admitted to the facility at the end of January 2025. R18 had the following diagnoses of chronic kidney disease stage 5, anemia, type 2 diabetes mellitus, and vitamin D deficiency.
R18's 1/29/25, admission MDS assessment identified R18's cognition was intact. R18 had no behavior and required moderate assistance with cares. R18 took a daily anticoagulant, diuretic, and antiplatelet. R18 attended dialysis.
R18's 1/24/25, care plan identified R18 required hemodialysis related to renal failure. R18 would have interventions should she have any signs of complications from dialysis occur through the review date. Staff were to encourage her to attend dialysis. Staff to monitor her intake. Staff to monitor and report sign or symptoms of infection to her access site. Staff were not to draw blood or take a blood pressure in arm with graft. The care plan lacked identification and location of her access sight to be monitored and of dialysis schedule or where R18 attended dialysis at. The care plan further lacked identification of nutritional status and diet to be provided.
R20's Administration Record identified R20 was admitted in August of 2024 with the following diagnoses: hemiplegia, dementia with other behavioral disturbance, history of stroke, diabetes mellitus type 2, anxiety, and insomnia.
R20's 2/14/25, quarterly MDS assessment identified R20's cognition was moderately impaired. R20 had no behaviors and required extensive assistance with most cares. R20 took pain medication, insulin, antipsychotic, antianxiety, antidepressant, antiplatelet, and hypoglycemic medications.
R20's Order Summary Report identified R20 had his blood sugar checked one time a day before breakfast, R20 took insulin glargine (long acting) 25 units QD for type 2 diabetes and Metformin HCI 1000 mg twice a day for type 2 diabetes. Monitoring of R20's blood sugars located in his Medication Administration Record for February 2025, identified documentation of blood sugar as low as 60 and as high as 366. There was no mention of R20's normal blood sugar range or when the provider should be notified for further direction if blood sugars are low or high.
R20's 2/5/25, care plan identified R20 was on a regular diet and would maintain adequate national status through the review date. The facility will provide and serve diet as ordered. There was no mention on R20's care plan that he was diabetic or for staff to monitor for hypo (low) or hyper (high) glycemia (blood sugar) and when to contact the provider for further guidance.
Interview on 3/4/25 at 8:15 a.m., with medical director identified his expectation was that a resident diagnosed with diabetes that the nursing staff would monitor for signs and symptoms of hypo or hyper glycemia.
R28's admission Record identified R28 was admitted in January of 2021, with the following diagnoses: retention of urine, history of bladder infections, and chronic kidney disease.
R28's 2/18/25, significant Minimum Data Set (MDS) identified R28's cognition was intact, she had no behaviors and was independent with cares. R28 had an indwelling catheter.
Review of R28's 3/10/21, care plan identified R28 had an indwelling catheter related to urinary retention. Staff were to place a leg bag on in the morning and a drain bag placed at night. Staff were to use enhanced barrier precautions, monitor and document intake and output per facility policy. Staff were to monitor signs and symptoms of pain due to the catheter and for signs of infection. There was no mention of how staff were to care for the Foley catheter or how often staff were to provide catheter care.
Interview on 3/3/25 at 11:24 a.m., with registered nurse (RN)-B confirmed that R28's care plan had no mention of providing catheter care and how frequently.
R42's admission Record identified R42 was admitted to the facility in August of 2024. R42 had the following diagnoses of type 2 diabetes mellitus, end stage renal disease, cirrhosis of liver, and history of traumatic fractures.
R42's 2/19/25, quarterly MDS assessment identified R42's cognition was intact. R42 was dependent on staff for most cares. R42 had some behaviors towards others and rejection of care. R42 took insulin daily, an antidepressant and antiplatelet daily. R42 attended dialysis.
R42's undated, care plan identified nutritional status as resident will consume 75% of meals and to modify diet as appropriate according to the resident's food tolerances and preferences. R42's care plan lacked identification that R42 was on dialysis, the location of an access site, any precaution that may be needed, or for any monitoring of an access site. The care plan lacked R42's dialysis schedule or where R42 attended dialysis.
R42's 3/4/25, Order Summary Report identified R42 was on a renal diet. The order summary lacked identification of dialysis access site monitoring and lacked dialysis schedule.
R1's Medical Diagnosis list from 3/3/25, identified R1 had a diagnosis of chronic atrial fibrillation and acquired coagulation factor deficiency.
R1's 12/17/24, significant change Minimum Data Set (MDS) assessment identified she admitted to the facility in September of 2024, her cognition was severely impaired and was dependent on staff for activities of daily living (ADL)'s. R1 was taking an anticoagulant.
R1's March 2025, administration record identified she was administered Warfarin daily. Administration record made no mention that staff should monitor for signs or symptoms of bleeding related to use of an anticoagulant.
Review of R1's undated care plan had no mention of anticoagulant use, signs or symptoms to watch for such as bleeding or bruising, or what and when to report to the nurse.
R7's 1/31/25, significant change Minimum Data Set (MDS) assessment identified her cognition was intact. R7 reported she had little interest or pleasure in doing things, she felt down and depressed, and had no energy nearly every day. R7 had physical impairments on both sides and was dependent on staff for ADL's. She had diagnosis of diabetes, dementia, anxiety, depression, pressure ulcer to the right buttock and right heal. R7 used antipsychotics and antidepressants on a routine basis, she used pain medication daily.
Continuous observation on 3/3/25, from 4:00 p.m. through 6:15 p.m.
4:00 p.m., R7 was seated in her wheelchair in the common/dining area at a table. She had pressure relieving boots on her feet the right boot extends to several inches below the knee, and the left boot was misplaced above the ankle, skin was visible below the boot. She had a cushion under her right elbow. Her legs were not elevated, her feet were on the floor and her chair did not have foot pedals. R7 had slid down in her chair and was leaning back with eyes closed.
4:19 p.m., R7 remained in her wheelchair, awake, and in the same position.
4:30 p.m., R7 remained in her wheelchair, awake, and in the same position. She stopped several staff to visit with them, however, none of the staff offered to reposition her and did not prompt her to adjust her position in her chair.
4:50 p.m., she remained in her wheelchair, in the same position. The facility social worker designee sat next to her, R7 complained that her wrist hurt.
4:58 p.m., staff offered R7 pain medication for her wrist.
5:21 p.m., a CNA brought a warm pack to R7 and placed it on her wrist. She did not offer to reposition her or encourage her to adjust her position in her chair.
5:24 p.m., Facility staff brought R7 her supper meal tray. R7 told staff she wanted to eat in her room, staff returned her tray to the cart.
5:28 p.m., staff are bringing her back to her room, R7's feet are dragging on the floor. They stop after about 20 feet and another staff assists by lifting her legs up and they bring R7 back to her room wheeling backwards. They were discussing that they cannot find the foot pedals for her wheelchair.
Interview at 5:30 p.m., with nursing assistant (NA)-D reported R7 had another wheelchair that is larger, however, she does not like to use it unless she is going out for an appointment. She reports that she delivered her room tray and that it was unusual that she was out in the common area as she normally stays in her room.
Observations continue:
5:35 p.m., R7 was in her room, she remained seated in her wheelchair. She was in front of her overbed table and had her meal tray in front of her.
5:55 p.m., staff entered R7's room, nursing assistants asked her if she was going to eat anything, R7 told staff to take her tray. nursing assistant offered other food options, R7 agreed to try some pudding. The staff left the room. The nursing assistant did not offer to reposition R7.
6:15 p.m., R7 remained in her room, seated in her wheelchair. Staff were in and out of her room several times, however, they did not offer to reposition her.
Interview on 3/3/25, at 6:15 p.m., With RN-B identified she was unsure how often R7 should be repositioned. She reviewed R7's care plan and identified she does not have scheduled repositioning. She reported she thought R7 had been up in her wheelchair since 1:00 p.m., she stated she had been out in the day room all afternoon. She identified that she would direct staff to reposition R7.
R7's 2/11/25, wound consultant note identified R7's skin to left and right heel is dark red, purple, blistered, and open. Open area to right heel medial is a stage 3, the area on the right heel is a deep tissue injury the right lateral foot is also a deep tissue injury, and the left heel is a deep tissue injury all are secondary to pressure. The wound consultant note identified that in addition to the current interventions in place staff were to implement scheduled repositioning every 2 hours.
Review of R7's undated care plan identified R7 had a pressure ulcer and staff should keep skin clean, monitor ulcer for signs of progression or declination, provide wound care per treatment order and encourage her to frequently shift weight. Staff should reposition R7 as she allows. The care plan made no mention of how often staff should reposition her.
Interview on 3/4/25 at 8:15 a.m., with medical director identified his expectation was that a resident receiving medications such as anticoagulants that the nursing staff would monitor for side effects, in addition he would expect residents who are at risk for or have a pressure ulcer would be repositioned or at minimum be offered repositioning on a scheduled basis.
R5's 122/25, Significant Change Minimum Data Set (MDS) identified was cognitively intact and was dependent on staff with cares and was incontinent of bowel and bladder. R5 had a diagnoses of atrial fibrillation, diabetes, anxiety, depression. R5 had a unhealed, unstageable deep tissue pressure ulcer that was present upon admission/entry or re-entry and was to receive surgical wound care and application of dressing to feet.
R5's, March Summary Report identified R5 was to cleanse the wound with normal saline, apply medihoney gel to both areas of the right foot and cover with foam dressing every 3 days and as needed.
R5's current, undated care plan identified:
1) R5 had stage 3 pressure ulcer, and the goal was to promote wound healing. Staff nurses were to measure pressure ulcers regularly, monitor for signs and symptoms of infection and provide wound care treatment.
2) R5 had a right foot big toe amputation, as well as skin impairment to the lateral (side) of the 5th digit of R5's right foot. Staff nurses were to apply Prevalon boots to R5's foot in bed and in wheelchair, and to use caution for transfers and mobility to prevent striking R5's arms, legs, and hands against sharp surfaces.
3) R5 was at risk for activities of daily living (ADLS) and the goal was to monitor for R5's improvement. R5 was to ask for assistance from staff if R5 required repositioning or elevation to meet R5's needs to prevent injury.
There was no mention on the care plan of R5's refusals of care or scheduled repositioning.
R26's 1/08/25, quarterly Minimum Data Set (MDS) identified R26 had a moderate cognitive impairment and had a diagnoses of diabetes, hypertension, arthritis, and seizures. R26 had orders for insulin and received insulin during the last 7 days of the look back period.
R26's, February Order Summary Report sheet identified R26's blood sugar was to be checked twice a day and was to receive glargine (long-acting insulin) 22 units subcutaneously (fatty layer between the skin and muscle) at bedtime.
R26's current, undated care plan made no mention in R26's care plan of diabetes management, as well as, protocols for hyperglycemia or hypoglycemia monitoring.
R37's 1/15/25, admission Minimum Data Set (MDS) identified R37 was cognitively alert and required substantial/maximal assistance with activities of daily living (ADLs). R37 had a diagnoses of malnutrition, anxiety, diabetes and cirrhosis. Upon admission, R37 had a stage 3 and stage 4 pressure ulcer and required non-surgical dressings to R37's bilateral feet.
R37's, March Order Summary identified:
1) bilateral heel wounds was to be cleansed with Vashe (wound cleanser), apply purocol plus to wound bed, cover with dry gauze, secure with kerlix and ace wrap every 2 days.
2) apply betadine swabsticks 10% povidone-Iodine to right plantar (bottom surface of the foot) daily.
R37's current, undated care plan identified R37 goal was to promote wound healing and staff nurses were to administer antibiotic therapy as prescribed and provide wound care treatments as ordered. There was no mention on the care plan of what wound care treatments was to be followed.
The facilities 11/30/21, Care Plans, Comprehensive Person-Centered policy identified the comprehensive person-centered care plan would describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being, and incorporate risk factors associated with identified problems. Assessments of residents are ongoing, and care plans are revised as information about the residents and residents condition change.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Food Safety
(Tag F0812)
Could have caused harm · This affected most or all residents
Based on observation, interview, and document review, the facility failed to ensure the ice machine, kitchen and food prep areas were kept clean and sanitary. This has the ability to affect all 56 res...
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Based on observation, interview, and document review, the facility failed to ensure the ice machine, kitchen and food prep areas were kept clean and sanitary. This has the ability to affect all 56 residents.
Findings include:
Observation and interview on 2/25/25 at 7:15 a.m., during the initial kitchen tour a stainless-steel food prep counter across from the stove had a lower shelf directly below. The lower shelf was used to store cutting boards, oatmeal, oil, cooking spray, and small cups used for serving condiments. The shelf had a dry black/brown substance on it and a brown liquid substance covering a large area of the shelf. In addition, approximately the first 3-5 inches from the edge of the shelf nearest to the stove and covering the full length of the shelf had a greasy, sticky build-up. The area had dirt and grime stuck to the greasy area. The shelf had a plastic container containing condiment cups, the container was visibly dirty with unknown brown substance. Food crumbs could be seen laying in the bottom of the container.
On 2/25/25 at 4:45 p.m., during a follow up observation of the kitchen, identified cook-C was sitting on the freezer using her cellular phone.
Interview on 2/25/25 at 4:45 p.m., with cook-C agreed with the above finding and identified they were not supposed to be sitting on the freezer as this area was at times used to set food on, in addition she identified they were not supposed to use their cell phones in the kitchen as this could be a source of cross contamination.
Interview on 2/26/25, at 10:28 a.m., with the dietary manager (DM), she agreed with the concerns regarding the cleanliness of the kitchen, she identified that staff are signing off that they completed the cleaning, she reported that she may need to do some re-training with staff and she may have to be more specific on her cleaning logs as to what staff are expected to clean.
Interview on 3/3/25 at 4:45 p.m., with the registered dietitian (RD), identified she would expect staff to only use their cell phone while on break and in the staff break room. Personal items such as cell phones should be left in a locker and not brought into the kitchen. She identified this practice could potentially cause cross contamination with food. In addition, she would not expect staff to use the chest freezer as a seating area. She identified that she has not completed any visual audits of the kitchen and was not aware of the lack of cleanliness. She would expect the dietary manager to be auditing regularly and ensuring the daily cleaning is completed properly.
Observation on 2/26/25, at 8:40 a.m., of the ice machine located in a hallway connecting the main building with a house where offices were located. The ice machine had a white crusty buildup (like mineral deposits) visible from the outside of the machine located between the plastic hinged lid/door and the machine. inside the door at the top of the opening just above the ice bin, a strip of metal had a black/gray/brown spotty build up going all the way across. Some of the buildup was removable with a dry paper towel and friction rubbing the area.
Interview on 2/25/25 at 8:40 a.m., with the Maintenance director identified he had been working in the building since last fall when they closed the other facility. He reported he does not keep a log of when he cleans and de-scales the ice machine, when it comes up in tells I clean it. He cleans it about every 6 months and does a deep clean about once a year. He reported it had been de-scaled last August of 2024 and cleaned a little before thanksgiving.
Review of the Manitowok Indigo Ice Machine Manufacturer Installation, Use, and Care Manual identified the ice machine should be cleaned and sanitized every 6 months.
Review of the General Sanitation of Kitchen policy identified the kitchen cleaning schedule with be outlined in writing, tasks will be assigned to the responsibility of a specific position, frequency of cleaning for each task will be defined. Employees will initial, and date when the task was completed.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0837
(Tag F0837)
Could have caused harm · This affected most or all residents
Based on interview and document review, 1 of 1 Governing Body failed to provied appropriate oversight to ensure deficient practice had been corrected and coompliance achieved.
Refer to F636, F656, F6...
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Based on interview and document review, 1 of 1 Governing Body failed to provied appropriate oversight to ensure deficient practice had been corrected and coompliance achieved.
Refer to F636, F656, F684, F758, F812, F842, F865, F880, F882, and F944.
Findings include:
Review of the QAPI meeting minute attendance from the 3/25/25 QAPI Meeting (meetings are held monthly) identified attendees present were the administrator, the director of nursing (DON) the assistant director of nursing (ADON), the infection preventionist (IP) the social services designee (SSD) and the pharmacist. The medical director was absent for this meeting. During the meeting, topics discussed were as follows:
1) Pressure Ulcers: There were 14 active pressure ulcers involving 5 residents. The facility goal was to have 5% pressure ulcer rate. Current facility percentage was left blank. After discussion, actions present were the facility was working on care plans and turning and repositioning, working on healing wounds. There was no measurable action or presentation of evaluation of the data to define commonalities such as where pressure ulcers were located on residents, possible causes, co-morbidities, areas for improvement, or potential education to staff or audits that should occur in order to achieve compliance.
2) Falls: There were a total of 16 falls in February. 2 documented minor injuries. There was no goal or current facility percentage listed. Actions identified were staff reviewed all care plans (CP) causative factors were reviewed. Isolation was a top contributor; however possible urinary tract infections (UTI) were noted as well. Staff were still looking at R1 t see if she could be care planned to safe transfers from bed in the lowest position as it seemed to be when she had been found on the floor. It was not plausible at that time. No other factors were identified or discussed such as time of day, residents requiring increased supervision, staff competence with transfers etc.
3) Infection control and antibiotic stewardship: There was no facility goal or current benchmark listed. There were 39 active cases of infection the previous month with 22 respiratory (26 new) with COVID, pneumonia, and RSV identified. 4 UTI, 1 case of bone infection, and 2 others noted but not identified. Actions taken were to continue isolation and testing and keeping residents on droplet precautions. It was noted they were working on getting the IP classes in infection control and surveillance, working on appropriate personal protective equipment (PPE) audits and handwashing. It was noted to continue for the foreseeable future There was no indication it had been discussed how the facility was to ensure the IP had received time to complete her training, who was in charge of oversight until that occurred, or how the facility was to achieve their goal or what education may be needed or evaluation of actions already in progress.
4) Plan of correction (deficiencies from the previous survey): Auditing for compliance with previous deficient practice had begun. Another area identified was regarding psychotropic diagnosis. Actions identified QAPI was to create/locate resources for training that could be implemented within the organizational structure. A few residents need to have their diagnoses reviewed and updated to ensure they had the appropriate diagnoses. There was no indication to identify any goals, or plans of action noted as to how the facility was going to achieve compliance, who was designated to oversee compliance of certain areas, or how they would achieve compliance noted as discussed.
5) Open positions: There were 20 positions open. There was no facility goal or current status noted, nor was there any discussion of how QAPI would work toward filling positions. There was also no mention of how staff shortages were affecting care at the facility, if staffing was being maintained according to positions noted to be required in the facility assessment in order to care for residents, or if the shortages had affected other areas such as the high number of pressure ulcers or resident falls etc
6) Grievances/Abuse reporting: 2 grievances were noted for call light response, 3 involving cares, 1 for environment, and 1 for diet. Actions noted were:
a) A call light audit was run, and education was to continue with staff. Audits showed an average of a 10-minute response time, however, there was no indication staff had observed call lights to ensure the electronic data was accurate and staff were not simply shutting off the light. 1 family reported the light was on for an extended time and made her worry that if it was related to something serious, the resident could have a poor outcome. There was no indication what was an acceptable call light wait time was, how long or what the results identified were, or it the long wait times could have been a result of a lack of staff availability.
b) Cares: A family felt care wasn't being provided to their standards. The care plan was changed to reflect requests. 1 resident felt staff treated her differently as she must wait longer for care. A meeting was held with family and the county case worker. Another family had voiced concerns over staff knowledge.
c) Diets: A resident continued to be served food that are listed as foods she can't have. Staff had been educated and signed an understanding of the food identified. There was no indication QAPI identified competencies may be warranted if this was an ongoing issue.
d) Antipsychotic Use: The facility goal was to have no more than 15%. there was no indication on what the present percentage was. Discussion: there was roughly 21% of antipsychotic medications used in the facility. Information was presented to the assistant DON (ADON) by the pharmacist (RPh). The notes included the last gradual dose reduction (GDR) and when drugs had been started. This was noted to help the MDS and keeping things more organized. There was no indication staff had reviewed deficiency related information regarding to correct diagnoses or if the pharmacist had reviewed all residents affected as part of his contractual service.
e) Other areas: were noted in QAPI for Adverse events, resident immunizations, abuse allegations etc. Those areas also lacked thorough analysis of data.
f) Emergency Meeting: Discussion was left blank. Action identified were each tag cited for the recertification survey previous to this survey. Audits were noted to be going forward from that point on to identify deficient practice. No staff were designated to make sure actions identified by the facility had been completed, residents identified or found to be at risk reviewed etc. QAPI identified the QAPI program deficiency cited needed to be more cognizant about documentation that reflects accuracy; however, no plan had been placed to ensure its completion by 4/3/25 (the completion date listed on the plan of correction) would occur.
Interview and document review on 4/8/25 at 1:02 p.m., with the administrator identified he indicated the QAPI committee met to discuss the results of their previous survey. He had not provided oversight himself, as the regional nurse consultant was responsible to write the POC and determine what steps were necessary to ensure compliance. He noted the facility had such a short window to get deficient practice corrected. He was unaware the DON and ADON had not ensured the IP had time to complete her education to be able to oversee the infection control (IC) program independently, nor was he aware the DON and ADON were not providing direct oversight of the program until the IP was trained and deemed competent. The administrator also agreed he was ultimately responsible to ensure staff such as the director of nursing (DON), had provided the appropriate oversight to ensure all items identified in their POC were implemented to correct the deficient practice. The facility had educated staff to the policies, but agreed meaningful education and competencies to check staff had understood the education and applied it correctly had not occurred. He also had not ensured staff were educated to what the facility's specific QAPI plans, and monitoring was, nor had he ensured they were educated to the QAPI 's new PIP programs. He identified the facility was planning to change how they did QAPI to ensure they could be compliant with analyzing data, and providing oversight of any deficient practice, education, etc., but that had not occurred yet.
Review of the 1/29/25, QAPI Policy identified the facility was to maintain a QAPI committee for continuous quality improvement and overall performance. One of QAPI's objectives was to establish and implement plans to correct deficiencies, and to monitor the effects of these actions plans on resident outcome. The governing body shall be ultimately responsible for the QAPI program.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0838
(Tag F0838)
Could have caused harm · This affected most or all residents
Based on interview and document review the facility failed to implement 1 of 1 facility assessment protocol related to ensuring staff competencies were identified and completed respective to staff dut...
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Based on interview and document review the facility failed to implement 1 of 1 facility assessment protocol related to ensuring staff competencies were identified and completed respective to staff duties performed. This has the ability to affect all 56 residents.
Findings include:
Interview on 3/04/5 at 8:15 a.m., with medical director voiced agreement the facility was to review, identify and determine appropriate interventions and oversight of outcomes brought forth
Interview on 3/04/25 at 2:26 p.m., with administrator identified the merge of two nursing homes, that included residents and staff, added an extra layer of challenges the facility was currently navigating. He identified updates of the facility assessment, had not yet been implemented, including staff education. However, He identified there was decisions made in relation to resident cares, resources and services that were to relay to all staff the facility's operational goals and performance improvement projects (PIP).
Review of August 2024 Facility Assessment Tool identified the leadership team would discuss goals to ensure direct care staff are trained to provide services to residents. The facility identified staff education, training, certifications, testing, and facility policies to support the care needed for the residents. In addition, the facility would gather input from residents, family members and staff of concerns and expectations that would meet residents needs through regulatory, operational, maintenance and staff training requirements. Lastly, the facility would review resources annually, and would evaluate day to day operations, including emergencies, to identify and act on opportunities for improvement and to ensure residents care maintain their highest practicable physical, mental and psychosocial well-being.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0865
(Tag F0865)
Could have caused harm · This affected most or all residents
Based on interview and document review, the facility failed to ensure data submitted to 1 of 1 Quality Assurance Performance Improvement (QAPI) committee was analyzed and documented to ensure areas id...
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Based on interview and document review, the facility failed to ensure data submitted to 1 of 1 Quality Assurance Performance Improvement (QAPI) committee was analyzed and documented to ensure areas identified had oversight for their perspective outcomes brought forth. This had the potential to affect all 56 residents.
Findings include:
Review QAPI minutes from February 2024 through January 2025, identified department heads were bringing data forth to QAPI on various topics such as infection control, falls, incident reports, vaccinations, etc. However, there was no documented benchmarks for goals the facility was trying to achieve, nor monitoring to determine if goals were met or QAPI needed to continue monitoring to ensure compliance.
Interview on 3/04/5 at 8:15 a.m., with medical director voiced agreement the facility was to review, identify and determine appropriate interventions and oversight of outcomes brought forth.
Interview on 3/04/25 at 2:09 p.m., with administrator identified the merge of two nursing homes, that includes residents and staff, added an extra layer of challenges the facility was currently navigating. He identified there was no measurable goals set, or if goals were met to improve areas identified in QAPI. He and the QAPI committee would need to formalize a process to identify improvements that would reflect changes as needed in QAPI.
Review of December 20219 Quality Assurance and Performance Improvement (QAPI) policy identified the facility would review clinical and nonclinical systems to determine areas of improvement. The facility's performance improvement project (PIP) was identified in areas that were unique to the facility's needs. The QAPI committee would establish benchmarks to determine facility improvements, analyze data for accuracy and determine root cause. Lastly, the QAPI committee would modify QAPI template, as well as the facility assessment as needed to identify complexities and/or evolving resources and services.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
QAPI Program
(Tag F0867)
Could have caused harm · This affected most or all residents
Based on interview and document review, the facility's Quality Assurance and Performance Improvement (QAPI) committee failed to identify facility specific concerns, implement an action plan to correct...
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Based on interview and document review, the facility's Quality Assurance and Performance Improvement (QAPI) committee failed to identify facility specific concerns, implement an action plan to correct the identified concerns or to ensure the committee participated in the development and oversight of implementation of systems, and to ensure quality of life and quality of care were maintained for 57 residents residing in the facility.
Findings include:
Review of QAPI minutes from February 2024 to January 2025, identified on 4/19/24 the facility was to implement a performance improvement project (PIP) of abuse allegations. There was no mention on how the facility would meet goals, monitor progress or evaluate current measures to ensure compliance.
Interview on 3/04/5 at 8:15 a.m., with medical director voiced agreement the facility was to review, identify and determine appropriate interventions and oversight of outcomes brought forth.
Interview on 3/04/25 at 2:26 p.m., with administrator identified the merge of two nursing homes, that includes residents and staff, added an extra layer of challenges the facility was currently navigating. He identified there were challenges and improvements related to resident cares, resources and services to be streamlined and identified in QAPI. He identified the facility had no performance improvement projects in place at this time.
Review of December 20219 Quality Assurance and Performance Improvement (QAPI) policy identified the facility would review clinical and nonclinical systems to determine areas of improvement. The facility's performance improvement project (PIP) was identified in areas that were unique to the facility's needs. The QAPI committee would establish benchmarks to determine facility improvements, analyze data for accuracy and determine root cause. Lastly, the QAPI committee would modify QAPI template, as well as the facility assessment as needed to identify complexities and/or evolving resources and services.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected most or all residents
Based off document and interview, the facility failed to ensure 1 of 1 resident (R41) with a highly infectious disease (Hepatitis C) was placed into the infection control (IC) surveillance data for mo...
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Based off document and interview, the facility failed to ensure 1 of 1 resident (R41) with a highly infectious disease (Hepatitis C) was placed into the infection control (IC) surveillance data for monitoring. In addition, the facility failed to ensure oversight of the IC program was maintained for tracking, trending, and analysis of data to prevent potential spread of infection. The facility also failed to include staff return to work information in surveillance to identify if they were appropriately vetted before their return for 1 of 3 months (January 2025) reviewed. This has the potential to affect all 56 residents.
Findings include:
R41's face sheet identified he was admitted to the facility in September 2024. R41 had a recent hospital stay 11/4/24 through 11/6/24 and had diagnoses of hypoparathyroidism (parathyroid glands do not produce enough parathyroid hormone and treated with medication), history of a lumbar spinal fracture, right leg fracture, right artificial hip, hypothyroidism (thyroid gland does not produce enough thyroid hormone), generalized anxiety disorder, and multiple fractures of ribs.
R41's 11/25/24, quarterly Minimum Data Set (MDS) identified R41 was admitted to the facility (from the now closed sister facility) in September 2024. R1 was noted to have delusions with no behaviors identified.
R41's 11/19/24, physician progress note identified the PCP noted additional diagnoses from the previous visit of chronic hepatitis C.
R41's current, undated care plan identified there was also no mention of his Hepatitis C diagnosis.
Review of the surveillance for February and March identified infections were getting logged into the tracking system in the facility electronic medical records system (Point Click Care (PCC) by facility staff. R41 was not listed as being included in surveillance for his diagnosis of Hepatitis C.
Review of the facility's previous revisit directed plan of correction for a deficiency cited in January 2025 identified the facility was to have contracted with a contracted infection preventionist (CIP). The contract began 2/17/25, The CIP was to have begun working immediately with the facility in assisting with the root cause analysis of the program related to the deficient practice, review the program as a whole, review the plan of correction, and support the facility in developing audit tools.
Interview on 3/3/25 at 11:00 a.m., with the administrator identified the infection preventionist was out on medical leave and registered nurse (RN)-B was to oversee the program in her absence.
Interview on 3/3/25 at 2:15 p.m., with RN-B identified she was never told to assist in oversight of the IC program. She had no knowledge of what was being inputted into the PCC program for tracking infections.
Review of the employee line listings for December 2024 through February 2025 identified in January, 2025, there were 3 staff illnesses reported. The symptoms resolved category and the return to work column were left blank. Illnesses recorded were coughs, fever, and abdominal pain. During follow-up email correspondence with the director of nursing (DON) on 3/4/25, The DON had to check with payroll for 2 staff, however she was also listed as having been ill that month. She noted she had forgot to put in her return to work date into the IC surveillance. The DON agreed all data needed to be inputted to ensure illnesses were tracked and staff were kept off work for the appropriate amount of time.
Interview on 3/03/25 at 5:37 p.m., with the DON identified the IP was off work beginning right after the State Agency revisit on 2/14/25. They had not had a meeting with a consultant until last week. The CIP had not yet reviewed or provided assistance with the IC program. The DON agreed R41's Hepatitis C was a highly infectious disease and should be on the surveillance. The facility had no one to cover IC during the IP continued absence. The facility had only first spoken to the hired consultant last week. They did not have a plan to cover the IP while on medical leave. Agreed IC needed appropriate oversight at all times to review data.
Interview on 3/4/25 at 8:16 a.m. with the medical director (MD)-A identified he was unaware that facility had no active IP due to medical leave and no staff had replaced her. He agreed the IC program required direct oversight. He was also unaware the CIP was not advised of the facility's inability to designate an IP in IP-A's absence. R41's Hepatitis C should be included on the facility's surveillance as it is a highly infectious disease.
There was no policy related to oversight of the IC program provided by the end of survey.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0882
(Tag F0882)
Could have caused harm · This affected most or all residents
Based off document and interview, the facility failed to ensure oversight of the IC program was maintained to provide appropriate oversight for tracking, trending, and analysis of data to prevent pote...
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Based off document and interview, the facility failed to ensure oversight of the IC program was maintained to provide appropriate oversight for tracking, trending, and analysis of data to prevent potential spread of infection. This had the ability to affect all 56 residents.
Based off document and interview, the facility failed to ensure 1 of 1 resident (R41) with a highly infectious disease (Hepatitis C) was placed into the infection control (IC) surveillance data for monitoring. In addition, the facility failed to ensure oversight of the IC program was maintained for tracking, trending, and analysis of data to prevent potential spread of infection. The facility also failed to include staff return to work information in surveillance to identify if they were appropriately vetted before their return for 1 of 3 months (January 2025) reviewed. This has the potential to affect all 56 residents.
Findings include:
R41's face sheet identified he was admitted to the facility in September 2024. R41 had a recent hospital stay 11/4/24 through 11/6/24 and had diagnoses of hypoparathyroidism (parathyroid glands do not produce enough parathyroid hormone and treated with medication), history of a lumbar spinal fracture, right leg fracture, right artificial hip, hypothyroidism (thyroid gland does not produce enough thyroid hormone), generalized anxiety disorder, and multiple fractures of ribs.
R41's 11/25/24, quarterly Minimum Data Set (MDS) identified R41 was admitted to the facility (from the now closed sister facility) in September 2024. R1 was noted to have delusions with no behaviors identified.
R41's 11/19/24, physician progress note identified the PCP noted additional diagnoses from the previous visit of chronic hepatitis C.
R41's current, undated care plan identified there was also no mention of his Hepatitis C diagnosis.
Review of the surveillance for February and March identified infections were getting logged into the tracking system in the facility electronic medical records system (Point Click Care (PCC) by facility staff. R41 was not listed as being included in surveillance for his diagnosis of Hepatitis C.
Review of the facility's previous revisit directed plan of correction for a deficiency cited in January 2025 identified the facility was to have contracted with a contracted infection preventionist (CIP). The contract began 2/17/25, The CIP was to have begun working immediately with the facility in assisting with the root cause analysis of the program related to the deficient practice, review the program as a whole, review the plan of correction, and support the facility in developing audit tools.
Interview on 3/3/25 at 11:00 a.m., with the administrator identified the infection preventionist was out on medical leave and registered nurse (RN)-B was to oversee the program in her absence.
Interview on 3/3/25 at 2:15 p.m., with RN-B identified she was never told to assist in oversight of the IC program. She had no knowledge of what was being inputted into the PCC program for tracking infections.
Review of the employee line listings for December 2024 through February 2025 identified in January, 2025, there were 3 staff illnesses reported. The symptoms resolved category and the return to work column were left blank. Illnesses recorded were coughs, fever, and abdominal pain. During follow-up email correspondence with the director of nursing (DON) on 3/4/25, The DON had to check with payroll for 2 staff, however she was also listed as having been ill that month. She noted she had forgot to put in her return to work date into the IC surveillance. The DON agreed all data needed to be inputted to ensure illnesses were tracked and staff were kept off work for the appropriate amount of time.
Interview on 3/03/25 at 5:37 p.m., with the DON identified the IP was off work beginning right after the State Agency revisit on 2/14/25. They had not had a meeting with a consultant until last week. The CIP had not yet reviewed or provided assistance with the IC program. The DON agreed R41's Hepatitis C was a highly infectious disease and should be on the surveillance. The facility had no one to cover IC during the IP continued absence. The facility had only first spoken to the hired consultant last week. They did not have a plan to cover the IP while on medical leave. Agreed IC needed appropriate oversight at all times to review data.
Interview on 3/4/25 at 8:16 a.m. with the medical director (MD)-A identified he was unaware that facility had no active IP due to medical leave and no staff had replaced her. He agreed the IC program required direct oversight. He was also unaware the CIP was not advised of the facility's inability to designate an IP in IP-A's absence. R41's Hepatitis C should be included on the facility's surveillance as it is a highly infectious disease.
There was no policy related to oversight of the IC program provided by the end of survey.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0944
(Tag F0944)
Could have caused harm · This affected most or all residents
Based on interview and document review, the facility failed to provide mandatory training on 1 of 1 facility specific Quality Assurance Performance Improvement (QAPI) Program to include goals and vari...
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Based on interview and document review, the facility failed to provide mandatory training on 1 of 1 facility specific Quality Assurance Performance Improvement (QAPI) Program to include goals and various elements of the program, how the facility intends to implement the program, staff's role in the facility's QAPI program, or how to communicate concerns, problems, or opportunities for improvement to the facility's QAPI program. This had the ability to affect all 57 residents.
Findings include:
Interview on 3/03/25 at 2:58 p.m., with Registered nurse (RN)-B and RN-D identified the facility held scheduled meetings for residents and staff. Both RN-B and RN-D had not attended QAPI meetings and was not aware of any facility specific performance improvement projects.
Interview on 3/03/25 at 3:04 p.m., with admission coordinator identified the facility plan was to prevent further infection control outbreaks related to COVID and respiratory syncytial virus (RSV).
Interview on 3/03/25 at 3:09 p.m., with licensed practical nurse (LPN)-A identified she was not aware of QAPI meetings held and/or specific QAPI goals.
Interview on 3/03/25 at 4:10 p.m., with RN-A identified she was aware the facility had monthly QAPI meetings and had not attended them. There were care areas and services the facility would need to address, but she could not identify any specific QAPI goals the facility had in place.
Interview on 3/03/25 at 4:23 p.m., with nursing assistant (NA)-A identified she has attended QAPI meetings, in the past, if her schedule allowed, but was not aware of any QAPI goals the facility was monitoring.
Review of email correspondence on 3/04/24 at 9:15 a.m., with director of nursing identified there was no formal education for employees of QAPI training.
Interview on 3/04/25 at 2:09 p.m., with administrator identified the facility provided QAPI education to staff upon employment and would work towards formalizing QAPI requirements for all employees going forward.
Review of December 20219 Quality Assurance and Performance Improvement (QAPI) policy identified the facility would review clinical and nonclinical systems to determine areas of improvement. The facility's performance improvement project (PIP) was identified in areas that were unique to the facility's needs. The QAPI committee would establish benchmarks to determine facility improvements, analyze data for accuracy and determine root cause. Lastly, the QAPI committee would modify QAPI template, as well as the facility assessment as needed to identify complexities and/or evolving resources and services.
Employee QAPI training was requested and not provided during survey.
Jan 2025
1 deficiency
1 IJ (1 facility-wide)
CRITICAL
(L)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Immediate Jeopardy (IJ) - the most serious Medicare violation
Infection Control
(Tag F0880)
Someone could have died · This affected most or all residents
⚠️ Facility-wide issue
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and document review the facility failed to implement infection control strategies for respirato...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and document review the facility failed to implement infection control strategies for respiratory protection to mitigate the risk and spread of Respiratory Syncytial Virus (causes infections of the respiratory tract) (RSV). As a result, the facility developed an outbreak where 13 residents (R4, R10, R5, R1, R14, R3, R2, R7, R8, R15, R13, R16, and R12) tested positive for RSV, and 7 residents were suspected to have RSV (R17, R19, R18, R21, R20, R6, R9); 3 residents (R4, R5, and R10) had to be seen in the emergency room, and 2 residents (R7, and R8) were hospitalized with RSV. These practices resulted in an immediate jeopardy (IJ) due to the likelihood of spread to the remaining 48 residents in the facility.
The IJ began on 12/28/24, when the facility failed to implement infection control strategies to mitigate the risk and spread of RSV in the facility. The Administrator, director of nursing (DON) (by phone), clinical nurse consultant (CNC)-A (by phone), Infection Preventionist (IP)-A, clinical manager (CM)-A, and assistant DON (ADON) were notified of the IJ on 1/14/24 at 5:37 p.m. The immediate jeopardy was removed on 1/15/25 at 2:49 p.m., but noncompliance remained at the lower scope and severity level F, which indicated no actual harm with the potential for more than minimal harm that is not immediate jeopardy.
Finding include:
Isolation: Isolation separates sick people with a contagious disease from people who are not sick. Quarantine separates and restricts the movement of people who were exposed to a contagious disease to see if they become sick.
Personal protective equipment (PPE): Personal protective equipment (PPE) refers to protective items or garments worn to protect the body or clothing from hazards that can cause injury and to protect residents from cross-transmission. These items may include a gown, gloves, eye protection and face mask.
Enhanced barrier precautions (EBP): refer to an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employs targeted gown and glove use during high contact resident care activities. Gowns and gloves are used as PPE.
Transmission based precautions (TBP): refer to actions (precautions) implemented in addition to standard precautions that are based upon the means of transmission (airborne, contact, and droplet) in order to prevent or control infections. Airborne, contact and droplet are the three subcategories under TBP.
Contact precautions: refer to measures that are intended to prevent transmission of infectious agents which are spread by direct or indirect contact with the resident or the resident's environment. Use with gloves, and gowns as PPE.
Droplet precautions: refer to actions designed to reduce/prevent the transmission of pathogens spread through close respiratory or mucous membrane contact with respiratory secretions, masks are used as PPE.
During an observation and interview on 1/10/25 at 8:30 a.m., registered nurse clinical manager (RNCM)-A stated the facility had Respiratory Syncytial Virus (RSV) and instructed staff to wear surgical masks. No signs were posted in the foyer or entrance area to alert visitors to wear a mask in facility. Fifteen residents were sitting in the dining room with 3-4 residents sitting at each table. No masks were on the residents. The facility staff were masked with surgical masks. Upon entrance to the dining room an unidentified nursing assistant (NA) moved the mask from under his chin to cover his nose and mouth while walking between residents.
During an interviews on 1/10/25 at 2:06 p.m., infection Preventionist (IP)-A stated the first case of RSV was identified on 12/28/24 (R4) and had a total of seven positive cases to date with a new case identified today 1/10/25 (R2).
R4 RSV positive on 12/28/24
R4's medical diagnoses dated 1/16/25, identified congestive heart failure (heart cannot pump blood well enough to meet the body's needs), and dependence on supplemental oxygen.
R4's hospital ED note dated 12/28/24, identified R4 was seen due to cough and shortness of breath. R4 had known chronic obstructive pulmonary disease (COPD) and may have a COPD exacerbation. R4's ED identified RSV test was positive and likely the cause of the COPD exacerbation.
There was no indication in the medical record, R4 was placed on isolation precautions (Droplet, contact precautions) with PPE upon return from the ED, even though they were diagnosed with RSV.
R4's progress note dated 1/6/25, identified R4 had complained of coughing up small amounts of blood clots. Examined the clots to be mucous clots tinged with blood related to R4's harsh cough. The progress note identified R4 was off isolation precautions for RSV today however, the record did not identify precautions had been implemented.
R4's progress note dated 1/9/25, identified R4 needed oxygen at 2 liters/min for shortness of breath with activity. R4's physician orders identified had an order for as needed oxygen. R4's medication administration record identified in December oxygen was used eleven times and in January used on 1/5/25, 1/9/25, and 1/13/25.
R4's progress notes dated 1/10/25, identified R4 stated that every time he breathed in it makes him cough and lung sounds with crackles. At 5:30 a.m. R4 was transferred to the hospital due to non-stop coughing. At 1:30 p.m. R4 returned from hospital with diagnoses of RSV, that had continued from 12/28/24.
R4's progress note dated 1/13/25, identified R4's cough was at baseline and will be removed from droplet precautions. R4's record did not identify precautions had ever been implemented.
R4's respiratory symptom screeners between 1/11/25-1/15/25, identified R4 had a cough on all days between 1/12/25 through 1/15/25.
R10 RSV positive on 12/31/25
R10's face sheet dated 1/15/25, identified diagnoses of hypoxemia (low oxygen) and diabetes.
R10's progress notes identified the following:
-12/28/24, R10 did not feel well and was coughing.
-12/30/24, R10 required nebulizer treatment for wheezing.
-12/31/24, indicated R10 had adventitious lung sounds, pain when breathing, nasal congestion, left ear pain, and cough. R10 was sent to the emergency department (ED).
R10's ED note dated 12/31/24, identified R10 was positive for RSV and diagnosis of acute bronchiolitis (inflammation of bronchi in the lungs) due to RSV. R10 came to ED with complaints of a cough and feeling ill for more than 10 days and getting worse. R10 stated the cough occurred constantly and had been gradually getting worse.
R10's progress note dated 12/31/24, identified ED called facility to notify of positive RSV test. Isolation precaution sign and tray/cart for personal protective equipment (PPE) was set up. Vital signs obtained on return from ED.
R10's physician visit note dated 1/9/25, identified R10 continued with a persistent cough after RSV infection and will be taken off isolation today. Increased Duo Neb to three times daily for 7 days.
R10's respiratory assessments between 1/11/25 through 1/4/25, identified R10 had diminished lung sounds on 1/12/25.
R10's record reviewed between 12/28/24 through 1/13/25, identified R10 had respiratory illness symptoms that began on 12/28/24. R10's record and facility surveillance did not identify immediate implementation of TBP (transmission based precautions) nor ongoing consistent symptom monitoring between 12/28/24 through 1/10/25.
R5 RSV positive on 1/2/25
R5's face sheet dated 1/16/25, identified diagnoses of diabetes mellitus type 2, and chronic kidney disease (condition where kidneys have been damaged).
R5's progress note dated 12/26/24, identified R5 complained of an irritated throat. R5 was given cough drop and cough syrup. R5's progress note did not identify a respiratory assessment or vital testing was done.
R5's progress note dated 12/28/24, identified R5 complained of throat irritation but did not indicate if a respiratory assessment, viral testing or provider was notified.
R5's progress note dated 1/1/25, identified R5 went to clinic appointment to have an medication injection and on 12/31/24, R5 was transported by a medical van service to location where had unknown labs drawn. R5's record did not identify if R5 was provided with a mask during transport.
R5's progress note dated 1/2/25, identified R5 complained of sore throat, congestion, runny nose and wheezing in lungs. COVID-19 test performed and negative results. Primary care provider was notified and ordered RSV test which was completed and sent to the clinic for results.
R5's laboratory report dated 1/3/25, identified positive RSV test completed on 1/2/25.
R5's progress note dated 1/3/25, identified R5's RSV test was positive. There was no indication that isolation/precautions were initiated even though R5 was positive for RSV.
R5's progress note dated 1/7/25, identified R5 went to an outside appointment and was transported by a medical van service at 7:30 a.m. and returned to facility around noon. There was no indication that transportation service or outside appointment facility were aware of R5's RSV diagnosis to prevent the spread of infection.
During an observation on 1/10/25 at 1:49 p.m., R5 was sitting alone at a table in the activity in the dining area playing bingo without a mask on. R5 coughed six times without a mask on and did not cover his mouth or sanitize his hands after coughing. R5's cough was wet/productive. There were ten other residents were in the area also playing bingo at tables spaced approximately 4-6 feet apart, one resident passed approximately 1-2 feet directly by R5.
R5's progress note dated 1/10/25 at 7:31 p.m., identified R5 had worsening respiratory symptoms and increasing worsening cough. R5 had bilateral wheezes. R5 stated he has not gotten better and feels worse. Resident requested to be seen in the emergency department for evaluation (ED)
R5's emergency department (ED) note dated 1/10/25 at 8:15 p.m., identified diagnoses of subacute cough. Presented to ED with dry cough. R5 was given breathing treatment and returned to the facility.
During an interview on 1/10/25 at 1:52 p.m., LPN-A stated R5 just came out of isolation this week for RSV, however unable to give specific date he was removed. LPN-A was not sure how it was determined that residents could be removed from isolation and was unsure when R5 tested positive. LPN-A reviewed R5's record and verified R5 tested positive on 1/2/25 and was on isolation for 7 days.
During an interview on 1/10/25 at 1:52 p.m., RN-A stated staff would monitor residents for symptoms of RSV through a cough and how they sound. They would be under precautions for seven days and then no longer were infectious.
R1-positive on 1/3/25
R1's face sheet dated 1/15/25, identified R1 had diagnoses that included diabetes mellitus type 2.
R1's record between 12/31/24 through 1/3/25 did not identify respiratory symptoms screening was completed.
R1's progress note dated 1/3/25, identified R1 was having a non-productive cough worsening throughout the day, complained of not feeling well in her chest, and had a hoarse voice. R1 was tested for RSV. At 9:10 p.m., R1's lab test returned positive for RSV. Sign placed and staff will wear PPE. The progress note did not identify what type of precautions were implemented nor identify if isolation was implemented on 1/3/25.
R1's progress notes dated 1/5/25 and 1/10/25, identified R1 went out to an appointment with a medical van transporting on 1/3/25 for wound care. R1's record did not identify if R1 wore a mask during the transport or if the wound clinic was informed of R1's positive test results.
R1's progress note dated 1/11/25, identified R1 was on isolation precautions and slept well.
R1 did not include respiratory assessments and monitoring were completed from 1/3/25-1/10/25 for RSV, even though the facility had several residents with RSV.
R1's respiratory assessments were completed once on 1/11/25, 1/14/25, and 1/15/25. Completed four times on 1/12/25, and twice on 1/13/25. The assessments identified on 1/11/25, R1 had a dry non-productive cough and shortness of breath. On 1/13/25 and on 1/14/25, R1 had wheezes throughout lung lobs.
During an observation on 1/10/25 at 10:13 a.m., R1 had two signs outside of her room, contact precautions and EBP (enhanced barrier precautions). Staff entered R1's room with no PPE on to transport her to the medical van for an appointment. R1 agreed to wear a mask when exiting room.
During an interview on 1/10/25 at 9:13 a.m., licensed practical nurse (LPN)-A stated R1 had two precaution signs outside of her room, contact was for the RSV and EBP was for her wound. LPN-A could not articulate the difference between contact and EBP precautions. LPN-A stated R1 would be finishing contact precautions today, 1/10/25. LPN-A was unsure of the exact date R1 tested positive. LPN was aware of R1 still having a cough because R1 was getting over RSV.
R14 RSV positive on 1/3/25
R14's face sheet dated 1/19/25, identified diagnoses of Parkinson's disease and congestive heart failure.
R1's record between 12/28/24 through 1/3/25 did not identify respiratory symptom screening was completed, even though the facility had several residents with RSV.
R14's progress note dated 1/3/25 at 2:48 p.m., identified R14 was not feeling well, poor appetite, lethargic, and weakness. Physician sent orders to test residents that are symptomatic for RSV; R14 tested positive for RSV. R14's record did not indicate TBP, and isolation were immediately implemented.
R14's progress note dated 1/7/24 identified R14 had all meals in their room and continued to receive therapy services.
R14's progress note dated 1/9/25, identified R14 was up in wheelchair for both meals. Progress note did not identify if R14 was in his room for meals.
R14's record did not identify if and when TBP and isolation were implemented nor include symptom monitoring between 1/3/25 through 1/9/25. Between 1/9/25 and 1/15/25, R14's record included respiratory assessment which did not identify symptoms of illness. On 1/15/24, R14's was on isolation precautions, however, did not address PPE requirements.
R3-positive on 1/3/25
R3's face sheet dated 1/16/25, identified diagnoses of diabetes mellitus type 2, and chronic kidney disease (damaged kidneys).
R3's unsigned and undated physician order included place in isolation precautions per facility infection control policy. Corresponding treatment administration records identified x' in the boxes indicating the order was not completed.
R3's record reviewed between 12/23/24 through 1/13/24, identified R3 had respiratory illness symptoms that began on 12/24/24. R3's record and facility surveillance did not identify immediate implementation of TBP after (PPE and isolation) on 12/23/24 nor identify ongoing symptom monitoring to determine appropriate discontinuation of PPE and isolation. R3's progress notes identified the following:
-12/23/24, R3 had a sore throat and nasal congestion. COVID test negative.
-12/24/24, R3 had a cough, an antibiotic and cough syrup was ordered by the physician.
-12/29/24, R3 had hoarse voice, adventitious (abnormal) lung sounds, cough with secretions, and nasal congestion. R3's record did not indicate the physician was notified of the ongoing symptoms.
-12/31/24, R3 had nasal congestion, crackles in lungs, and cough. Negative COVID test.
-1/1/25, R3 had cough, congestion, and not feeling well.
-1/2/25, R3 complained not feeling well, loss of appetite, and dry non-productive cough.
-1/3/25, R3 tested positive for RSV.
-1/4/25, R3 was administered cough medication.
-1/12/25, indicated R3 did not receive a shower due to isolation precautions.
-R3's progress note dated 1/13/25, identified R3 remained on precautions for RSV symptoms which included raspy voice, and occasional cough. Lung sounds were clear.
During an observation on 1/10/25, R3 was in her wheelchair inside her room. R3 was sleeping. Two precaution signs posted on entrance to her room directing staff to use contact precautions and enhanced barrier precautions. A red biohazard bag was noted in R3's recliner with used personal protective gowns coming out of the top and resting on the armrest of the recliner. In addition, a red bin with the top open and multiple isolation gown noted to be hanging out the top and touching the sides of the bin.
R2-RSV positive on 1/8/25
R2's face sheet dated 1/22/25, identified diagnoses of type 2 diabetes.
R1's record between 12/31/24 through 1/7/25 did not identify respiratory symptoms screening was completed, even though the facility had several residents with RSV.
R2's progress note dated 1/8/25, identified R2 to be coughing, adventitious sounding, tested for COVID and RSV. R2's record did not identify TBP were implemented. During record review on 1/10/24 at 8:00 a.m. R2's RSV test results were not included in her record.
During an observation on 1/10/25 at 9:13 a.m., LPN-A stated she was aware R2 had a cough, and she knew she was tested for COVID-19/Influenza A&B and RSV but was unsure if she was negative. LPN-A entered R2's room with gloves on, no mask and no gown. While LPN-A used one of R2's fingers to check her blood sugar, R2 had her face turned toward LPN-A, R2 coughed three times without covering her mouth. LPN-A touched R2's hands then her own clothing.
R2' progress note dated 1/10/25 at 1:37 p.m., identified call placed to hospital following up on lab results. R2 was positive for RSV. At 10:20 p.m., R2 was placed on droplet precautions.
During an interview on 1/10/25 at 9:22 a.m., registered nurse (RN)-A stated she noted R2 had a cough on 1/8/25 and performed a COVID-19 test in house and did a swab for a quad test (COVID-19/Influenza A&B/RSV) test and took to the clinic. RN-A stated she was not sure of R2's test results but thought R2 tested negative. RN-A thought RSV would be droplet precautions verses contact precautions because RSV was a respiratory virus which required droplet. RN-A stated as of today 1/10/25, the facility had two active cases of RSV currently in the same unit R1 and R3.
During an interview on 1/10/25 at 2:06 p.m., infection preventionist (IP)-A stated the facility had just received R2's positive test results for RSV collected at 4:00 p.m. on 1/8/25 that resulted on 1/8/25 at 5:22 p.m. IP-A stated R2 should have been placed on respiratory precautions on 1/8/25 due to being symptomatic. IP-A stated she was unaware a test had been performed on R2 on 1/8/25. IP-A confirmed R2 was not on contact or droplet precautions since 1/8/25 and would be placed in isolation today, 1/10/25.
During an interview on 1/10/25 at 2:33 p.m., (RNCM)-A stated R2 was tested for COVID on the evening of 1/8/25 due to coughing in-house and a quad test was taken to the clinic. R2 was not put on isolation. R2 only had a cough on 1/8/25 and had not had one since. R2 did not leave her room very often; R2 ate in her room and did not attend activities and was not on TBP until 1/10/25 after the facility became aware.
R7 RSV positive on 1/8/25
R7's face sheet dated 1/17/25, identified diagnoses of diabetes mellitus type 2, dementia, atrial fibrillation.
R7's medical record did not identify respiratory assessment screening between the confirmed RSV outbreak on 12/31/24 through 1/8/24 the date R7 presented to the hospital with respiratory illness symptoms.
R7's progress note dated 1/8/25, indicated R7 had irregular rapid heart rate, was lethargic, nauseated, tired, and pale. R7 was sent to the ED.
R7's emergency department (ED) note dated 1/8/25, identified R7 presented in ED from the nursing home with atrial fibrillation and rapid ventricular rate in the context of decreased oral intake, generalized weakness and cough. R7's ED note identified R7 tested positive for RSV with reported symptoms that started on 1/6/25.
R7's hospital Discharge summary dated [DATE], identified R7 was admitted [DATE] to 1/10/25 for atrial fibrillation with rapid ventricular rate, RSV with acute bronchiolitis due to RSV, and acute cystitis (bladder infection). R7's discharge summary stated R7's presentation, including the rapid ventricular rate was triggered by acute RSV infection.
R7's progress note dated 1/10/25, identified occasional cough due to RSV positive and placed on droplet precautions. R7's progress note did not identify if/when isolation was implemented.
R7's respiratory assessments dated 1/10/25 through 1/15/25, identified cough on 1/10/25, 1/13/25 and 1/15/25.
During an interview on 1/10/25 at 2:33 p.m., RNCM-A stated residents that were RSV positive did not need to isolate, if they came out of their room they had to wear a mask and distance themselves from other residents. Nursing monitored for common signs and symptoms and test if needed. Nursing did not document monitoring for every resident in the electronic record showing that monitoring was done. RNCM-A would start staff and resident tracing if the need developed.
During an interview on 1/10/25 at 3:00 p.m., RNCM-A was in-person, and director of nursing (DON) via phone, DON verified that no monitoring had been completed of residents had been completed and no symptom monitoring of all residents had been done. DON stated IP-A should be ensuring these steps were completed.
R8 RSV positive on 1/10/25.
R8's face sheet dated 1/17/25, identified diagnoses of Alzheimer's, and dementia.
R8's record between 12/31/24 through 1/9/25 did not include respiratory illness screening.
R8's progress note dated 1/10/25 at 9:12 a.m., identified R8 was not eating this morning and unable to swallow pills and spit everything but water out.
R8's progress note dated 1/10/25 at 8:44 p.m., identified outbreak of RSV per resp. screener R8 should be tested for RSV however did not identify if R8 had symptoms. Call placed to medical provider and test sent to lab.
R8's progress noted dated 1/11/25 at 6:21 a.m., identified R8 was on droplet precautions for RSV pending results. R8's note indicated R8 had a new cough through the night. R8's record did not address isolation was immediately implemented.
R8's progress note dated 1/11/15 at 12:31 p.m., identified lab results were positive for RSV. R8 unable to stay in room and had been wandering mostly in the dining room, sat at a table by himself, and was unable to keep mask pulled up on his face.
R8's emergency department (ED) notes dated 1/13/25, identified R8 was seen on 1/13/25 at 9:33 p.m., with diagnoses of sepsis, and RSV. R8 was sent to ED for generalized and weakness and low blood pressure after testing positive at facility for RSV. ED gave breathing treatment and intravenous methylprednisolone, and normal saline. R8 was transferred to hospital. R8's hospital note dated 1/16/25, identified a stay from 1/14/25-1/16/25, with diagnoses of septic shock, with return to facility on hospice care.
R15 RSV positive on 1/10/25
R15's face sheet dated 1/17/25, identified diagnoses of bradycardia (slow heart rate), and acute respiratory failure with hypoxia.
R15's progress note dated 12/31/24, identified R15 had a large emesis. R15's record did not include further assessment.
R15's between 12/28/24 through 1/2/25 did not include respiratory illness screening, even though the facility had several residents with RSV.
R15's progress note dated 1/3/25 at 4:00 a.m., identified R15 stated she could not breathe. Oxygen saturation was 84% on 3 liters per minute of oxygen via nasal cannula. Noted clammy skin, and R15 was sweaty. At 3:56 p.m., R15 had a hoarse voice, was lethargic, and low appetite. Notified hospice.
R15's progress note dated 1/5/25, indicated R15 was provided breathing treatment for audible wheezes and chest discomfort. At 10:44 p.m., R15 had non-productive cough, complained of a sore throat, and had an emesis.
R15's progress note dated 1/6/25 at 2:30 a.m., identified complaints of pain to lower back and chest area when she coughs. At 3:48 a.m., coughing was at a minimum and wheezing was heard while breathing.
R15's progress note dated 1/8/25 at 10:35 p.m., cough syrup had been given and was effective.
R15's progress note dated 1/9/25 at 12:27 a.m., identified as needed oxygen was administered and effective.
R15's progress notes indicated oxygen remained in place on 1/9/25, and 1/10/25.
R15's progress note dated 1/10/25, identified respiratory assessment completed and indicated R15 should be tested for RSV. R15 was put on precautions pending test results. R15's record did not identify what type of precautions were implemented.
R15's record identified test results on 1/11/25 at 2:27 p.m. were positive for RSV.
R15's progress note dated 1/11/25 at 2:41 p.m., identified oxygen in use, moist/loose productive cough.
R15's progress note dated 1/12/25, identified left and right lungs had crackles on auscultation, moist/loose productive cough present with small secretions.
R15's progress note dated 1/13/25 at 1:53 p.m., identified R15 was coughing and gagging as she coughed.
Although R15 demonstrated respiratory symptoms that began on 1/3/25, there was no indication testing had been completed with the onset of symptoms nor TBP were implemented until 1/10/25, 7 days after symptoms were identified. There was no indication that symptom monitoring was completed between 1/3/25 through 1/10/25.
During an interview on 1/14/25 at 9:30 a.m., RN-A stated R15 was positive for RSV and had a roommate. For the roommate we pull the curtain and have her wear a mask when she leaves the room.
During an observation on 1/14/25 at 9:34 a.m., R15 and roommate were both sitting in wheelchairs in their room. The curtain was partially drawn. R15 coughed which was very wet sounding, she did not cover her mouth or sanitize hands after.
R13 RSV positive on 1/13/25
R13's face sheet dated 1/15/25, identified diagnoses of chronic obstructive pulmonary disease (COPD) (inflammation and obstruction of lung airways).
R13's record identified between 12/31/24 through 1/9/25 did not include respiratory illness screening, even though the facility had an onset of RSV.
R13's progress note dated 1/13/25 at 2:15 p.m., identified during respiratory screener R13 complained of cough, coughing up clear phlegm, experienced chest tightness. Placed on droplet precautions. Physician ordered test. At 8:53 p.m., RSV results returned positive. R13's record did not identify if/when isolation was implemented.
R16 RSV positive on 1/13/25
R16's face sheet dated 1/19/25, identified diagnoses of congestive heart failure (heart cannot pump blood well enough to meet the body's needs), and acute kidney failure.
R16's record identified between 12/28/24 through 1/9/25 did not include respiratory illness screening, even though the facility had several residents with RSV.
R16's progress note dated 1/13/25 at 4:30 a.m., identified lung sounds wheezy and persistent non-productive cough. 5:47 a.m., a respiratory assessment was completed, and cough was noted to be dry and non-productive.
R16's progress note dated 1/14/25 at 4:35 a.m., identified R16 was placed on droplet/contact precautions for RSV positive test on 1/13/35. At 10:24 p.m., cough was noted to be moist and non-productive with wheezing noted in lungs.
During an observation on 1/14/25 at 10:56 a.m., R16 was in the activity/dining area sitting in a recliner without a mask on with multiple other residents in the area who also did not have masks on.
R12-RSV positive on 1/14/25
R12's face sheet dated 1/17/25, identified diagnoses of myalgia (muscle pain).
R12's record identified between 12/28/24 through 1/9/25 did not include respiratory illness screening, even though the facility had several residents with RSV.
R12's progress note dated 1/13/25, identified new non-productive cough during respiratory screener. Lung sounds clear. Quad test completed and sent to lab. Droplet precautions Education provider to staff to perform hand hygiene, cough etiquette and distancing outside of room. R12's progress note did not indicated isolation was initiated.
R12's lab report dated 1/14/25, identified RSV detected from nasal swab.
During an interview on 1/14/25 at 9:25 a.m., activity aide (AA)-B stated the staff use hand sanitize prior to doing anything and wipe down things that they reuse. AA-B stated residents have the right to leave their rooms and when they do, they should be encouraged to mask up. AA-B was unsure if the residents had to wear a mask outside of their rooms but thought they did. AA-B thought residents would have to stay farther away from other residents if they were supposed to be on precautions and left their rooms.
R17 suspected respiratory disease 1/10/25
R17's face sheet dated 1/19/25, identified R17 had diagnoses that included type 2 diabetes.
R17's record between 12/28/24 through 1/7/25 did not include respiratory illness screening, even though the facility had several residents with RSV.
R17's progress noted dated 1/8/25, lungs clear and no cough.
R17's record did not include a respiratory screener on 1/9/25.
R17's respiratory illness screener dated 1/10/25 thorough 1/15/25 did not identify any respiratory symptoms.
R17's progress note dated 1/10/25 at 8:52 p.m., identified outbreak of RSV per respiratory screener resident should be tested for RSV. Test sent to lab. R17's progress note did not identify isolation or PPE was initiated.
R17's progress note dated 1/11/25 at 6:28 a.m., identified R17 was placed on droplet precautions for RSV pending lab test results. R17 was noted to have an occasional non-productive cough throughout the night. At 12:23 p.m., cough was moist and non-productive. At 1:45 p.m., identified lab results were negative for RSV, influenza A and B, and COVID.
R17's record did not identify an alternative diagnosis for the new cough and did not indicate when precautions were removed.
During an observation and interview on 1/14/25 at 9:51 a.m. R17 sat in a recliner in the activity room without a mask on, which was not in accordance with R17's record dated 1/11/25 that directed droplet precautions. NA-A confirmed R17 was sitting in a recliner in the activity room with no mask on.
R19 suspected respiratory disease 1/10/25
R19's face sheet dated 1/19/25, identified R19 had diagnoses that included type 2 diabetes.
R19's record reviewed from 12/28/24 through 1/9/25, was not evident of ongoing consistent symptom monitoring was completed between 1/3/25 through 1/9/25, even though the facility had several residents with RSV.
R19's progress note dated 1/10/25 at 8:51 p.m., identified the respiratory screener indicated R19 should be tested for RSV. R19's progress note did not specify symptoms or that isolation or TBP were initiated.
During an observation on 1/10/25 at 1:10 p.m., R19 was laying in her bed with no respiratory symptoms observed.
R19's progress note dated 1/11/25 at 8:08 a.m., identified R19 was placed on droplet precautions. No cough and afebrile. At 1:27 p.m., test results for respiratory diseases returned negative. Moist, non-productive cough noted. R19's progress notes did not indicate isolation or TBP were initiated after symptom onset on 1/11/25.
R19's respiratory symptom screeners between 1/10/25-1/14/25, identified a moist non-productive cough on 1/11/25.
R19's progress note dated 1/14/25, identified R19 left facility for an appointment out of state and did not return until after supper.
R18 suspected respiratory disease 1/10/25
R18's face sheet dated 1/23/25, identified R18 had diagnoses that included type 2 diabetes
R18's record reviewed from 12/28/24 through 1/9/25, did not include respiratory symptom screening, even though the facility had several residents with RSV.
R18's progress note date [TRUNCATED]
Dec 2024
6 deficiencies
1 Harm
SERIOUS
(G)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Actual Harm - a resident was hurt due to facility failures
Accident Prevention
(Tag F0689)
A resident was harmed · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and document review the facility failed to complete comprehensive fall analysis and implement individualized ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and document review the facility failed to complete comprehensive fall analysis and implement individualized interventions to prevent re-current falls and/or mitigate the risk for falls with major injury for 2 of 3 residents (R7, R5) reviewed for falls. The facility's failures resulted in actual harm for R7 when she sustained left tibial fracture that required surgical repair.
Finding include:
R7's face sheet dated 12/12/24 identified R7 had diagnoses that included acquired absence of right leg above knee and type 2 diabetes.
R7's admission Minimum Data Set (MDS) dated [DATE], identified R7 was admitted to the facility on [DATE] and had severe cognitive impairment with no signs or symptoms of delirium, behaviors or history of falls within six (6) months of admission. R7 had functional limitations in range of motion of one lower extremity, used a wheelchair, and was dependent on staff for hygiene needs, lower body dressing and chair to bed transfers. R7's ability to sit to stand and walk was not attempted due to medical condition. R7 was always incontinent of bowel and bladder, and administered insulin in addition to psychotropic, anticoagulant, and opioid medications.
R7's undated fall Care Area Assessment (CAA) included, resident currently has falls related to cognitive deficits and amputation of LRL (sic). Resident will have less than 2 falls per month through the review date. The CAA indicated and identified R1 was at risk for falls related to cognitive impairment, diagnoses of cardiac dysrhythmias, incontinence, loss of limb, anxiety disorder, schizophrenia, and the medications as identified in the admission MDS. The CAA indicated falls would be addressed in the care plan with the overall objective to avoid complications and minimize risks.
R7's fall risk evaluation dated 9/4/24, indicated R7 was at risk for falls with a history of three or more falls in the past three months. R7 was disoriented, chair bound/incontinent and was not able to perform gait/balance evaluation. The interventions listed were to evaluate for falls and if falls occur alert the provider.
Although R7's fall risk evaluation and the MDS identified R7 was at risk for falls, R7's care plan dated 9/4/24 did not include and/or address a plan of care for falls. R7's care plan dated 9/4/24 identified the following focuses and interventions:
-Current Functional Performance informed staff R7 required one person physical assist for toileting, for transfers R7 required total assist of two person with a full body mechanical lift using amputee sling.
-Impaired physical mobility related to amputation leading to phantom limb included but was not limited the direction of for staff to allow R7 adequate time for response and ensure call light available.
-Documented Safety -Concerns directed staff to perform safety risk evaluations on admission, as needed, and upon change of condition and Safety Measures- including strategies to reduce the risk of infection, falls, injury initiated as appropriate.
In review of R7's fall record between 9/5/24 through 12/1/24 identified R7 had 11 total falls. R7's falls incident reports identified the following:
R7's fall incident report dated 9/5/24, at 5:25 a.m. indicated R7 had an unwitnessed fall in her room with no injury. R7 had been found on the floor next to her bed with blankets under her bottom, she appeared to have slid from the bed. R7 stated she needed to get up and use the bathroom so she wouldn't be late for school. The incident report identified predisposing factors as R7 was admitted within 72-hours and confused, but did not indicate/identify R7 had needed to use the bathroom as a factor. The report did not include comprehensive fall analysis nor identify immediate fall prevention interventions and not evident R7's care plan was revised.
R7's fall incident report dated 9/7/24 at 4:51 a.m. indicated R7 who was wheelchair bound had an unwitnessed fall in her room with no injury. A nursing assistant (NA) had been completing the 30-minute checks and found R7 on the floor drinking water in good spirits with stool smeared on her floor mat. R7 had reported she wanted to get up and get her water. In response to staff asking how she got on the floor, R7 gestured her hand in a gliding motion towards the floor. Predisposing factors included R7 was admitted within 72-hours, but did not/indicate identify R7's bowel incontinence nor R7's location of water and/or need for water. The report did not include a comprehensive fall analysis nor identify immediate fall prevention interventions. Furthermore not evident the care plan was revised to reflect the implementation of when/duration of 30-minute checks or usage of floor mat.
R7's fall incident report dated 9/13/24 at 7:30 a.m. indicated R7 who was wheelchair bound normally does not ambulate at all had an unwitnessed fall. R7 was found sitting on the floor next to her bed and could not clearly inform staff if she hit her head or if her bottom hurt or not. Education provided to resident not get out of bed by herself but due to confusion instructions may not be understood. Predisposing factors identified included: confused, impaired memory, and incontinent. The report did not specify if R7 was incontinent when she was found. The report did not include a comprehensive fall analysis nor identify other fall interventions other than the immediate education that may not have been understood by R7. Further not evident of an assessment/evaluation to identify effectiveness of the education provided nor evident the care plan was revised to include resident education.
R7's fall incident report dated 9/22/24 at 8:58 a.m. p.m. indicated at 5:25 p.m. R7 was in her room when an NA saw her pulling on the mattress, causing R7 to slide out of her wheelchair onto floor. R7 reported she had wanted to go to bed. Predisposing factors identified as confusion. The report did not include a comprehensive fall analysis nor identify immediate fall prevention interventions. Further not evident R7's care plan was revised.
R7's fall incident report dated 10/19/24, indicated R7 had a witnessed fall with no injuries at 9:30 a.m. when she appeared to be repositioning herself in her wheelchair and slid out of her chair landing on her bottom. Prior to the fall during breakfast, R1 had been agitated/behavioral and very confused. R7 Unable to give description. Predisposing factors checked were none, but noted mental status as alert and confused. The report did not include a comprehensive fall analysis nor identify immediate fall prevention interventions. Further not evident R7's care plan was revised.
R7's fall incident report dated 11/3/24, indicated R7 had unwitnessed fall around 3:15 p.m. with no injuries. R1 was found by housekeeping staff sitting on floor, on her blue mat, leaning against her bed around 3:15 p.m. Prior to fall NA had just been in room, and found R7 sitting at the edge of the bed. NA assisted R7 back to bed and bed was in the lowest position. R7 was at her night stand and going through her stuff when she lowered herself to the floor. R7 unable to say what she was doing when she lowered herself to the floor but told family she was trying to get into bed. R1 was alert and confused. Predisposing factors included, confused and impaired memory. The report did not include a comprehensive fall analysis nor identify immediate fall prevention interventions. Further not evident the care plan was revised to include appropriate bed height and usage of the floor mat.
R7's care plan was revised to include a fall focus on 11/15/24, that identified R7 was at risk for falls however did not have individualized interventions that would prevent and/or mitigate R7's risk for falls including the usage of the fall mat, 30-minute checks, resident education, and bed height that was identified in the fall incident reports. The fall care plan only directed staff to evaluate for falls on admission and as needed and if a fall occurs, notify the provider.
R7's fall incident report dated 11/26/24 at 1:40 p.m. indicated R7 had an unwitnessed fall with no injuries. R7's physician found R7 sitting on her floor mat. R7 reported she purposely put herself on the floor to get up. R7 was alert and confused. No predisposing factors were identified. Additionally, the report did not include a comprehensive fall analysis nor identify immediate fall prevention interventions.
R7's fall incident report dated 11/27/24 at 6:45 a.m. indicated R7 had an unwitnessed fall in her room, she was found sitting on her floor mat next to her bed. R7 appeared calm but was not able to state what happened. The fall resulted in a skin tear to left lower leg with minor bleeding. Predisposing factors identified as confused. The report did not include a comprehensive fall analysis nor identify immediate fall prevention interventions.
R7's fall incident report dated 11/29/24 at 7:00 a.m., indicated R7 had an unwitnessed fall and had an open area to her left shin. NA found R7 sitting on the floor mat next to her bed. The report included when asked why she was on the floor resident pointed to room mate. Then resident stated that she wanted to get up. The predisposing factor was identified as Resident is concerned about recent new room mate. The report did not include a comprehensive fall analysis nor identify immediate fall prevention interventions.
R7's fall incident report dated 11/30/24 at 2:00 p.m., indicated R7 had an unwitnessed fall. NA found resident sitting on the floor next to the bed. R7 was alert and confused. The bed was in waist high position with no fall mat next to bed. R7 reported her whole leg hurt when the nurse did range of motion (ROM). R7 was sent to the emergency room for further evaluation and the aide was provided with education on following the care plan. Predisposing factors included, confused. The report did not include a comprehensive fall analysis nor identify immediate fall prevention interventions.
R7's fall incident report 12/1/24 at 4:53 a.m. indicated R7 had an unwitnessed fall with no injuries. NA found R7 sitting on her floor mat next to her bed with her leg bent in front of her and incontinent of bowel, call light was in place and bed was in the lowest position. R7 was alert to person and place. Nurse had just been in her room at 4:35 a.m. to check on R7 since she was self-transferring from bed to the floor frequently. Predisposing factors identified as incontinent and R7 is very curious about roommate-wants to know what she is doing all the times. The report did not include a comprehensive fall analysis nor identify immediate fall prevention interventions.
R7's progress notes dated 12/2/24 at 7:02 a.m., R7 was sent to ER due to left lower extremity became swollen, red, and painful. At 11:54 a.m. the ER called the facility informing R7 was being sent to another hospital for broken leg and possible surgery.
R7's emergency department note dated 12/2/24, identified a hematoma (collection of blood) to the proximal (near) the tibia/fibula are of left lower leg and a fracture of the left proximal end of left tibia and was sent to another hospital for surgery.
R7's hospital Discharge summary dated [DATE], identified R7 was admitted on [DATE] for a closed fracture of left proximal tibia that required surgery on 12/3/24, cellulitis and abscess of left lower extremity. R7 was discharged back to the facility on [DATE] on IV antibiotics.
The records did not include and was not evident the facility completed a comprehensive fall analysis that identified potential causal factors and/or root cause(s) so that appropriate determinations for individualized fall interventions could be developed and implemented to remove R7's fall risk associated with the potential causal factors/root cause.
R5
R5's face sheet dated 12/16/24, identified diagnoses of malnutrition (condition where body does not get enough nutrients), chronic kidney disease (condition where kidneys have been damaged), osteoarthritis (condition with joint pain and stiffness), and weakness.
R5's quarterly Minimum Data Set (MDS) dated [DATE] identified R5 had severe cognitive impairment. R5 was dependent on staff for dressing, grooming and hygiene and required maximum assistance for all transfer. R5 had two or more falls with no injury and one fall with minor injury.
R5's fall care plan dated 8/17/24, indicated R5 was high risk for falls related to weakness, history of falls with the following: Call don't fall signs posted in room, anticipate needs, call light within reach, physical therapy (PT) to evaluate and treat or as needed.
R5's fall incident report dated 10/12/24, indicated R5 had an unwitnessed fall at 7:40 p.m. R5 was found in her room laying on her back next to walker. Predisposing risk factors included confusion and ambulating without assistance. Immediate action taken: R5 assessed with no injuries noted. [NAME] removed and call light placed within reach. R5's record did not include a comprehensive analysis of the fall and R5's care plan was not revised.
R5's fall incident report dated 10/13/24, indicated at 11:30 p.m. an NA witnessed R5 attempting to self-transfer in her room and was going to fall so NA assisted R5 to the floor. R5 stated I have to go I want to walk, can I go but she don't state where she want to go. No injuries were noted. Predisposing factors included confused, gait imbalance, using a walker, and alert but confused. Immediate actions taken: [NAME] removed and call light placed within reach. R5's record did not include a comprehensive analysis of the fall and R5's care plan was not revised.
R5's fall incident report dated 10/15/24, indicated R5 had an unwitnessed fall at 6:00 a.m. R5 was yelling and when NA entered R5's room, R5 was found sitting upright behind a closed door. R5 was confused and unable to give any detail of what happened but kept asking staff to lock the door. Resident has delusions of men coming into her room and keeps trying to shut the door. No injuries noted. Predisposing factors included alert and confused, gait imbalance, impaired memory incontinent using a walker, and wanderer. Immediate action taken: R5 assessed for injuries and placed in wheelchair and took to dining area for close observation. R5's record did not include a comprehensive analysis of the fall and R5's care plan was not revised.
R5's fall incident report dated 10/29/24, indicated R5 had an unwitnessed fall at 9:45 p.m., R5 had been in her bed and was found sitting on floor in front of wheelchair close to the bathroom, with gripper socks on, call light at bedside, and had been toileted within 30 minutes, no incontinence. R5 was unable to explain what happened. Predisposing factors included, confused. Immediate action taken: R5 was assessed for injury and noted to have bump on back of head. R5's record did not include a comprehensive analysis of the fall and R5's care plan was not revised.
During an interview on 12/11/24 at 4:10 p.m., director of nursing (DON) confirmed causal analysis were not being completed and care plans were not revised. DON indicated she expected the facility policy be followed. After a fall occurs, a causal analysis was supposed to be completed and immediate interventions developed, implemented, and identified in the care plan.
Review of the facility policy Falls, Clinical Protocol dated 10/4/2021, indicated the following:
-Cause identification, 1) for an individual who has fallen, the staff and practitioner will begin to try to identify possible causes within 24 hours of the fall. the staff; 3) the staff and practitioners will continue to collect and evaluate information until either the cause of the fall is identified, or it is determined the cause cannot be found or is not correct.
-Treatment/management, 1) based on preceding assessment, the staff and physician will identify interventions to try to prevent subsequent falls and to address the risk clinically significant consequences of falling. 2) if under lying causes cannot be readily identified or corrected, staff will try carious relevant interventions, based on assessment of the nature or category of falling, until falling reduces or stops or until a reason is identified for it continuation.
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
Report Alleged Abuse
(Tag F0609)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and document review the facility failed to ensure alleged violations involving abuse/neglect were reported to...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and document review the facility failed to ensure alleged violations involving abuse/neglect were reported to the State Agency (SA) timely for 2 of 2 resident (R5, R7) reviewed for abuse/neglect.
Findings include:
R5's quarterly Minimum Data Set (MDS) dated [DATE] identified severe cognitive impairment and dependent for dressing, grooming and hygiene.
R5's care plan focus dated 12/5/24, identified R5 was at end of life and utilizing hospice. Interventions included coordinate care with hospice and other end of life services.
During an interview on 12/12/24 at 8:43 a.m., hospice registered nurse (HRN)-D stated R5 was recently certified for hospice care. HRN-D visited R5 in the facility on 12/8/24 at 11:30 a.m. HRN-D reported when she entered R5's room, R5 was in bed and unresponsive, both eyes were matted shut and dark brown material on both corners of her mouth. HRN-D stated R5 appeared to be in same position she had placed her the day prior, R5's bed linens were soiled and incontinent pad on and was heavily saturated with urine. HRN-D did not inform the nurse on duty of her concerns due to being upset.
During an interview on 12/12/24 at 3:04 p.m., HRN-D indicated she was not an employee of the facility rather employed by the hospice agency in which the facility had a contract with; she would be considered a contracted staff. HRN-D stated in the event of potential abuse/neglect she normally would report this to the nurse in charge, social service, or the director of nursing (DON). HRN-D stated the concerns she had for R5's cares on 12/8/24 were not reported to facility staff, social services, or director of nursing.
During an interview on 12/12/24 at 1:35 p.m., the DON stated hospice was to report abuse/neglect concerns to the nurse on duty.
During an interview on 12/12/24 at 2:50 p.m., Administrator stated his expectations for any hospice visit to report to the nurse on duty and if there were concerns, hospice staff would report this to the DON, who would share the concerns to the Administrator.
R7's face sheet dated 12/12/24, identified diagnoses that included amputation of right leg (removal of limb).
R7's quarterly MDS dated [DATE], identified severe cognitive impairment and dependent for dressing, toileting, and transfers.
R7's fall care plan dated 11/15/24 identified R7 was at risk for falls. Interventions to evaluate for fall risk on admission and as needed and if fall occurs, alert provider.
Review of R7's incident report dated 11/30/24, indicated R7 had an unwitnessed fall on 11/30/24 at 2:00 p.m., R7 was sitting on the floor next to her bed and did not have fall mat and bed at waist high position. R7 stated she had pain in her left leg.
R7's progress notes dated 11/30/24 R7 was sent to emergency room (ER) for evaluation of left leg pain, x-rays were negative, and returned to the facility.
Review of R7's incident report dated 12/1/24, indicated R7 had an unwitnessed fall on 12/1/24 at 4:35 a.m., R7 was found sitting on a mat near her bed and left leg bent in front of her. R7 was assessed and denied pain. However, progress notes on 12/2/24 identified R7 was sent to the ER due to left lower extremity became swollen, red, and painful. The ER called the facility to notify R7 was being sent to another hospital for broken leg and possible surgery.
R7's progress note dated 12/3/24 at 11:36 a.m., identified hospital case manager called facility and stated R7 had a left tibia fracture, cellulitis, and abscess to left lower leg. R7 will be having surgery on 12/3/24.
During an interview on 12/11/24 at 3:47 p.m., DON stated R7's fracture of left tibia was a serious injury and with having uncertainty of how it occurred, it should have been reported.
Review of the facility Abuse, Neglect, Exploitation or Misappropriation-Reporting and Investigating policy undated, identified if resident abuse, neglect, or injury of unknown source is suspected, the suspicion must be reported immediately to the administrator, director of nursing and the other officials according to state law. Immediately is defined as: within two hours of an allegation involving abuse or result in serious bodily injury or within 24 hours of an allegation that does not involve abuse or result in serious bodily injury.
Review of the facility Hospice and Nursing Facility Services Agreement dated 10/1/21 indicated hospice shall report to the facility all alleged violations involving mistreatment, neglect or verbal, mental, sexual, and physical abuse within 24 hours of hospice becoming aware which was inconsistent with the facility policy and federal requirements for reporting allegations of abuse and neglect. This polilcy was not consistent with the federal requirements for reporting allegations of abuse/neglect.
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
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 interview and document review the facility failed to accurately comprehensively assess pressure ulcers in order to dete...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and document review the facility failed to accurately comprehensively assess pressure ulcers in order to determine, develop, and implement individualized interventions to reduce the risk and/or prevent new pressure ulcers and/or deterioration of existing pressure ulcers for 2 of 3 residents (R3, R4) reviewed for pressure ulcers.
Findings include
Definitions:
Pressure ulcer/Injury (PU/PI): 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 occurs because of intense and/or prolonged pressure or pressure in combination with shear.
Deep tissue pressure injury: Intact skin with localized area of persistent non-blanchable deep red, maroon, purple discoloration due to damage of underlying soft tissue. This area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue. This injury results from intense and/or prolonged pressure and shear forces at the bone-muscle interface. The wound may evolve rapidly to reveal the actual extent of tissue injury, or may resolve without tissue loss.
Stage 2 pressure ulcer: partial thickness loss of skin presenting as a shallow open area with a red or pink wound bed, without slough (a soft, stringy, white or yellow substance can appear in wounds and is made up of dead cells and other materials). May also present as an intact blister or open/ruptured serum filled blister. This stage should not be used to describe moisture associated skin damage (MASD) including incontinence associated dermatitis, intertriginous dermatitis (inflammation of skin folds), medical adhesive related skin injury, or traumatic wounds (skin tears, burns, abrasions).
Stage 3 pressure ulcer: full thickness skin loss. Subcutaneous fat may be visible, but bone, tendon or muscle is not exposed. Slough maybe present but does not block the depth of tissue loss.
Stage 4 pressure ulcer: full thickness tissue loss with exposed bone, tendon or muscle. Slough and eschar (a hardened, dead tissue It can appear black, brown, red, tan and may be fluid filled or crusty.)
Unstageable pressure ulcer: slough and/or eschar present and covers the wound bed making it impossible to stage the wound.
R3's admission Minimum Data Set (MDS) dated [DATE], indicated R3 did not have cognitive impairment with diagnoses of diabetes, arthritis, and dementia. R3 was dependent on staff for activities of daily living (ADLs) except for eating and used a manual wheelchair for mobility. R3 was at risk for pressure ulcers and had four stage 3 pressure ulcers present on admission with interventions of pressure reducing device for chair and bed, nutrition/hydration, pressure ulcer care, applications of non-surgical dressings and applications of ointment/medications other than to her feet.
R3's care plan history identified care focuses, goals, and revisions since admission, however implementation dates were not identified. The care plan identified R3 had a documented pressure ulcer (did not specify location). Interventions included encourage resident to shift weight frequently, low air loss mattress, wheelchair cushion, reposition resident as allows, monitor ulcer for signs of progression or decline and provide wound treatment.
R3's physician orders included wound treatments, however, also included heal protectors while in bed every night shift for offloading heels for wound prevention with a start date of 8/21/24.
R3's wound records were reviewed between 10/8/24 through 12/6/24. The records included weekly wound assessments for multiple pressure ulcers varying in stages that were not consistently accurate nor comprehensive; one of which was a wound(s) on the right heel. The records indicated on 10/8/24 a large blister that ruptured on R3's heel was identified; the area deteriorated to two different pressure ulcers a stage 3 and an unstageable ulcer. Additionally, it was not evident the care plan was consistently evaluated and revised to include pressure relieving interventions to prevent or mitigate the risk of deterioration, prevention, or mitigation of risk there of.
R3's progress note dated 10/8/24 at 1:31 p.m., identified during wound rounds on 10/3/24 two new darkened areas to R3's right outer foot, and a new area to R3's right inner foot. R3's heel is macerated, and heel is open and fragile.
R3's Skin and Wound Evaluation dated 10/8/24, identified wound type as a ruptured blister that had started on 10/6/24, however, R3's record does not identify the presence of an intact blister and could not be determined when the blister ruptured. Further, the record did not address cause of the blister so appropriate pressure reducing interventions could be developed and implemented to prevent re-current blisters. Description included, no drainage, edges attached and macerated; the wound was healable. Intervention was suspension/protection device; it was not evident R3's care plan was revised.
R3's corresponding photo of right heel dated 10/8/24, was not consistent with the evaluation. The photo identified a ruptured blister covering the bottom of the heel; the skin was macerated, crack or open area of the maceration from 12:00'oclock to 3:00 o'clock. Additionally, from 9:00 o'clock to 3:00 o'clock the underlying tissue was light purple which was not identified in the wound evaluation.
R3's Skin and Wound Evaluation dated 10/11/24, identified shearing on right heel that started on 10/6/24 was described as shearing that measured 0.9 cm x 1.7 cm. Edges attached, fragile surrounding tissue, and improving. Interventions identified as heel suspension/protective device. It was not evident the care plan was revised.
R3's corresponding photo was inconsistent with the evaluation dated 10/11/24. The photo identified sloughing skin from maceration and at the 10:00 o'clock to 12:00 o'clock position there was a dark red area. This area was not identified on the evaluation. During an interview on 12/18/24 at 9:31 a.m., director of nursing (DON) stated the wound type was not shearing.
R3's Skin and Wound Evaluation dated 10/20/24, identified wound on right heel was identified as a stage 2 pressure ulcer that measured 4.21 cm x 3.99 cm with no depth identified. No drainage, edges attached, calloused surrounding tissue, stable and healable. Interventions of cushion (was not specified), heel suspension/protection device (was not specified) and turning/repositioning program (was not specified). It was not evident the care plan was revised with the aforementioned interventions.
R3's corresponding photo of right heel, was inconsistent with the evaluation dated 10/20/24. The photo identified multiple dark purple areas that varied in size consistent with deep tissue injuries. These areas were not addressed in the evaluation.
R3's physician progress note dated 10/22/24, indicated the wounds have extended in size, not improving, and now has maceration of the heel of the right lower extremity.
R3's Skin and Wound Evaluation dated 10/25/24, identified wound on right heel was a stage 2 pressure ulcer with measurements of 0.64 cm x 0.69 cm. with no depth identified. Edges attached, surrounding tissue calloused, fragile, and improving. Goal of care was healable. Education: resident refused alternating pressure mattress. Interventions: suspension/protection device (was not specified) and turning/repositioning program (was not specified). It was not evident the care plan was revised.
R3's corresponding photo of right heel was inconsistent with evaluation dated 10/25/24. Photo identified 5 purple areas consistent with deep tissue injuries; one area had a whitish/yellow center. These areas were not identified in the evaluation.
During an interview on 12/18/24 at 9:31 a.m., DON stated R3's wound on 10/25/24 should have been marked as a deep tissue injury and not a stage 2.
R3's Skin and Wound Evaluation dated 11/2/24, identified wound on right heel was a stage 2 pressure ulcer that measured 1.5 cm x 1.13 cm. with no depth identified. 80% slough, 10% eschar, moderate serosanguineous drainage, edges attached, surrounding tissue calloused. Progress is stalled. Goal of care was healable. R3 refusing air mattress and prevalon boots. Interventions none. It was not evident the care plan was revised.
R3's corresponding photo for 11/2/24 did not reflect the documentation. The photo identified the back of the heel had a reddened area and two purplish/red areas noted at the bottom of the heel that was not identified in the evaluation.
R3's significant change Minimum Data Set (MDS) dated [DATE], indicated R3 had an increase in the number of pressure ulcers since admission MDS. R3 had one stage 2, and three stage 3, and one unstageable.
R3's Skin and Wound Evaluation dated 11/8/24, identified the wound on right heel was stage 2. Wound measurements 1.27 cm x 3.45 cm with no depth identified. 100% eschar, moderate serosanguineous drainage. Progress is deteriorating. Goal of care was healable. Interventions of heel suspension/protection device (was not specified). It was not evident the care plan was revised.
R3's corresponding photo for the 11/8/24 evaluation did not reflect the documentation. The photo identified two open wounds: one on each side of the heel. It could not be ascertained which wound the documentation was entered for. The pressure ulcer on the right side of the heel was larger than the left side. Right: had an open area with a yellowish base/center, surrounding tissue was whitish with purple border. Left: had depth, whitish center, surrounding tissue either black or bluish (could not be further described because of the angle of the picture).
R3's wound care nurse practitioner note dated 11/11/24, identified R3 was seen for an outpatient wound center follow up on 11/11/24 for right foot ulcer. Wound to right heel described as a Stage 3 with measurements of 1.5 cm x 1.2 cm x 0.2 cm. Ulcer base is 100% slough and near probe to bone.
R3's Skin and Wound Evaluation dated 11/13/24, identified wound on right heel was a stage 2 pressure ulcer that measured 3.47 cm x 0.73 cm, no depth with 100% eschar, no drainage, edges attached, surrounding tissue calloused and stable. Interventions of cushion (was not specified) heel suspension/protection device (was not specified), moisture barrier, nutrition/dietary supplementation. It was not evident the care plan was revised.
R3's corresponding photo for the 11/13/24 evaluation did not reflect the documentation. The photo identified two separate wounds both consistent with unstageable pressure ulcer. The evaluation did not identify which wound the description/measurements were for.
During an interview on 12/18/24 at 9:31 a.m., DON stated after viewing image for 11/13/24, this should have been marked as an unstageable pressure ulcer.
R3's Skin and Wound Evaluation dated 11/22/24, identified wound on left side of the right heel as a stage 2 that measured 2.0 cm x 1.85 cm x 0.4 cm. with 10% slough, 10% eschar, rolled edges, surrounding tissue fragile. Progress was deteriorating. Goal of care was healable. Note: both areas increased in size, unable to capture both areas in 1 picture, obtained separate pictures. Noted resident has increased pain while lying in bed do to contracture of right lower leg, appears to increase pressure to right heel. Area cleansed with normal saline Used Kerlix to secure gauze in place, whole roll used to offer some padding and is willing to wear prevalon boots. Interventions cushion, heel suspension/protection device, moisture barrier, moisture control. It was not evident the care plan was revised. The right pressure wound was described as an unstageable ulcer that measured 2.46 cm x 1.88 cm x 0.2 cm (even though the wound was unstageable) 20% slough and 20% eschar.
R3's corresponding photo for the 11/22/24 evaluation for the right heel wound (left side) did not reflect the documentation. The photo identified two wounds right wound larger than the left. Left wound: open with macerated edges with dark purple area that was consistent with a deep tissue injury that surrounded almost ½ the wound; this area was not identified on the evaluation.
R3's Skin and Wound Evaluation dated 12/1/24, identified wound on right heel was a deep tissue injury that measured 2.7 cm x 1.9 cm, 10% slough, 80% eschar, attached edges, dry/flaky and fragile. Wound was deteriorating. Interventions: cushion (was not specified), nutrition, and positioning wedge. It was not evident the care plan was revised. The corresponding photo was consistent with the wound description, however, was not consistent with a deep tissue injury rather an unstageable ulcer according to the definition.
R3's Skin and Wound Evaluation dated 12/5/24, identified wound on right heel was deep tissue injury that measured 1.8 cm x 1.0 cm x 0.2 cm with 100% eschar, rolled edges, calloused, dry/flaky and fragile. The wound was stable and healable. Interventions included incontinence management and heel suspension/protection. The wound in the corresponding photo was not consistent with a deep tissue injury rather an unstageable ulcer according to the definition. It was not evident R3's care plan was revised however, physician order dated 12/5/24 directed prevelon boots to both feet.
R3's Wound Care Clinic notes dated 12/6/24 identified Stage 4 pressure ulcer on right posterior heel acquired on 1/1/20 (conflicting information per previous facility wound assessments of start date of 10/6/24). Wound measurements are 2.2 cm x 2.0 cm, with no measurable depth with eschar. Right lateral heel identified as a chronic stage 2 pressure ulcer, acquired on 1/1/20 (conflicting information per previous facility wound assessments of start 10/6/24). Measurements 2.0 cm x 2.0 cm x 0.2 cm. Adipose tissue (body fat) exposed with slough and eschar. Wounds were debrided by provider. New orders for specialty bed/mattress for pressure reduction-keep pressure off right heel.
R3's Wound Evaluation dated 12/12/24, identified wound on right heel was a stage 3 pressure ulcer that measured 0.45cm x 0.72 cm. no drainage, fragile surrounding skin, stable and healable. Interventions of heel suspension/protection device and nutritional supplement.
During an interview on 12/18/24, DON stated the assistant director of nursing was monitoring the wounds and she noted there was inconsistency of the images and assessments of R3's wounds. DON indicated R3 developed the wounds from propelling herself in her wheelchair with her feet and she refused the blue boots. R3's interventions did not make it in her care plan. DON stated her expectation for any wound that are deteriorating was to have a new intervention place in the care plan. DON stated R3 was refusing dressing changes at times and the dressing changes done at different intervals.
R4
R4's quarterly MDS dated [DATE], indicated R4 did not have cognitive impairment with diagnoses that included diabetes, coronary artery disease, renal insufficiency, and dementia. R4 had range of motion impairment to one side of her body and required partial to substantial assist with dressing upper body and dependent on staff for lower body dressing. R4 did not have a toileting program and was always incontinent of bladder and frequently incontinent of bowel. R4 was at risk for pressure ulcers but had none. R4 did have a diabetic foot ulcer she received application of dressing to feet with or without topical medication. R4 had pressure relieving devices in bed and on her electric wheelchair.
R4's skin integrity care plan dated 6/12/24 indicated R4 had actual skin impairment related to incontinence and history of vulvar cancer. R4 had areas of MASD to right upper thigh, left gluteal cleft, coccyx, and left buttocks.
R4's Skin and Wound evaluation dated 11/27/24, identified MASD/IAD to coccyx that measured 1.1 cm x by 0.3 cm and no depth documented. The area was in house acquired and new as of 11/26/24. The area was 100% granulation filled, no evidence of infection. Light amount of serous drainage without odor. The surrounding skin is dry and flaky, fragile skin at risk for breakdown. Notation of resident is on repositioning program, spends quite a bit of time lying in bed and up to recliner and power chair for short bits of time. Reminded resident to continue with repositioning. Staff educated on following resident care plan, repositioning every 2 hours and check and change.
R4's corresponding photo dated 11/27/24, identified an open slit on R4's coccyx. The base was yellow in color and the surrounding tissue was pink. This wound is not consistent with MASD and by definition is consistent with a stage 2 pressure ulcer.
R4's Skin and Wound evaluation dated 12/5/24, identified MASD/IAD to coccyx measured 1.3 cm x 0.3 cm and no depth documented. There was 90% granulation and slough were present over 10% of the wound. There was no evidence of infection. The edges appeared flushed with the wound bed or as sloping edge. The surrounding skin looked fragile, at risk for breakdown. Treatment was to cleanse with soap and water and apply barrier cream. Area was noted to be improving.
R4's corresponding photo dated 12/5/24 was not consistent with the evaluation. Photo identified an open slit in the coccyx with visible depth that was not assessed/documented on the evaluation.
During an interview on 12/12/24 at 2:11 p.m., registered nurse (RN)-D stated assistant director of nursing (ADON), was responsible to review the quarterly care plans when she does the care conferences and was to make updates. RN-D was responsible for the annual care plan updates when she completed the annual and significant change MDS. RN-D further stated they had switched over to a different program and it did not allow them to make the care plans individualized. They had to use what was in the drop-down box.
During an interview on 12/11/24 at 3:45 p.m., DON stated therapy decided the type of pressure relieving device or the wound care provider. All residents have a pressure relieving mattress throughout the facility. DON further stated her expectation was the residents care plan were updated with current interventions, so the staff knew what they were.
Facility policy Pressure Injuries Overview 9/29/21, identified the purpos of the procedure was not provide information regarding definitions and clinical features of pressure injuries. The policy included the descriptions of pressure ulcers and associated terms used to desribe features of the pressure ulcer. This policy did not address components of a comprehensive assessment nor pressure relieving interventions.
Facility policy Wound Care dated 9/29/21, indicated to 1) verify the physician's order for the procedure, 2) review resident's care plan for special needs, example: pain medication. Documentation included: 1) The type of wound care given. 2) The date and time the wound care was given. 3) The position in which the resident was placed. 4) The name and title of the individual performing the wound care. 5) Any change in the resident ' s condition. 6) All assessment data (i.e., wound bed color, size, drainage, etc.) obtained when inspecting the wound. 7) How the resident tolerated the procedure. 8) Any problems or complaints made by the resident related to the procedure. 10) If the resident refused the treatment and the reason(s) why. Under Reporting 1) Notify supervisor if the resident refuses the wound care, 2) report other information in accordance with facility policy and professional standards of practice.
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 F0849
(Tag F0849)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and document review, the facility failed to have a clear communication process between hospice and the facili...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and document review, the facility failed to have a clear communication process between hospice and the facility of a change in hospice services to be provided and to designate a member of the facility's interdisciplinary team to coordinate care to the resident by the facility and hospice staff for 1 of 1 (R5) resident who received hospice services.
Findings include:
R5's face sheet dated 12/16/24, identified diagnoses of malnutrition (condition where body does not get enough nutrients), chronic kidney disease (condition where kidneys have been damaged), osteoarthritis (condition with joint pain and stiffness), and weakness.
R5's quarterly Minimum Data Set (MDS) dated [DATE] identified severe cognitive impairment and dependent for dressing, grooming and hygiene.
During an interview on 12/10/24 at 4:08 p.m., registered nurse (RN)-H reported that R5 was seen by hospice registered nurse (HRN)-D on 12/8/24. RN-H stated she did not receive any new recommendations about R5's plan of care from HRN-D during her shift. RN-H stated that hospice nurses normally notify the nurse on duty after visits and communicate any new recommendations. RN-H stated she did not inquire with HRN-D about R5's visit on 12/8/24.
During an interview on 12/12/24 at 8:43 a.m., hospice registered nurse (HRN)-D stated R5 was admitted to hospice on 12/5/24 with a diagnosis of malnutrition. HRN-D visited R5 in the facility on 12/8/24 at 11:30 a.m. and stated she had told an unidentified nursing assistant that R5's plan of care changed and recommended R5 be turned, repositioned, and provided oral cares every two hours. HRN-D also indicated she had concerns pertaining to R5's care being completed. HRN-D did not tell the nurse on duty of her recommendations for the changes to R5's care plan nor communicate the care related concerns.
R5's care plan focus dated 12/5/24, identified R5 is at end of life and utilizing hospice. Interventions included coordinate care with hospice and other end of life services. R5's care plan did not identify or a address a repositioning schedule and oral cares.
During an interview on 12/12/24 at 3:04 p.m., HRN-D stated she typically would tell the nurse on duty of any changes she recommended but did not communicate this to the nurse on duty after R5's visit on 12/8/24. HRN-D indicated no documentation was recorded in the facility's electronic health record (EHR) about the change in plan of care for R5.
During an interview on 12/12/24 at 1:38 p.m., RN-A stated she was not aware of a designated person in the facility that hospice was supposed to communicate changes, and that hospice nurse should report any concerns or changes in plan of care to the nurse on duty.
During an interview on 12/12/24 at 1:53 p.m., RN-C stated that he was not aware of a designated staff member in the facility that hospice is communicate changes, and hospice nurses should talk to the nurse on duty.
During an interview on 12/12/24 at 1:35 p.m., the director of nursing (DON) stated her expectations for any hospice visit would be that the hospice nurse would report to the nurse on duty any updates or changes.
During an interview on 12/12/24 at 2:50 p.m., Administrator stated his expectations were for hospice to report to the nurse on duty and if concerns, they would report this to the DON, who would share the concerns to the Administrator.
Review of the facility Hospice Program Policy (undated) identified facilities responsibility to communicate with the hospice provider to ensure that the needs of the resident are addressed and met.
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
Infection Control
(Tag F0880)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interview and documents review the facility failed to ensure enhanced barrier precautions (EBP-where gown...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interview and documents review the facility failed to ensure enhanced barrier precautions (EBP-where gown and gloves used for high contact resident care activities) was used for 1 of 1 resident (R7). In addition, the facility failed to ensure handwashing/hand hygiene was implemented for 2 of 2 residents (R7, R9) observed for handwashing/hand hygiene.
Findings include:
R9's admission Minimum Data Set (MDS) dated [DATE], identified diagnosis of dementia and was dependent on staff for all mobility, grooming and hygiene.
During an observation and interview on 12/11/24 at 10:16 a.m., R9 was in bed and nursing assistant (NA-N) and registered nurse (RN-F) were performing peri care for an incontinent bowel movement. RN-F did not perform hand hygiene prior to placing gloves on. RN-F removed R9's soiled pad, then completed incontinence cares on R9. RN-F placed soiled pad in trash, then removed gloves without performing hand hygiene. RN-F stated that hand washing/hand hygiene should be done before and after cares, and when hands are visibly soiled. RN-F stated she is aware that she did not perform proper hand hygiene while doing R9's incontinent cares.
R7's face sheet dated 12/12/24, identified diagnoses of diabetes mellitus type 2 (a condition that affects how the body uses sugar) and cellulitis (potentially serious skin infection) of left leg.
During an observation and interview on 12/11/204 at 11:56 a.m., R7 was in her room and RN-A was administering intravenous (IV) antibiotics through R7's IV catheter. R7's room had signage by the door indicating enhanced barrier precautions were needed. RN-A disconnected and flushed the IV after completion of infusion, RN-A was only wearing gloves and no gown. RN-A did not perform hand washing/hand hygiene after removing gloves. RN-A stated R7 was on EBP due to having an IV catheter and she also was getting wound care. RN-A stated EBP would be needed for any dressing, toileting, foley care, wound care and IV care. RN-A stated that EBP would not need to be used during just transferring a resident.
During an interview on 12/11/24 at 3:47 p.m., director of nursing (DON) stated that EBP should be used for any resident with an IV, urinary catheters or wounds and her expectation is that if a resident is on EBP that staff would use the appropriate precautions for any physical touch of that resident.
The facility policy on enhanced barrier precautions undated, identified that EBP is required for any for any resident needing device care, such as a central line.
The facility policy on hand washing/hand hygiene dated 8/25/21, identified hand hygiene to be performed before moving from contaminated body site to clean body site during resident care.
CONCERN
(E)
📢 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 F0728
(Tag F0728)
Could have caused harm · This affected multiple residents
Based on interview and document review, the facility failed to ensure 4 of 4 nursing assistants (NA-T, NA-D, NA-G, and NA-U) reviewed were deemed competent to complete cares for residents. This had th...
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Based on interview and document review, the facility failed to ensure 4 of 4 nursing assistants (NA-T, NA-D, NA-G, and NA-U) reviewed were deemed competent to complete cares for residents. This had the potential to affect all 45 residents residing in the facility.
Findings include:
Review of the facility job description Non-Certified Nursing Assistant (NA) and training requirements dated August 2021, indicated the primary purpose of this position is to provide resident with routine daily nursing care and services in accordance with the resident's assessment and care plan and as directed by supervisors. After completing facility competency training, all residents' lifts, transfers and activity of daily living (ADL) care, the non-certified aide must complete these tasks with the assistance of a facility Certified Nurse Aid (CNA).
Review of NA-T's employee record indicated NA-T was hired on 9/10/24. NA-T's orientation sign off sheet was not completed with the date and sign off sections for training completed were left blank. Further, NA-T's file did not include competency training records that identified NA-T was deemed competent for resident lifts, transfer, and ADL's.
During an interview on 12/11/24 at 12:52 p.m., NA-T stated she was an uncertified nursing assistant and began working 2 months ago. NA-T stated she assisted residents with dressing, toileting, and assists with transfers with the mechanical lifts. NA-T stated she was registered for a nursing assistant course in June of 2025 and training was done by a certified nursing assistant and indicated she was not signed off for skills competencies.
Review of NA-D employee record indicated NA-D was hired on 10/9/24. NA-D's file did not include an orientation record nor competency training records that identified NA-D was deemed competent for resident lifts, transfer, and ADL's. There were no competencies noted in NA-D's file for resident lifts, transfers and ADL's.
Review of NA-G's employee record indicated NA-G was hired on 8/12/24. NA-G's orientation sign off sheet was not completed with the date and sign off sections for training completed were left blank. Further, NA-G's file did not include competency training records that identified NA-G was deemed competent for resident lifts, transfer, and ADL's.
During an interview on 12/10/24 at 3:51 p.m., NA-G stated he was an uncertified nursing assistant and began working in the facility about four months ago. NA-G stated he assisted residents with dressing, toileting and eating. NA-G stated he is not allowed to use the mechanical lifts. NA-G stated training was with a certified nursing assistant and indicated he was not signed off for skills competencies. NA-G further stated he was not currently enrolled in and NA classes and the next was not until February 2025 and he had not decided if he was taking that class.
Review of NA-U's employee file indicated NA-U was hired on 11/1/24. NA-U's orientation sign off sheet was not completed with the date and sign off sections for training completed were left blank. Further, NA-U's file did not include competency training records that identified NA-U was deemed competent for resident lifts, transfer, and ADL's.
During an interview on 12/11/24 at 3:45 p.m., director of nursing (DON) stated the assistant director of nursing (ADON) was to have performed competencies for all new employees before they worked on the floor. DON indicated competency records should be located in the employee file and if they were not then she was not sure where they would be kept. DON stated it was her expectation all new employees were competency tested prior to working on the floor and the record of the training/testing be kept in their employee file.
The facility training program requirements were requested and not received.
Aug 2024
1 deficiency
1 IJ
CRITICAL
(J)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Immediate Jeopardy (IJ) - the most serious Medicare violation
Accident Prevention
(Tag F0689)
Someone could have died · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, observation and document review the facility failed to safely use a mechanical lift per manufactures recomme...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, observation and document review the facility failed to safely use a mechanical lift per manufactures recommendations to transfer 1 of 1 resident (R1), who required a mechanical lift for transfers. This resulted in an immediate jeopardy (IJ) when R1 fell from a full body mechanical lift causing R1 to suffer three fractures to his thoracic and lumbar spine (T1, T6, and L1) requiring hopsital admission. In addition, the facility failed to ensure a system for completed comprehensive assessments for sling size and/or care plan developement and/or the care plan was followed for for 8 of 8 residents (R1, R2, R3, R5, R6, R7, R8, R9) reviewed who required full body mechanical lifts.
The IJ began on 8/25/24 when staff failed to ensure lift sling was properly secured prior to the transfer causing R1 to fall from the mechanical lift. The administrator, regional nurse, and director of nursing (DON), and assistant director of nursing (ADON) were notified of the IJ on 8/27/24 at 4:55 p.m. The IJ was removed on 8/28/24 at 5:00 p.m., when the facility had implemented immediate corrective action to prevent recurrence, but noncompliance remained at a lower scope and severity of a E with no actual harm with potential for more than minimal harm that was not immediate jeopardy.
Findings included:
During observations on 8/27/24 between 10:23 a.m. to 2:28 p.m. the facility used the EZ-Way brand full body mechanical lifts and not the Hoyer brand full body mechanical lifts which the facility identified in their progress notes/documentation.
A Facility Reported Incident (FRI) submitted to the state Agency (SA) on 8/26/24 at 1:03 a.m., alleged potential caregiver neglect when R1 fell backwards from the sling of the Hoyer (brand name of full body mechanical lift) during a transfer and sustained increased pain, emergency department (ED) evaluation, and compression fractures to his back.
R1's admission Minimum Data Set (MDS) identified R1 was admitted on [DATE] and no other information was available.
R1's brief interview of mental status (BIMS) dated 8/21/24, indicated R1 was severely cognitively impaired.
R1's care plan dated 8/23/24 indicated R1 had diagnoses of vascular dementia, chronic kidney disease, and major depressive disorder with psychotic features. Also indicated R1 required two staff assist with a large sling and full body mechanical lift for transfers. R1 required one assist with bed mobility, eating, personal hygiene, dressing, and toileting.
R1's [NAME] (abbreviated care plan for nursing assistants (NA)) as of 8/27/24 indicated R1 required two staff assist with Hoyer Lift with large sling.
R1's Lift/Transfer Evaluation dated 8/22/24, indicated R1 could not bear weight, was cooperative with transfers and repositioning, did not have any upper extremity strength, and could not assist with transfers. R1's weight range was between 100-200 pounds and does not lack any sensation in any body parts.
An undated facility document labeled Sling Sizes indicated R1 required a large sling.
R1's progress notes dated 8/25/24 at 11:17 p.m., indicated staff were transferring R1 from bed to wheelchair using Hoyer lift. While R1 was in the air he fell backwards, head was facing down. R1 hit his head on the floor and sustained a lump to the back of the head. R1 sent to ED for evaluation. A follow up progress note dated 8/25/24 at 11:29 p.m., indicated R1 had been transferred to a higher level of care hospital due to fractures and fluid in the lungs.
R1's Progress Note dated 8/26/24 at 3:41 p.m., indicated R1 admitted to hospital and had a T1 fracture (upper back spine), T6 spinal fracture (mid back spine), L1 cerebral fracture (lower back) and was receiving pain management.
During an interview on 8/27/24 at 1:30 p.m., nursing assistant (NA)-A indicated she was assisting NA-D with R1's transfer on 8/25/24 when R1 fell out of the lift. NA-A Indicated it was the first time she had worked with R1 that day. NA-A was not sure which size lift sling R1 was supposed to use but used the lift sling that was already underneath him in the chair, NA-A thought it may have been maroon/large but was not sure. NA-A stated R1's fall happened so fast, he just fell out.
During an interview on 8/27/24 at 1:40 p.m., NA-D indicated she assisted NA-A with R1's transfer on 8/25/24 when R1 fell out of the lift. NA-D indicated it was her first time working with R1. NA-D explained they were transferring R1 from the bed to the recliner and one of the sling loops came off the lift hook and R1 fell out of the lift to the floor. NA-D Further indicated the sling was under R2 in bed so that is the one they used to transfer him. NA-D was not sure what color or size it was. NA-D verified they did not check R1's care plan indicating the sling size and did not stop to check the tension of the straps when lifting R1. NA-D Identified the sling sizes were on the resident's [NAME] and a list was posted on the linen closet door.
During an interview on 8/27/24 at 3:43 p.m., the director of nursing (DON) indicated NA-A and NA-D must not have stopped and checked that the lift sling loops were secured when R1 was lifted, and the sling was not taut. Further indicated, it was expected that staff would use the care planned sling, double check the size of the sling prior to transfer, and do their safety checks during the transfer to avoid resident injury. They were unsure what size the sling was when R1 fell.
R2
R2's admission Minimum Data Set (MDS) identified R1 was admitted on [DATE] and no other information was available.
R2's BIMS dated 8/27/24 indicated R2 was cognitively intact.
R2's care plan dated 8/23/24, indicated R2 transferred with two total staff assist. R2 required assist of one staff with toileting, dressing, and bed mobility. Two staff assist with personal hygiene. The care plan did not identify the use of a full body mechanical lift or sling size. Diagnoses include hemiplegia, osteoarthritis, diabetes, and anxiety disorder.
R2's [NAME] as of 8/27/24, indicated R2 transferred with two-person physical assist. The [NAME] did not identify the use of a full body mechanical lift or sling size.
R2's Lift/Transfer Evaluation dated 8/22/24, indicated R2 could not bear weight, was cooperative with transfers and repositioning, did not have any upper extremity strength, and could not assist with transfers. R1's weight range is between 100-200 pounds and lacks sensation in some part of the body.
An undated Facility document labeled Sling Sizes indicated R2 required a large sling.
During an observation on 8/27/24 at 10:23 a.m., R2 was noted to be in his recliner with a beige full body lift sling under him. According to the EZ-Way Sling Color Coding System chart, a beige sling was a size medium sling.
During an observation on 8/27/24 at 11:57 a.m., NA-C wheeled R2 out of his room in his wheelchair with the beige/medium sling under him in the wheelchair indicated R2 was transferred with the medium sling versus the large sling that R2 required for safe lift transfer.
R3
R3's significant change MDS dated [DATE], identified R3 was dependent on staff for toileting, lower body dressing, transfers, and bed mobility.
R3's BIMS dated 8/19/24, indicated R3 had intact cognition.
R3's care plan revised 3/17/24, indicated R3 required assist of two staff with Hoyer lift and large sling for transfers. R3 required one assist with bed mobility.
R3's [NAME] dated 8/27/24, indicated R3 transferred with two staff assist and Hoyer lift with large size sling.
R3's Lift Mobility Status dated 7/30/24, indicated R3 could bear weight on at least one leg, could grip the lift bar with at least one hand, was cooperative, less than 342 pounds and was to be transferred by a Hoyer lift.
An undated Facility document labeled Sling Sizes indicated R3 required a large sling.
During observation and interview on 8/27/24 at 10:49 a.m., R3 was sitting in a recliner when nursing assistant (NA)-A and NA-B placed a beige full body sling underneath her. NA-B stated, it is a brown sling, so it is a medium sling and referred to a color-coded chart on the lift with weights on it. Further indicated the nurses weighs the resident and then put the sling size in the [NAME] so the NA's knew what sling size to use for transfers. NA-B confirmed the beige sling was the correct sling and proceeded with the transfer from recliner to wheelchair even though the [NAME] directed the use of large size sling.
R5
R5's admission Minimum Data Set (MDS) identified R5 was admitted on [DATE] and no other information was available.
R5's BIMS dated 8/27/24, indicated R5 was cognitively intact.
R5's care plan dated 8/26/24, identified R5 required two staff assist for transferring using a Hoyer lift and large sling. R5's diagnoses included osteoarthritis of both knees, diabetes, dementia, hearing loss, and anxiety disorder.
R5's progress notes dated 8/27/24, indicated R5 also required two staff assist with bed mobility, dressing, and toileting.
R5's [NAME] dated 8/27/24 indicated R5 was totally dependent on two staff for transferring using the Hoyer lift and large sling.
R5's Lift/Transfer Evaluation dated 8/22/24 indicated R5 was cooperative with transfers and repositioning; did not have upper extremity strength and could not assist with transfers; is less than 200 pounds and did not lack sensation in any part of the body.
An undated facility document labeled Sling Sizes indicated R5 used a large Hoyer sling for transfers.
During an observation on 8/27/24 at 10:20 a.m., R5 was noted to be sitting in her wheelchair with a beige full sling underneath her in the chair. According to the EZ Way Sling Color Coding System chart, a beige sling was a size medium sling.
During observation and interview on 8/27/24 at 11:51 a.m., R5 was noted to be sitting in her wheelchair with a beige sling under her in the wheelchair when registered nurse (RN)-A and NA-B began to hook the beige sling up to the full body mechanical lift. RN-A and NA-B both stated R5 used a beige sling, size medium for transfers. As they began to lift R5 off the wheelchair, the SA evaluator stopped them and advised them R5's care plan directed that R5 used a large burgundy sling. RN-A indicated that the medium sling they were using worked for R5 so she would just change the care plan. RN-A and NA-B proceeded with the transfer from wheelchair to bed with the beige/medium sling.
R6
R6's significant change MDS dated [DATE], indicated R6 had impairment on both upper and lower extremities and was totally dependent for transfers. No behaviors.
R6 BIMS dated 7/26/24 indicated intact cognition.
R6's care plan revised on 5/13/24, indicated R6 transferred with two assist and EZ-Stand (sit to stand lift) with all transfers using a large sling. The resident was also dependent on staff for bed mobility, dressing, and toileting. Care plan did not reflect R6's use of full body mechanical lift nor did it identify which sling to use for transfers with the full body mechanical lift.
R6's [NAME] dated 8/27/24, indicated transfers were to be completed with assist of two with the EZ-Stand lift with all transfers using the large sling. [NAME] did not reflect R6's use of full body mechanical lift nor did it identify which sling to use for transfers with the full body mechanical lift.
R6's Lift Mobility Status dated 7/30/24, indicated R6 could bear weight on at least one leg, could grip the lift bar with both hands, is cooperative, less than 342 pounds and lift will by the EZ-Stand lift.
An undated facility document labeled Sling Sizes indicated R6 used a large Hoyer sling for transfers.
During observation and interview on 8/27/24 at 11:40 a.m., R6 was seated in a wheelchair with a beige/medium sling underneath her when NA-B and NA-C came in the room with an EZ-Stand lift and a large harness and assisted R6 to stand. A beige/medium full body sling was hanging over a bar in R6's room. When asked, R6 indicated they (staff) used that in the mornings to get her out of bed and weigh her. R6 indicated she disliked the full body lift and confirmed the beige sling was used every morning. NA-B verified the beige/medium sling was used every morning to transfer R6 out of bed. NA-C also verified the beige/medium sling was used every morning to transfer R6 out of bed and was the correct size for R6.
R7
R7's quarterly MDS dated [DATE], indicates R7 had no impairment on upper extremities but was impaired on both lower extremities, and dependent with transfers. Diagnoses included osteoarthritis to the left knee, below the knee amputee right leg, and anxiety disorder.
R7's BIMS dated 6/15/24, indicated intact cognition.
R7's care plan last revised on 2/8/24, identified R7 transferred with two assist and Hoyer lift with a large sling. R7 also required staff assist with dressing lower half of body, personal hygiene, and toileting.
R7's [NAME] was requested but not received.
R7's Lift Mobility Status dated 6/22/24, indicated R7 could not bear weight, could tolerate a semi-reclined position, and lift to be used was a Hoyer lift. No other information was provided.
An undated facility document labeled Sling Sizes indicates R7 used a large Hoyer lift sling for transfers.
During observation and interview on 8/27/24 at 1:15 p.m., R7 was in bed and was noted to have a green full body sling in her wheelchair. R7 indicated she had an amputated leg so is unable to walk and needed to be transferred with a Hoyer lift. R7 further verified the green sling in the wheelchair was used for every transfer. According to the EZ-Way Sling Color Coding System chart, a green sling was considered a size extra-large sling.
During an intterview on 8/27/24 at 1:20 p.m., NA-C indicated R7 was transferred with the full body mechanical lift and the green sling that was in the wheelchair. Further indicated the NAs tell the nurses the resident's weight and they tell them what size sling to use and the sling size was then written on a sheet of paper in the linen closet.
R8
R8's annual Minimum Data Set (MDS) dated [DATE], indicated R8 had no upper extremity impairment, impaired movement on lower extremities, dependent on staff for all transfers and mobility. Diagnoses included cerebral infarction (stroke), peripheral vascular disease, arthritis, and anxiety.
R8's BIMS dated 8/5/24, indicated moderate cognitive impairment.
R8's care plan last revised on 8/26/24, indicated R9 transferred with the EZ-Stand with assist of two and extra-large sling. R8 also required assist of two staff with dressing and toileting. The care plan did not identify the use of a full body mechanical lift or sling size.
R8's [NAME] was requested but not received.
R8's Lift Mobility Status dated 8/3/24, indicates R8 could bear weight on both legs, grab the lift bar with both hands, was cooperative, weight was less than 342 pounds, identified lift to be used as the EZ-Stand lift with extra-large sling.
An undated facility document labeled Sling Sizes, indicated R8 used an extra-large Hoyer sling for transfers.
During an observation on 8/27/24 at 2:28 p.m., R8 was noted sitting in a recliner and had a black sling under him. According to the EZ Way Sling Color Coding System chart, a black sling was considered a size double extra (XX)-large sling.
R9
R9's admission MDS was in progress and identified R9 was admitted on [DATE] with no other information available.
R9's BIMS dated 8/23/24, indicated intact cognition.
R9's care plan dated 8/23/24, did not address transfer status or mobility status.
R9's [NAME] dated 8/27/24, indicated R9 transferred with two staff assist. Did not specify mode of transfer nor sling size.
R9's progress note dated 8/23/24 at 1:21 p.m., indicated R9 admitted that day and was a two person assist with Hoyer lift and needed two staff for cares and activities of daily living (ADLs). The progress note did not identify the sling size.
R9's Lift Mobility assessment dated [DATE], indicated R9 could not bear weight, was cooperative with transfers and repositioning, did have upper extremity strength, could not assist with transfers, and weight was 100-200 pounds.
An undated facility document labeled Sling Sizes did not indicate what size sling R9 used for transfers.
During observation on 8/27/24 at 11:13 a.m., R9 was noted to be in his wheelchair with a burgundy sling under him. According to the EZ-Way Sling Color Coding System chart, a burgundy sling is considered a size large sling. A large sling is indicated for a weights withing 190 -320 pounds.
During an interview on 8/27/24 at 12:00 p.m., RN-A indicated they only used the resident's weight to determine what sling size to use and referred to the chart on the lift.
During an interview on 8/27/24 at 3:10 p.m., the assistant director of nursing (ADON) indicated the lift/transfer evaluations did not determine what size sling to use. Further indicated she was not sure how the sling size was determined other than weight.
During an interview on 8/27/24 at 3:43 p.m., the director of nursing (DON) indicated the facility did not have a good system of sling sizing for the residents that used lifts and was not aware that the wrong sling sizes were in the resident rooms and in use. Further indicated if staff were using the wrong size lift slings, it increased the resident's chance of falling out of the lift.
During a follow-up interview on 8/27/24 at 4:02 p.m., the DON confirmed the wrong size lift slings were found in resident's rooms and stated all slings being used would be the correct size for the resident before any further lift transfers were completed.
During an interview on 8/29/24 at 11:10 a.m., the EZ-Way company representative indicated if staff were not using the correct sized slings or stopping to do safety checks on the loop connections, it increased a resident's risk of falling out of the lift resulting in serious injury to the resident.
The facility policy titled, Lifting Machine, using a Mechanical last reviewed 2/7/22, indicated the purpose of the procedure is to establish the general principles of safe lifting using a mechanical lifting device. It is not a substitute for manufacturer's training or instructions. The policy indicates staff to measure the resident for the proper sling size and purpose, according to the manufacturer's instructions. Double check the sling and machines weight limits against the resident's weight; place the sling under the resident and visually check the size to ensure it is not too large or to small; attach the sling straps to the sling bar according to the manufacturer's instructions; make sure the sling is securely attached to the clips and that it is properly balanced; check to make sure the resident's head, neck, and back are supported; before the resident is lifted double check the security of the sling attachment; examine all hooks, clips, or fasteners; check the stability of the straps; ensure the sling bar is securely attached and sound; lift the resident 2 inches from the surface and check the stability of the attachments, the fit of the sling, and the weight distribution; check the resident's comfort; slowly lift the resident only as high as necessary to complete the transfer.
EZ Way Sling Sizing Chart, Form #2-150 Revised 7/31/18, indicated it is important to evaluate the width of a patient in relation to the width of the sling; it is important that no portion of the patient overlap the sides of the sling; color coding is used on the binding of sling but not used for specialty slings; it is important that the base of the sling be positioned two inches below the tailbone and the top of the sling is parallel with the top of the shoulder line (base of the neck). Further identifies the size/weight designations are merely estimates and basic guidelines. A proper fit will depend on factors other that weight measurements, including the height and girth of a patient. A proper fit will involve the judgement of the caregiver.
The IJ was removed on 8/28/24 at 5:00 p.m. when it was verified the facility implemented the following corrective actions:
*The facility policy, Lift Machine Using Mechanical Lift Policy and Procedure was reviewed by the facility and nurse leadership.
Facility clinical leadership in-serviced all nurses and nurse aides on the Lift Machine Using Mechanical Lift Policy, the EZ Way *Sling Sizing Color Coded Chart with emphasis on measuring weight and height, where to locate this information in the care plan/[NAME] and performed return demonstration lift mobility competencies.
*The clinical interdisciplinary team (IDT) team were in-serviced on the admission and quarterly assessment schedule that included lift mobility and any changes to the resident status, the care plans updated as needed.
*Assessments and care plans of current residents who utilized mechanical lifts were reviewed and updated. All residents were measured per manufacturer recommendations. Resident's rooms were searched, and any incorrect slings were removed.
May 2024
2 deficiencies
1 IJ
CRITICAL
(J)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Immediate Jeopardy (IJ) - the most serious Medicare violation
Accident Prevention
(Tag F0689)
Someone could have died · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to comprehensively assess and implement interventions to provide adequa...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to comprehensively assess and implement interventions to provide adequate supervision for 1 of 1 residents (R1) who had a history of exit seeking behaviors. R1's elopement from the facility in an unlocked motor vehicle, resulted in an immediate jeopardy (IJ). The facility implemented immediate corrective action and was issued as past non-compliance.
The immediate Jeopardy (IJ) began on 4/22/24, when R1 exited the facility and staff did not respond timely to the activation of a door alarm by R1's WanderGuard bracelet. R1 got into an unlocked vehicle and drove around the city for 1.5 hours until police stopped him. The Director of Nursing (DON), Assistant Director of Nursing (ADON), Social Service Designee (SSD), were notified of the IJ on 5/1/24 at 5:30 p.m. The facility implemented immediate corrective action on 4/23/23, and the IJ was issued at past non compliance.
Findings include:
R1's face sheet printed 5/1/24, identified diagnoses of Alzheimer's, dementia, and senile degeneration (mental deterioration associated with age) of the brain.
R1's admission Minimum Data Set (MDS) dated [DATE], identified an admission date of 2/24, indicated R1 had severe cognitive impairment with inattention, diabetes, disorganized thinking and daily wandering behaviors. R1 was independent walking throughout the facility. R1 had adequate vision and hearing and was able to make self understood and understood others.
R1's elopement risk assessment dated [DATE], identified R1's risk factors for elopement included R1 was ambulatory, and habits of wandering and exit seeking. Additional risk factors included R1 had eloped from this setting or a previous one, family voiced concerns R1 may tend to exit seek or elope, and R1 was taking medications that may cause confusion. Analysis concluded that R1 was at risk for elopement and interventions included a personal safety alarm, frequent monitoring (was not defined), and staff aware of elopement risk.
R1's care plan dated 2/15/24, identified R1 was a high risk for elopement and wandering related to senile dementia and history of elopement attempts. Interventions included, assess elopement status quarterly and as needed. Distract from wandering by offering pleasant diversions, structured activities, food, conversation, television, book (western preference). Wander guard (personal safety alarm that alerts staff if resident attempts to leave the facility) to right lower ankle. The careplan did not include intervention of frequent monitoring as per the elopement assessment dated [DATE].
R1's progress notes between 2/22/24 to 4/14/24 identified R1 had multiple documented occurrences where R1 had attempted to leave the facility and/or had exit seeking behaviors without further assessment and revisions to R1's individualized care plan to continuously manage R1's exit seeking behaviors in order to prevent and/or mitigate the risk of elopement from the facility.
R1's progress note dated 2/22/24, identified R1 did exit the front door again.
R1's progress note dated 2/25/24, identified R1 was found exiting the door by A-wing. Wander guard alarmed and he was found near the nursing assistant supply room at the top of the ramp by the ice machine. R1 was easily redirected back to room.
R1's progress note dated 3/7/24, identified R1 attempted to open door and alarm went off so he stopped.
R1's progress note dated 3/10/24, identified R1 was walking towards the exit door, managed to get outside the facility and was easily redirected in at 3:21 p.m. At 9:47 p.m., R1 walked out of the facility and staff brought him back in immediately.
R1's progress note dated 3/13/24, identified R1 attempted to go outside and was easily redirected.
R1's progress note dated 3/24/24, identified R1 was exiting seeking and set off the wander guard multiple times.
R1's progress note dated 3/31/24, identified R1 continued to be 1:1 visual staffing to prevent leaving the building.
R1's progress note dated 4/3/24, identified R1 attempting to open emergency door on B-wing. The alarm scared him, and he walked away.
R1's progress note dated 4/9/24, identified R1 was wandering facility, 1:1 provided. Nurse followed R1 as he exited the building and was able to easily redirect back into the facility.
R1's progress note dated 4/11/24, identified staff saw R1 walk out of the exit door and managed to get out and staff brought him back in. Another time R1 did not exit the building but did open the door and walked back in the facility by himself.
A facility reported incident submitted to the State Agency dated 4/14/24, identified R1 had exited the building and went to the front patio/fence area. Returned to facility without difficulty. The summary identified the facility would include an order to check the wander guard every shift for placement and functioning, will continue to discuss with family about potential different placement, and R1's care plan updated with activity of choice as R1 had been a gardener. The care plan 2/15/24 was not updated to reflect the activity intervention.
The facility elopement risk assessment dated [DATE], identified the same information from the 2/15/24 assessment but concluded with interventions of exit alarm, secure unit placement, visual barriers (stop sign, ribbon, tape, etc.), staff aware of elopement risk, and personalization of room. No changes were made to the care plan.
During an interview on 5/1/24 at 9:02 a.m., registered nurse (RN)-A stated an awareness of R1's behaviors, R1 frequently wandered around the building and exit seek. R1 was independent with walking around the facility. R1 could sometimes walk very fast however, other times he would walk very slowly. When it was cold R1 would go into the entry way and return to the building without assistance. R1 could be distracted from wandering with food, following nurses around during medication passes, and watching sports or the lake. RN-A would always tell R1 at the beginning of the shift to not leave without her. R1 would not be safe to drive a car.
During an interview on 5/1/24 at 9:18 a.m., housekeeper (H)-A stated R1 would always try to go outside so every time she worked, she would look for R1 to make sure he was safe inside the facility.
R1's progress note dated 4/20/24, identified R1 had been exit seeking after family left.
R1's medication administration record (MAR) for April 2024, identified on 4/22/24 R1 received Seroquel (antipsychotic) 25 milligrams (mg) at 1:00 p.m., and haloperidol (antipsychotic) 2 mg was given at 6:13 p.m., morphine 0.5 mL was given at 6:13 p.m.
R1's progress note dated 4/22/24, identified R1 had attempted to leave the building twice. Nurse gave as needed medication of Haldol and morphine to calm R1. At 6:41 p.m., wander guard alarm sounded and at 6:42 p.m., staff opened the front door and did not see anyone but saw a vehicle drive away from the facility. Staff began a search for R1. A staff member realized his car was missing during the search and police were notified of missing resident and motor vehicle. Police returned R1 to facility at 8:15 p.m. R1 was transferred to a locked memory unit. Progress note identified R1 was driving a car around the city of Worthington, Minnesota for almost 1.5 hours without a drivers license and medication that could impair mental status, vision, and reaction time.
During observation on 5/1/24 at 4:52 p.m., the distance from the front door to where the staff members vehicle was parked was approximate 120 feet. The facility is located across the street from a lake off a road that in one direction runs along the lake shore with a stretch of road that has the lake on both sides. If one were to turn right out of the facility the road either goes along the side of the lake or leads to highway 60 after a couple of turns.
The police record dated 4/22/24, case 2024002271 identified they received two calls at 6:58 p.m. the first call reported a missing vehicle and the second call reported a missing resident. Officers arrived on scene and determined the incidents were related. At approximately 7:45 vehicle owner reported he found the vehicle being driven east on [NAME] Street and officers stopped the vehicle on county road 33 near [NAME] Avenue, according to Google maps was approximately 3.7 miles from the facility. The vehicle was returned to the owner and the resident was transferred back to the facility.
The facility Elopement document dated 4/22/24, identified R1 as a wanderer, exit seeking along with confusion and impaired memory. Early afternoon and late evening the day of the event, there were a lot of visitors and other resident in and out of the facility prior to the incident. R1 had been restless prior to occurrence.
A facility reported incident submitted to the State Agency dated 4/25/24, identified an alarm sounded at 6:41 p.m. Upon staff going outside to locate R1 they saw a motor vehicle leaving the premise. 911 was notified and staff searched the premise and did not locate R1. Sheriff returned R1 to the facility at 8:15 p.m. (1.5 hours after the documented time R1 had left the facility). The summary identified R1 had wanted to go home. R1 was transferred to a sister facility upon return.
During an interview on 5/1/24 at 1:20 p.m., trained medication aide (TMA) indicated she had worked the evening shift on 4/22/24. TMA stated right before R1 left the facility around 6:45 p.m., R1 had been in a recliner by the window in view of the nursing station with licensed practical nurse (LPN)-A. TMA had left the area and went to Hall-C to use the restroom. She had heard the alarm, returned to the area, however R1 was not there. TMA went outside to the right, and LPN-A went to the left, but could not find R1 so she returned to building to alert all staff to begin the search.
During an interview on 4/30/24 at 3:11 p.m., nursing assistant (NA)-A stated staff had to always watch R1 because he would try to leave, mainly through the front door. R1 wore a WanderGuard that would activate an alarm if he tried to exit the facility however, the WanderGuard did not lock the doors. NA-A worked the evening shift of 4/22/24, when R1 went missing sometime after supper, she could not remember what time it was. NA-A had last seen R1 sitting in a recliner by the window in the dining room. NA-A explained she and NA-B had been in a resident's room with the door closed so she did not hear the door alarm sounding until she came out of the room at which point they went to the front door. NA-A did not know how long the alarm had been sounding before hearing it. NA-B told NA-A he was going to drive around to look for R1 but found his car missing from the parking lot.
During a phone interview on 5/1/24 at 10:50 a.m., NA-B stated the evening of 4/22/24 he was in a room with NA-A so they did not hear the alarm until they left the resident's room. NA-B did not know how long the alarm had been sounding but LPN-A was already outside looking for R1 when he got outside. NA-B walked toward the lake across the street from the facility because he was worried R1 had got in and drowned. As NA-B walked he passed a few people and asked them if they had seen R1. The group of ladies told NA-B they saw an older man walking down the path. That is when NA-B decided to return to the facility to get his car to search. When NA-B returned to the facility he found his car missing. NA-B and LPN-A got in a vehicle and drove around looking for R1. NA-B stated when they got to highway 60, approximately two miles from the facility, they saw R1 in the car going the opposite direction so they made a U-turn to follow him. NA-B called the police back to tell them they located R1 driving NA-B's car. The police advised them to follow R1 and not attempt to get him to stop, the police would intervene and pull R1 over. NA-B said R1 was really speeding but driving nice by himself. NA-B was worried R1 would get in an accident and hurt himself or someone else. NA-B stated he did not realize he had left his keys in the car when he had been on break. NA-B was surprised R1 knew how to start his vehicle, I had to have instructions from [NAME] to learn.
During an interview on 5/1/24 at 12:52 p.m., NA-C stated the evening on 4/22/24 she did hear the alarm but was with a resident and could not immediately respond. NA-C did not know how long the alarm had been sounding prior to being shut off. After she completed cares with the resident, NA-C headed toward the front door and met NA-A and NA-B also going outside. NA-C went toward the lake and asked two ladies walking if they saw R1 which they had not. When NA-C walked back toward the facility, that is when we noticed NA-B's vehicle missing. NA-C went back into the building and that is when R2 told her that R1 had got in a vehicle and drove away. NA-C went back to helping residents in the facility
During an interview on 5/1/24 at 10:05 a.m., R2 who had moderate cognitive impairment according to the quarterly MDS dated [DATE], stated from his window he watched R1 walk really fast out of the building and got into a vehicle. R1 backed up, made a U-turn, and drove off. R2 saw staff outside the building looking for R1, but was not sure if it was before or after R1 was in the vehicle.
During an interview on 5/1/24 at 9:24 a.m., LPN-A stated on 4/22/24, R1 attempted to leave two times on his shift prior to the incident. After R1's first attempt to get out of the facility, he was redirected to sit in a chair in the dining room. After R1's second attempt he was assisted to sit in the recliner by the window to look at the lake and because R1 was restless and agitated LPN-A gave him morphine and haloperidol at 6:15 p.m. After 20 minutes R1 continued to sit in the chair awake and appeared calm so LPN-A left the nurses station to go downstairs. LPN-A heard the door alarming at approximately 6:41 p.m. LPN-A went outside and saw a car turning left out of the parking lot. LPN-A did not think much of it because he did not think R1 would drive a car. When LPN-A came back into the building he met NA-B who reported his car was missing. After the notifications to family, facility, and 911 were made NA-B and LPN-A took LPN-A's vehicle and began the search by turning left out of the facility parking lot. LPN-A drove down the road and there was a stop sign to go left or right and he took a right. LPN-A and NA-B passed two stop lights and then saw NA-B's car. They called the police while following R1 so they could stop him. R1 was going a minimum of 35 miles per hour. R1 went on a roundabout that led to a gravel road and that is when the police pulled him over. R1 got out of NA-B's car smiling. LPN-A reported he was surprised R1 had been driving good, he stopped at the stoplights but R1 should not have been driving especially after taking morphine and haloperidol. R1 was always exit seeking, he would try to escape the facility any chance he got. R1 should have had 1:1 supervision but there was not enough staff scheduled to provide that, instead R1 had the wander guard that alerted staff as he was exiting the building. In response to R1's exit seeking behaviors the direction and interventions were always to educate R1 not to leave, keep an eye on him, and provide him with medication. LPN-A was unaware of any other interventions that were utilized to prevent R1 from exit seeking or leaving the facility.
During an interview on 5/1/24 at 1:50 p.m., family member (FM)-A stated R1 was an outdoors person and loved the outside view at the facility. FM-A wished the facility had doors that locked. FM-A stated when she was told R1 was driving a vehicle she was terrified that R1 would hurt himself, or if some little kid was out and [R1] mistook the gas for the brake.
During an interview on 5124 at 2:09 p.m., director of nursing (DON) and assistant director of nursing (ADON) stated their expectations when a resident was exit seeking was to stay with the resident, divert, redirect, find out what the resident was seeking, distract them and see when the last time their needs were addressed. DON stated it would be hard to say what would have stopped R1 from exit seeking on 4/22/24. ADON stated there was a lot of business in the facility that day and that always seemed to be a trigger for R1.
The facility policy titled Wander Management System updated 6/22, identified a wander management alarm system may be used on a resident who is deemed unsafe through the nursing assessment and documented on the resident's care plan that the resident was at risk for elopement. The wander management system should be checked every shift for placement and weekly for function.
The facility policy titled Resident Elopement reviewed 6/22, identified that staff shall investigate and report all cases of missing residents.
1. Staff shall promptly report any resident who tries to leave the premises or is suspected of being missing to the charge nurse or DON.
4. if an employee discovers that a resident is missing from the facility, he/she shall initiate a search of the building and premise, if not located, notifications made to Administrator, DON, resident representative, physician, law enforcement, volunteer agencies, state agency. Proved search teams with resident identification information, initiate an extensive search of the surrounding area.
5. when resident returns to the facility examine the resident for injuries, contact the physician, notify resident representative, notify search teams, apply wander guard bracelet with MD order as needed, complete and file a risk management incident, report to the state agency and update care plan accordingly. Document relevant information in the resident's medical record.
The past non-compliance IJ began on 4/22/23. The IJ was removed, and the deficient practice corrected on 4/23/24 when it was verified the facility had implemented corrective action that included:
-discharged R1 to a secured memory care facility on 4/22/24.
-The facility developed a new protocol to have staff always present in the area of the door leading out of the facility on 4/23/24.
-The facility re-educated staff on response time to the door alarms, and providing adequate supervision for wandering residents on 4/23/24.
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
Transfer Notice
(Tag F0623)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and document review, the facility failed to provide timely discharge notification in writing to the resident/...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and document review, the facility failed to provide timely discharge notification in writing to the resident/resident representative, and the Ombudsman for 1 of 1 residents (R1) reviewed for discharge.
Findings include:
R1's face sheet printed 5/1/24, identified diagnoses of Alzheimer's, dementia, and senile degeneration (mental deterioration associated with age) of the brain.
R1's admission Minimum Data Set (MDS) dated [DATE], identified an admission date of 2/24, severe cognitive impairment with inattention, diabetes, atherosclerotic heart disease, diverticulitis, hypertension, falls, urine retention, hyperlipidemia, disorganized thinking, daily wandering behaviors, and was on hospice.
R1's care plan dated 2/16/24, identified a focus that R1 chose to remain at the facility for long-term care cognitive impairment/hospice care.
R1's progress note dated 4/22/24 at 8:18 p.m., identified that R1's son was called and R1 would be admitted to a dementia unit. Son stated that he would rather R1 stay at the facility. Informed that since he left, we no longer have a say in the matter, and we have to make sure to ensure R1's safety. Son stated that is too bad. At 9:02 p.m., R1 was transported to the other facility via staff car with some personal belongings sent with. At 9:10 p.m., call placed to R1's daughter to update on course of events. Daughter is very upset that resident was moved. Ensured that they could move him to any facility that they want but the dementia unit is secure and tonight he demonstrated what he was capable of, and we are fortunate that no further incidents occurred that could have been tragic. Daughter stated not understanding how this could happen, he moved like a turtle. Reassured daughter that I do not want to argue the facts, but I want her to know that her father is safe and the plan of action for the night.
During an interview on 5/1/24 at 1:50 p.m., family member (FM)-A stated that R1 loved the facility and they did not want him to leave. FM-A indicated the facility had not notified her of discharge in writing on 4/22/23, and given no opportunity to appeal the discharge prior to R1 being discharged .
During an interview on 5/1/24 at 2:09 p.m., with the Director of Nursing (DON) and Assistant Director of Nursing (ADON), and Social Service Director (SSD), the DON stated that they were able to provide for all of R1's needs except more involvement with different departments and structured to what R1 likes. The facility provided a lot of distraction, 1:1 supervision, getting R1 more involved in activities. The DON stated that they have taken care of residents with needs like R1 that ambulated, wandered, participated in activities, and were redirectable. We were usually able to redirect and distract. The SSD stated that they did not follow the 30-day discharge notice per corporate, for his safety, and the safety of other residents.
During an interview on 5/2/24 at 10:42 a.m., Ombudsman (O)-A stated that she was at the facility on 4/26/24 was verbally told that they had moved R1 because corporate told us we couldn't keep him so he moved to the other facility. The facility told O-A that the family did not want R1 to move. O-A explained to the facility that they needed to notify the Ombudsman with discharge information along with family and that it needed to be sent. They have a right to appeal and remain at the facility during the process. O-A stated that this was an unauthorized discharge. O-A stated they told me about R1's elopement and how he drove on the narrow road with the lake on both sides. O-A asked about what was in care plan to keep R1 safe and individualizing it to meet R1's needs and the DON and SSD stared at me with deer in the headlights. O-A stated she still has not received the notice of discharge to another facility for R1.
The facility policy Preparing a Resident for Transfer or Discharge reviewed 1/23, identified that resident will be prepared in advance for discharge.
-A post-discharge plan is developed for each resident prior to his or her transfer or discharge. This plan will be reviewed with the resident, and/or his or her family, at least twenty-four hours before the residents discharge or transfer from the facility.
-nursing will obtain orders for discharge/transfer, as well as recommended discharge services and equipment
Dec 2023
15 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
Report Alleged Abuse
(Tag F0609)
Could have caused harm · This affected 1 resident
Based on interview and document review the facility failed to report an allegation of potential abuse timely to the facility management staff and the State Agency for 1 of 1 resident (R8) reviewed.
F...
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Based on interview and document review the facility failed to report an allegation of potential abuse timely to the facility management staff and the State Agency for 1 of 1 resident (R8) reviewed.
Findings include:
R8's 10/21/23, annual Minimum Data Set (MDS) identified R8 had moderately impaired cognition. R8 was dependent on staff for toileting and cares. R8 had impairment bilaterally in her lower extremities. R8 had inattention and disorganized thinking that fluctuated. R8 had verbal behaviors directed towards others 1-3 days and other behaviors not directed towards others such as screaming, 1-3 days. R8 had no toileting program and was frequently incontinent of bladder and always incontinent of bowel. R8 took a daily anti-psychotic, anti-anxiety, and anti-depressant. R8's 11/30/23, Significant Change MDS assessment identified R8 had severe cognitive deficit.
R8's 5/5/23, care plan identified R8 preferred to use bedpan for toileting and refused to sit on a commode most of the time. R8 required 1 staff assist with bed mobility and was able to assist with turning by using the grab bars on the bed. Behavioral focused area last revised 9/7/22, identified R8 was found to be verbally aggressive. She yelled out to staff to come to her room. She was to ask staff to come back to her room right after they stepped out even after they asked if there was anything else she needed. R8 was socially inappropriate and was known to undress, bang on the walls, threaten staff, call the facility, and making false accusations against staff. There was no mention what staff were to do if R8 made accusations against them.
Interview on 12/18/23 at 12:06 p.m., with R8 identified a guy had helped her earlier today and shook her when he rolled her on her side. R8 reported she told the guy she was going to report him, and he responded he did not care. R8 stated she told the nurse about him.
Interview on 12/18/23 at 5:21 p.m., with licensed practical nurse (LPN)-D identified R8 reported to her a guy was rough when rolling her. LPN-D reported she was unaware of who the male staff was and then reported that R8 was sometimes confused. LPN-D said R8's anxiety was high today. LPN-D reported that R8 will report staff so someone goes into talk to her. LPN-D said there were 2 male staff on duty, and she checked to see who had assisted R8 however, everyone on duty had been in to assist R8 during the shift. LPN-D said if there were concerns, she would report them to the director of nursing (DON), but it depended on the circumstance, as sometimes R8 got upset with staff if they did not come fast enough when she wanted help. Today R8 was upset because the guy (nurse aide (NA-G), a contracted staff) left the room after R8 was placed on the bedpan and R8 wanted him to stay there. LPN-D revealed R8 liked to report staff for things when things did not go exactly as she wanted. LPN-D confirmed she had checked with NA-G and he said he left her room to give her privacy and had visited with R8. LPN-D revealed that R8 had reported her concerns to her around noon-ish that day. LPN-D would not answer if she had reported the allegation of abuse to the DON at that time.
Additional interview on 12/18/23 at 5:43 p.m., with LPN-D identified she had followed up again with R8 who advised her she had not wanted to make a complaint against NA-G. She then reported the allegation to the DON and thought the DON had went in to talk with R8. She also revealed the social service designee (SSD) had been in to talk to R8 during the day due to R8's anxiety. She was unaware if the SSD had knowledge of the incident.
Interview on 12/19/23 at 8:35 a.m., with LPN-B who identified if R8 made a report about a staff member, licensed staff were to make sure R8 was ok and interview the resident to determine as much information about the incident as possible, then interview the staff in question and call the DON for direction before letting the staff proceed with work. LPN-B reported that R8 was known to threaten to report staff sometimes but not frequently. She reported R8 yelled out for help a lot.
Interview on 12/19/23 at 10:10 a.m., with R8 identified a guy had rolled her onto her side and shook her. R8 said she told the nurse and the nurse visited with her and then the head nurse came in and visited with her. She later said there was also a girl in with the guy that shook her and stated she will lie for him. R8 then reported she only spoke to the nurse that was helping her and that no one else talked to her yesterday. She confirmed the guy had not been back to assist her as she had told him he could not come back. She reported when he shook her it made her feel like a pig and when she was asked if she was afraid of this person she stated, yes wouldn't you be.
Interview on 12/19/23 at 10:31 a.m., with nursing assistant (NA)-G identified that R8's mood depended on the day and some days R8 was angry and cursed at staff and complained and other days she was fine. NA-G confirmed he was the staff that had assisted R8 yesterday and R8 accused him of being rough when he turned her on her side. NA-G reported he was the only staff member in the room at the time. He reported R8 was mad and cursing saying this is bullshit as he assisted her to change her brief. He reported after assisting her with her brief she was fine and asked him to help her call her husband. NA-G reported R8 will call her husband if she feels staff are not helping her fast enough or doing a good enough job. NA-G said yesterday was the first time R8 had complained about how he assisted her, and he had assisted her many times. NA-G confirmed that the nurse did speak to him yesterday and asked what had happened and he reported all he had done was turn her on her side to change her brief.
Interview on 12/19/23 at 10:45 a.m., with the DON identified she was unaware of any accusation of staff being rough with R8 yesterday. She reported she was in the building into the evening and had no knowledge of an accusation of staff being rough. She revealed the nurse on duty should have interviewed R8 and informed her immediately so she could interview the staff and other residents. The DON noted R8's care plan identified she had previously made false accusations against staff however, that had not meant staff would not report allegations of potential abuse and facility management would investigate all allegations.
Interview of 12/20/23 at 11:30 a.m. with the SSD identified she was unaware of the allegation of potential abuse with rough care. R8 never mentioned that when she spoke with R8 on 12/18/23.
Review of 10/21/22, Abuse, Neglect, Exploitation or Misappropriation Reporting and Investigation policy identified all reports of abuse would be reported to the state agency and thoroughly investigated by facility management. All reports of abuse must be reported immediately to the administrator and to other officials according to state laws. The administrator will make report to state official immediately within 2 hours of an allegation involving abuse or result in serious bodily injury. Upon receiving an allegation of abuse the administrator was responsible for determining what actions (if any) are needed for the protection of the residents. All reports would be thoroughly investigated. Employees who have been accused of resident abuse would be placed on leave with no resident contact until the investigation was completed. A follow up 5-day report of the investigation with sufficient information to describe the results of the investigation and any corrective action taken if allegation was verified.
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
Assessment Accuracy
(Tag F0641)
Could have caused harm · This affected 1 resident
Based on observation, interview, and document review, the facility failed to ensure the Minimum Data Set (MDS) assessment accurately reflected the status and needs for 1 of 1 resident (R9) for depress...
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Based on observation, interview, and document review, the facility failed to ensure the Minimum Data Set (MDS) assessment accurately reflected the status and needs for 1 of 1 resident (R9) for depression.
Findings include:
R9's undated, current care plan identified R9 would be free from discomfort or adverse reactions to antidepressant medication through the review date. Staff were to administer antidepressant medication as ordered by physician. Staff were to monitor and document side effects and effectiveness of medication every shift and report adverse reactions of medications and consult Southwest Mental Health for services. The care plan identified side effects for antidepressant medication but lacked identification of target symptoms that were to be monitored for effectiveness.
R9's 10/02/23 Southwestern Mental Health Center Standard Diagnostic Assessment identified R9 had a depression disorder.
R9's 11/09/23, quarterly Minimum Data Set (MDS) assessment identified R9 had no cognitive impairment. R9 had little interest in doing things, feeling down, depressed, or hopeless, trouble concentrating on things, and feeling tired or having little energy for 12 to 14 days. R9 took a daily antidepressant and antipsychotic. R9 had a diagnosis of anxiety but did not indicate a diagnosis of depression. R9 had cerebral infarct of right middle cerebral artery (stroke occurs when blood flow from the main carotid artery of the brain suddenly stops), peripheral vascular disease, nicotine dependence, and anxiety.
R9's 12/21/23, physician Order Summary Report identified the following medication orders:
1) mirtazapine 15 milligrams (mg) at night for depression
2) risperidone (used to treat schizophrenia, bipolar disorder, or irritability associated with autistic disorder) 1 mg at night for depression disorder
3) clonidine 0.1 mg three times a day for anxiety and depression
The physician Order summary had no indication of target symptoms ordered to treat with use of the antidepressants.
Interview on 12/20/23 at 5:13 p.m., with registered nurse (RN)-A stated R9's depression diagnosis was not listed on his current medical record or in the MDS.
Interview on 12/21/23 at 9:02 a.m., with DON-A stated R9's depression diagnosis wasn't identified and had no behavior monitoring in place for R9's depression.
A policy was requested but none provided by the end of the survey.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Quality of Care
(Tag F0684)
Could have caused harm · This affected 1 resident
Based on interview and document review, the facility failed to have an integrated hospice care plan for 1 of 1 resident (R27).
Findings include:
R27's 12/6/23, Significant Change Minimum Data Set (MDS...
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Based on interview and document review, the facility failed to have an integrated hospice care plan for 1 of 1 resident (R27).
Findings include:
R27's 12/6/23, Significant Change Minimum Data Set (MDS) assessment, identified diagnoses of malignant neoplasm of the lung (cancer), chronic obstructive lung disease (COPD), required oxygen therapy and was admitted to hospice care.
R27's current, undated care plan identified there was no mention R27 was on hospice services, what services the facility was to provide, nor services the hospice agency was to provide.
Interview and document review on 12/19/23 at 10:02 a.m., with LPN-A identified R27's care plan failed to contain documentation of any hospice services, R27's oxygen use, or use of a Foley catheter which should have been documented and included ont he facility care plan. LPN-A agreed it was not documented on what services hospice was to provide.
Interview on 12/19/23, at 10:14 a.m., with the director of nursing (DON) confirmed her expectation for coordination of services between hospice providers and the facility. She confirmed the information on hospice and facility provided services had not been included in R27's current care plan.
Interview and document review on 12/19/23 at 2:25 p.m., with the hospice registered nurse (RN)-B reported she had previously visited R27 weekly, but following a discussion on the evening of 12/18/23 the decision was made to decrease visits to once weekly for RN and twice for NA services. The social services provider was scheduled to visit 1-2 times a month and as needed. RN-B identified a blue binder, located at the nursing station contained a calendar with scheduled hospice staff visit dates. Review of the calendars for December 2023 and January 2024 with RN-B confirmed they were blank and had not been competed as per policy. RN-B confirmed the care plan for R27 had not been updated as per policy until 12/19/23 and facility and hospice staff should have coordinated services to be provided and documented those services provided by each entity in the facility care plan.
Review of the May 5, 2021, Hospice Program policy identified a coordinated plan of care was to be developed between the facility, hospice agency and the resident/family. The plan of care was to include hospice staff schedules, pain and/or comfort management plans, and be revised or updated as indicated.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Tube Feeding
(Tag F0693)
Could have caused harm · This affected 1 resident
Based on observation, interview, and document review the facility failed to ensure staff sanitized a gastronomy tube (G-tube) port prior to initializing enteral feeding (nutrition provided thru a tube...
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Based on observation, interview, and document review the facility failed to ensure staff sanitized a gastronomy tube (G-tube) port prior to initializing enteral feeding (nutrition provided thru a tube directly into the stomach) for 1 of 1 resident (R14) during 2 of 2 observations.
Findings include:
R14's undated, current Medical Diagnosis identified diverticulitis (small bulging pouches in the digestive tract that become inflamed or infected) of intestine, disease of digestive system, neutropenia (abnormally low count of a type of white blood cell), malignant neoplasm (cancerous tumor) of lip, oral cavity and pharynx and mild cognitive impairment.
R14's undated care plan, identified R9 had potential for alteration in nutrition and dehydration due to malignant neoplasm. Staff were to monitor the G-tube site for signs of infection and would provide enteral feeding and water flushes as ordered.
R14's 10/1023, quarterly Minimum Data Set (MDS) identified R14 had a feeding tube. R14 would receive 51% or more of total calories and 501 milliliters (ml) a day or more of fluid intake through tube feeding. R14 had no cognitive impairment or behaviors. R14 was dependent for eating, toileting and cares.
R14's 12/20/23, physician Order Summary Report identified R14 had a regular diet, with regular texture and regular (thin) consistency and would eat only at noon meals. R14 had enteral tube feeding via gravity (natural flow infusion) ordered for twice a day with 30 milliliters (ml) of water to be used for a flush and additional fluid before and after feeding twice daily, and 250 ml of a free water flush 1 x day for additional hydration.
Observation and interview on 12/19/23 at 9:07 a.m., licensed practical nurse (LPN)-A washed her hands, donned PPE (personal protection equipment) (gown and gloves, gathered R14's medications and feeding supplies before entering R14's room. R14 had enhanced barriers precautions, requiring staff to wear PPE when accessing her gtube. R14 was sitting her recliner watching television. LPN-A entered R14's room and placed clamped feeding bag and tubing up on the IV pole next to R14's recliner and her supplies on the R14's bedside table. R14's tubing had no cover on the port and was exposed. LPN-A washed her hands and donned gloves, grabbed a stethoscope, placed them in her ears and put the diaphragm on R14's left side of her abdomen. LPN-A grabbed a syringe, attached it to R14's G-tube port without first sanitizing the uncovered port, then pulled back to check for gastric residual in the port. R14's port had less than 5 mLs of residual gastric fluid. LPN-A pushed 30 mLs of water through syringe into R14's G-tube. LPN-A asked R14 if she had any discomfort. R14 stated no. LPN-A removed the syringe and placed the syringe tip to R14's port. LPN-A administered R14's levothyroxine in the piston syringe attached to the port, poured the medication into port closed the gtube port, drew up 30 mLs of water and pushed it through the piston syringe into R14's gtube. LPN-A removed the inner portion of the syringe and connected the feeding bag to R14's G-tube port. LPN-A unclamped the feeding bag releasing the enteral feed by gravity. LPN-A removed her gloves and her PPE, left the room and sanitized her hands. LPN-A was asked if she sanitized the feeding tube port before connecting it to R14's gtube. LPN-A stated she was not trained to sanitize it before connecting it and would implement the practice.
Observation and interview on 12/19/23 at 4:28 p.m., with LPN-F washed her hands, donned PPE and gloves, grabbed R14's piston syringe and water to the bedside table. R14 was sitting in recliner with television on. LPN-F grabbed the stethoscope and placed them in her ears and put the diaphragm on R14's left side of her abdomen. LPN-F grabbed R14's syringe, attached it to R14's G-tube port without sanitizing the port, then pulled back to check for gastric residual in the port. R14's port had less than 5 mLs of gastric residual. LPN-F pushed 60 mLs of water through the syringe into R14's gtube. LPN-F separated the syringe, and poured Miralax (treat occasional constipation) medication through the syringe, mixed in water into R14's G-tube and closed the port. LPN-F then reconnected both syringe pieces and drew up 60 mLs of water and pushed it through R14's G-tube. R14's feeding bag port had been observed uncovered on the IV pole in the room. LPN-F connected the clamped feeding bag tube to the R14's G-tube. LPN-F then unclamped the feeding bag, releasing the enteral feed by gravity. LPN-F removed her gloves and her PPE, left the room and sanitized her hands. LPN-F was asked if she sanitized the feeding bag port before connecting it to R14's gtube. LPN-F stated she did not wipe the port before connected it to R14's gtube.
Interview on 12/20/23 at 9:49 a.m., director of nursing DON-A identified her expectations would be for nurses to use clean technique when preparing or administering enteral feedings by sanitizing the port before connecting a syringe to lessen the chances of potential infection.
Review of September 2021, Enteral Tube Feeding via Gravity Bag policy identified aseptic (clean) technique would be used when preparing and administering enteral tube feedings. There was no mention staff should sanitize the port.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Medication Errors
(Tag F0758)
Could have caused harm · This affected 1 resident
Based on interview and document review the facility failed to comprehensively assess and identify target behaviors and non-pharmacological interventions for scheduled antidepressant and antipsychotic ...
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Based on interview and document review the facility failed to comprehensively assess and identify target behaviors and non-pharmacological interventions for scheduled antidepressant and antipsychotic medication for 1 of 5 residents (R23) reviewed for unnecessary medication usage.
Findings include:
R23's 11/30/23, significant change Minimum Data Set (MDS) assessment identified R23 had moderately impaired cognition. R23 had no behaviors identified. R23 had diagnosis of thyroid disorder, fracture, seizure disorder, depression, and manic depression bipolar type. R23 took a daily antidepressant and antipsychotic.
R23's 9/11/23, care plan identified R23 used an antidepressant for depression. R23 would be free from discomfort or adverse reactions to antidepressant medication through the review date. Staff were to administer antidepressant medication as ordered by physician. Staff were to monitor and document side effects and effectiveness of medication every shift. The care plan identified side effects for antidepressant medication but lacked identification of target symptoms that were to be monitored for effectiveness. R23 used an antipsychotic medication for bipolar management. R23 would remain free of psychotropic medication complication, including movement disorder, discomfort, hypotension, gait disturbance, constipation, or cognitive impairment through the review date. Staff were to administer the psychotropic medication as ordered by the physician and monitor for side effects and effectiveness every shift. The care plan identified side effects for psychotropic medication however, had no mention of target behaviors to monitor for effectiveness.
R23's 12/20/23, physician Order Summary identified the following medication orders:
1) Bupropion HCI ER (antidepressant) 150 milligrams (mg) every day (QD) in morning for depression.
2) Fluoxetine HCI (antidepressant) 20 mg QD in morning for major depressive disorder, severe with psychotic symptoms.
3) Fluoxetine HCI (antidepressant) 40 mg QD in morning for major depressive disorder, severe with psychotic symptoms.
4) Olanzapine (antipsychotic) 20 mg QD at bedtime for Bipolar.
The order summary had no indication that the antidepressant nor the antipsychotic medication were being monitored for effectiveness or what the target symptoms were that the medications were ordered to treat.
Interview on 12/20/23 at 3:49 p.m., with director of nursing (DON) identified her expectation was residents receiving psychoactive medication would have target behaviors identified for what the medication was being prescribed to treat. She also reported residents receiving psychoactive medication had non-pharmacological intervention in place. She agreed if there were no target behaviors identified it would be hard to assess if the medication was effective or not. She expected the facility policy for psychoactive medication use to be followed.
Review of the 7/13/23, Antipsychotic Medication Use policy identified residents would only be prescribe antipsychotic medication to treat specific condition indicated. The provider would identify and document symptoms that may warrant the use of an antipsychotic medication. If a resident was admitted and was already receiving an antipsychotic medication the resident would be assessed for appropriateness and indications for use. Antipsychotic medications are ordered to treat specific condition and will be used within the dosage guidelines. Medication monitoring for side effects and effectiveness including any intervention effectiveness, with any adverse consequences reported to the provider.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0849
(Tag F0849)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and document review, the facility failed to ensure coordinated hospice services were documented...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and document review, the facility failed to ensure coordinated hospice services were documented as scheduled for 1 of 1 resident (R27), have a clear communication process for hospice to notify the facility of their updates, for the facility to notify the hospice of changes to R27's health status, need of potential transfers for care, or delineation of hospice services to be provided.
Findings include:
R27's 12/6/23, Significant Change, Minimum Data Set (MDS) identified R27's diagnoses of malignant neoplasm of the lung (cancer), chronic obstructive lung disease (COPD), and received oxygen. R27's cognition was intact, and she required limited to extensive assistance for most cares and would attempt to self-transfer at times and required a gait belt, walker, and assistance of one for ambulation.
R27's progress notes identified R27 was hospitalized on [DATE] through 12/1/23 following a fall when she attempted to self-transfer. She returned to the facility on [DATE] and was admitted to hospice.
Interview on 12/18/23 at 2:02 p.m., with R27 reported she had started hospice after she came back from the hospital because she had lung cancer, and it was spreading. R27 was not certain when the hospice nurse or aide were supposed to come, but she thought it was weekly. R27 denied receiving a schedule or having knowledge of when hospice staff would be visiting or what services they would provide.
Observation of R27 on 12/19/23 at 9:04 a.m., as she was lying in bed, was offered and refused breakfast and stated she wanted to sleep longer. R27 denied pain and shortness of breath and had her oxygen on via nasal cannula.
Interview on 12/19/23 at 9:08 a.m., with nursing assistant (NA)-H reported she was aware R27 was on hospice, but she was not certain when hospice staff would visit. She reported she was not aware of a schedule of visits but thought there may be a book at the nurses desk that contained the information.
Interview and document review on 12/19/23 at 9:29 a.m., with licensed practical nurse (LPN)-B reported there was a hospice book at the nurse's station that contained contact and schedule information. She reported she thought hospice staff documented their visits, but she was not certain where to find their documentation. LPN-B reported hospice staff did not have access to Point Click Care (PCC), and she thought a report was sent to the facility after each weekly visit. LPN-B retrieved the hospice book which contained a copy of a blank calendar for the months of December 2023 and January 2024 and reported she thought they were supposed to have written down the dates for visits. The calendar in the book was where she would expect to find the schedule of visits and since it had not been filled out, she was not certain when they would be visiting.
Interview on 12/19/23 at 10:02 a.m., with LPN-A reported Hospice had a book kept at the nursing station with the contact information and schedules for visits, but confirmed the current schedule for December 2023 and January 2024 were blank and she was not certain when they would be coming to the facility.
Interview and review of R27's medical record on 12/19/23 at 10:14 a.m., with the director of nursing (DON) identified visits were to be marked on the calendars so staff would be aware of when hospice would come. There was no mention on R27's care plan of any hospice services to provide to delineate their provision of services.
Interview on 12/19/23 at 2:25 p.m., with registered nurse (RN)-B (hospice) reported she was previously coming twice weekly but following discussion with R27 on 12/18/23, the decision was made to decrease visits to once weekly for the RN and twice weekly for the hospice aide. Hospice social services came to see residents 1-2 times a month or as needed, and all hospice visits should have been documented on the calendar. RN-B confirmed the calendar had not been completed as per policy to include dates of hospice staff visits. RN-B reported hospice documentation by both the nurse and aide was completed on a remote chart since hospice staff did not have access to the facility PCC. A verbal update was given to facility staff following a hospice visit and documentation was sent to the facility weekly after hospice documented care and findings in their records. RN-B confirmed there would normally be a physician order for use of a Foley catheter with direction for use. She agreed R27's care plan had not been updated to include hospice information prior to notification on 12/19/23.
Review of the May 5, 2021 Hospice Program policy identified a coordinated plan of care was to be developed between the facility, hospice agency and the resident/family.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected 1 resident
TBP
Observation on 12/20/23 at 3:59 p.m., of R183's room door had a new sign posted that read Enhanced barrier. Wear gloves and gown for high contact activities.
R183's 12/20/23 progress note identif...
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TBP
Observation on 12/20/23 at 3:59 p.m., of R183's room door had a new sign posted that read Enhanced barrier. Wear gloves and gown for high contact activities.
R183's 12/20/23 progress note identified at 11:31 a.m., R183 had tested positive for COVID-19. R183's room door had been shut and the DON and staff on duty had been notified. Additional note at 2:30 p.m., identified R183 had all services provided in R183's room until they would be off isolation. R183's physician and family had been notified of the positive test result.
Interview and observation on 12/20/23 at 4:02 p.m., with director of nursing (DON) identified R183 had new diagnosis of COVID-19 and had been placed on precautions. The DON was unsure who was responsible to set up the personnel protective equipment (PPE) and post the signage. The DON confirmed the wrong sign had been placed on R183's door that identified Enhanced barrier precautions The DON then placed a sign on the door that identified Contact precautions. Everyone must wash hands before and after, and use a glove, gown, mask, and face shield. Additionally, a sign that identified how to don and doff PPE, and a stop sign was placed on the door to See nurse before visiting resident. Next to the door was a cart with PPE supplies which also included N95 masks and face shields.
Interview and observation on 12/21/23 at 8:56 a.m., with licensed practical nurse (LPN)-C who reported the facility had multiple precaution signs that they used depending on what type of precaution a resident was on. She confirmed and displayed a stack of precaution signs located at the nurse's station on the 300 wing. The signs observed included enhanced precautions, contact precaution, droplet precautions, and airborne precautions. LPN-C confirmed that residents who have tested positive with COVID-19 were to have droplet precautions put into place.
Interview and observation on 12/21/23 at 9:03 a.m., with DON identified she had signage for droplet precautions and airborne precautions. She was unaware she had posted the incorrect Contact precaution sign on R183's room door. The DON confirmed a resident positive with COVID-19 should be placed on Droplet or Airborne precautions. The DON then obtained both a sign for Droplet precautions and Airborne precautions and posted both signs on R183's room door.
Review of October 2021, Isolation Categories of Transmission-Based and Enhanced Precautions policy identified standard precaution are used during times of resident cares, transmission-based precautions include 3 types:
1) Contact,
2) Droplet,
3) Airborne.
Use was to be determined by the specific pathogen and how it was spread. Staff were to place the appropriate notification on the room door when a resident was placed on TBP. Contact precautions were implemented when a resident was suspected or was known to be infected with an microorganism that was transmittable via direct contact. Droplet precautions were to be implemented when a resident has been suspected or confirmed to be infected with an microorganism that can be transmitted by droplets such as sneezing, coughing, or suctioning. Airborne precautions are implemented when a resident has been infected with an pathogen that can be transmitted long distance through the air. Enhanced precautions would only be implemented to protect from exposures to anticipated blood or body fluids.
Based on observation, interview, and document review, that facility failed to use appropriate infection control technique during 1 of 1 dressing change for resident (R28). In addition, the facility failed to ensure appropriate Infection control (IC) signage was posted outside 2 of 6 resident (R8, and R 103 x 2) rooms that had been placed on transmission-based precautions (TBP).
Findings include:
DRESSING CHANGE
Observation and interview on 12/19/23 at 12:19 p.m., with licensed practical nurse (LPN)-A as she performed a dressing change on R28's right shin, and right and left foot wounds identified R28 was seated in his recliner with both feet wrapped and resting on the floor. LPN-A obtained a plastic carrier with dressing supplies, placed it on the uncovered floor, placed a chux on the floor and picked up the plastic carrier and set it on the chux. She then applied gloves and sat on the floor to begin removing the stockinet from R28's right shin. A quarter sized area of dried red drainage was noted on the stockinet which was removed and placed on the chux on the floor. LPN-A removed the dressing covering the wounds on R28's right shin, posterior calf, and covering 2nd toe of right foot and placed the used dressings on the chux. LPN-A retrieved bottle of VASHE solution (wound cleanser), and bottle of saline from the tray, and when asked stated it had been sent back with R28 from the wound clinic last week. LPN-A used the bottle of saline to pour onto the old dressing to loosen it and handled the bottle of saline and old dressing with her gloved hands. A moderate amount of serosanguinous drainage was noted on the dressing and once removed was placed on the chux on the floor beside the clean dressing supplies. LPN-A then returned the bottle of saline to the carrier and placed it inside without disinfecting the outside of the bottle in order to co-mingle supplies appropriately without contamination. LPN-A then removed her gloves and performed hand hygiene, applied new gloves, obtained the VASHE solution and applied it onto a sterile gauze pad. After applying the solution, LPN-A returned the contaminated bottle back into the carrier to be co-mingled with other supplies without first disinfecting the bottle to prevent potential contamination. LPN-A then retrieved betadine solution and placed that onto a sterile gauze pad and applied to the scabbed areas on R28's right toe and posterior shin areas. LPN-A removed her contaminated gloves and placed them on the clean barrier chux she had placed on the floor, performed hand hygiene and applied new gloves. LPN-A then retrieved moisturizing lotion, applied it, and returned it to the bin with the contaminated items.
Further observation on 12/19/23 at 12:42 p.m. with LPN-A as she changed the dressing on R28's left foot identified the previously mentioned contaminated and soiled dressings and gloves remained on the chux barrier on the floor as she began the dressing change on the left foot. A trash can with a plastic liner was noted beside R28's nightstand and would have been within LPN-A's arms reach but was not used. LPN-A then removed R28's contaminated soiled dressings on his left foot. Without changing gloves or performing hand hygiene, LPN-A picked up the bottle of contaminated VASHE solution from the bin and applied the solution to a sterile gauze pad, contaminating the pad. She then applied the solution to the wound and dabbed the wound dry with the contaminated gauze pad. She then removed her gloves and performed hand hygiene and applied new gloves. LPN-A then cut a new abdominal (ABD) pad, placed it over the wound and taped it secure. She then replaced the stockinet to cover the wound area on the left foot. LPN-A removed her contaminated glove from her right hand and used that hand to open R28's nightstand drawer to obtain a pair of clean gripper socks without removing both gloves and performing hand hygiene. She reached into the drawer and handled the socks and other miscellaneous items with both her ungloved and soiled gloved hand contaminating the socks and any items within that drawer. She then applied the gripper socks with her ungloved and contaminated gloved hand. LPN-A then removed the contaminated glove, placed it on the chux, and rolled up the chux barrier pad to cover the soiled dressings without performing hand hygiene. LPN-A then picked up the dressing supply bin and returned it to the top of the nightstand in R28's room. She then went to the bathroom to wash her hands. After washing her hands, LPN-A had not donned new gloves. She then collected the contaminated chux barrier pad with her clean hands that contained the soiled, contaminated dressings, without donning gloves or a gown or placing those items in a plastic bag, and left R28's room. She disposed of the items in the soiled utility room and then performed hand hygiene.
Interview on 12/19/23 at 12:50 p.m. with LPN-A reported she had used a barrier pad as not to placed the contaminated dressings or previously used items on the floor and was unaware she had contaminated her clean area. When asked about using the trash can, replied she had not thought of that. When asked about the contamination of using her same gloved hand that had changed the dressing on R28's left foot to retrieve his clean socks, she stated she was unaware she had done that. LPN-A agreed she had not followed IC procedures for wound care, contaminated clean items, failed to disinfect containers of multi-use wound treatments, and sterile gauze etc. She was unaware she had cross contaminated R28's wounds with germs from not using proper IC technique.
Interview on 12/20/23 at 4:30 p.m. with the director of nursing/infection preventionist (IP) reported her expectation for staff to follow IC protocols when completing dressing changes and voiced agreement with the above noted concerns.
Review of the September 29, 2021, Wound Care Policy identified staff were to use a disposable item such as a chux to establish a clean surface for putting clean supplies on that were to be used during the procedure. Gloves were to be discarded and hand hygiene performed appropriately. Staff were to disinfect reusable supplies and surfaces of bottles or containers with a disinfectant as needed.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0883
(Tag F0883)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and document review, the facility failed to offer and provide the most recent Centers for Disease Control (CD...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and document review, the facility failed to offer and provide the most recent Centers for Disease Control (CDC) education regarding the potential risks and benefits of the pneumococcal vaccine for 2 of 5 residents (R8, R9) reviewed for immunizations. Furthermore, the facility failed to have a method or system to ensure the facility offer or provided any initial or updated vaccine to residents per Centers for Disease Control (CDC) vaccination recommendations.
Findings include:
Review of the current CDC pneumococcal vaccine guidelines located at https://www.cdc.gov/vaccines/vpd/pneumo/hcp/pneumo-vaccine-timing.html, identified for:
Adults [AGE] years of age or older, staff were to offer and/or provide based off previous vaccination status as shown below:
a) If NO history of vaccination, offer and/or provide:
aa) the PCV-20 OR
bb) PCV-15 followed by PPSV-23 at least 1 year later.
b) For PPSV-23 vaccine ONLY (at any age):
aa) PCV-20 at least 1 year after prior PPSV-23 OR
bb) PCV-15 at least 1 year after prior PPSV-23
c) For PCV-13 vaccine ONLY (at any age):
aa) PCV-20 at least 1 year after prior PCV13 OR
bb) PPSV-23 at least 1 year after prior PCV13
d) For PCV-13 vaccine (at any age) AND PPSV-23 BEFORE 65 years:
aa) PCV-20 at least 5 years after last pneumococcal vaccine dose OR
bb) PPSV-23 at least 5 years after last pneumococcal vaccine dose
e) Received PCV-13 at any age AND PPSV-23 AFTER age [AGE] Years:
aa) Use shared clinical decision-making to decide whether to administer PCV20. If so, the dose of PCV-20 should be administered at least 5 years after the last pneumococcal vaccine.
R8's 10/21/23, annual Minimum Data Set (MDS) assessment identified R8 was [AGE] years old and had diagnoses of Heart failure and hypertension, anxiety, and depression.
R8's immunization record identified R8 had received the pneumococcal polysaccharide vaccine (PPSV-23) on 5/16/95 and had received the pneumococcal conjugated vaccine (PCV-13) on 6/28/18. R8's medical record did not include evidence R8 or R8's representative received education regarding pneumococcal vaccine booster, the physician notified, or indication R8 was offered the PCV-20 at least 5 years after prior pneumococcal vaccine per CDC guidance.
R9's 11/9/23, quarterly Minimum Data Set (MDS) assessment identified R9 was [AGE] years old and had diagnoses of hypertension, stroke, and peripheral vascular disease.
R9's immunization record identified R9 had received pneumococcal polysaccharide vaccine (PPSV-23) on 8/14/17 (approximately at [AGE] years of age). R9's medical record did not include evidence R9 or R9's representative received education regarding pneumococcal vaccine booster and there was no indication R9 was offered PCV-20 at least 1 year after prior PPSV-23 or a PCV-15 at least 1 year after prior PPSV-23 per CDC guidance.
Interview on 12/20/23 at 3:49 p.m., with the director of nursing (DON) identified that neither resident had been offered updated vaccination and should have been. The DON revealed the facility had no method after admission to ensure vaccines were offered to residents when eligible.
Review of undated, Pneumococcal Vaccine policy identified residents would be offered pneumococcal vaccines to prevent pneumonia. Upon admission residents would be assessed for eligibility to receive the pneumococcal vaccine series and when indicated would be offered unless medically contraindicated. Pneumococcal vaccines would be made in accordance with current CDC recommendations.
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 F0940
(Tag F0940)
Could have caused harm · This affected 1 resident
Based on interview and record review, the facility failed to ensure that 1 of 1 agency staff (nursing assistant (NA)-G) was oriented to the facility policies and procedures including Abuse, Neglect, E...
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Based on interview and record review, the facility failed to ensure that 1 of 1 agency staff (nursing assistant (NA)-G) was oriented to the facility policies and procedures including Abuse, Neglect, Exploitation or Misappropriation, Reporting, and Investigating.
Findings include:
Interview on 12/19/23 at 10:31 a.m., with NA-G revealed he had worked with R8 on 12/18/23 and confirmed R8 had accused him of being rough when he turned her on her side. NA-G revealed the nurse had come and talked to him about R8 accusing him of being rough. NA-G reported R8 was in a bad mood and was cursing at him while he assisted her to turn on her side. NA-G revealed he had not told anyone that R8 had accused him of being rough during cares as R8 was fine after he had changed her incontinent product and even had him assist her to call her husband.
Review of NA-G training records obtained from the agency NA-G was employed by included a copy of an employee handbook and policies that covered the NA job description, resident abuse, neglect, and reporting. NA-G had a signature that was time stamped at 3:26 p.m. on 12/19/23, after this surveyor requested NA-G training records.
Interview on 12/20/23 at 9:24 a.m., with trained medication assistant (TMA)-A who was also the staffing coordinator, identified NA-G was an agency staff. When agency staff start at the facility, they usually come an hour or two before their shift starts to get orientated to the floor. As the staffing coordinator, she was unaware of any other type of orientation that was required such as being oriented to facility policies. TMA-A reported there was no documentation that NA-G had been orientated to the facility specific policies prior to working his first scheduled shift.
TMA-A was unsure if NA-G was aware of who he should report concerns to especially if a resident accused staff of potential abuse or rough care, but would assume that the agency staff would know to report to the charge nurse.
Interview on 12/20/23 at 11:38 a.m., with director of nursing (DON) revealed the facility had no orientation on policies and procedures for contractual staff including NA-G. She reported the only training she could provide for NA-G regarding abuse and reporting was the training that NA-G received through his agency.
Review of October 2023, Facility Assessment identified all new staff are required to have onboarding videos in Healthcare Academy and in Relias. All new hires will also have competencies related to their job description and for any sort of special care needs for facility residents. There was no mention of training or orientation for contractual staff providing services being oriented to facility specific policies.
Review of 11/23/22, Orientation Program for Newly Hired Employees, Transfers, Volunteers identified those staff providing services under contractual arrangements shall be orientated to the facility policies. The orientation program included tour of facility, description of the resident population, instructions in an emergency, resident care procedures, and introduction to administrative structure. The policy identified contractual staff would receive general orientation and an in-depth review of the facility's policies and protocols that would be documented on a check list form identifying what materials had been reviewed.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Respiratory Care
(Tag F0695)
Could have caused harm · This affected multiple residents
R25's 9/22/23, quarterly Minimum Data Set (MDS) assessment, identified R25's Brief Interview for Mental Status (BIMS) had mild cognitive impairment and diagnosis of cerebral edema (swelling that occur...
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R25's 9/22/23, quarterly Minimum Data Set (MDS) assessment, identified R25's Brief Interview for Mental Status (BIMS) had mild cognitive impairment and diagnosis of cerebral edema (swelling that occurs in the brain) and chronic obstructive pulmonary disease. The MDS failed to identify R25 used oxygen therapy.
R25's November 2023, Medication Administration Record (MAR) identified oxygen (O2) as needed to maintain O2 saturation over 90% every shift titrated as needed. Oxygen tubing was to be changed on Saturdays. The MAR identified O2 tubing had last been replaced on 11/25/23.
Observation on 12/18/23 at 3:41 p.m., of R25's tubing identified her tubing was labeled as last changed on 11/28/23.
Observation on 12/18/23, identified R183 had an oxygen concentrator with humidifying bubbler. The oxygen tubing and humidifier identified no date to indicate when it had last been changed.
Observation on 12/19/23 at 10:15 a.m., R183's oxygen tubing and bubbler remained undated.
R183's 12/12/23, admission Minimum Data Set (MDS) assessment identified she was dependent on staff for assistance with cares. R183 had shortness of breath or trouble breathing with exertion, while at rest and when lying flat. diagnosis of chronic obstructive pulmonary disease with acute exacerbation (COPD) and acute and chronic respiratory failure with hypercapnia (build up of carbon dioxide in your bloodstream).
R183's administration orders identified she was receiving 2 liters of oxygen per nasal cannula at rest and 4 liters with activity to maintain oxygen saturations between 90%-92% for COPD. R183's orders lacked any indication staff were to change oxygen tubing or humidifier on a regular basis.
Interview on 12/19/23, at 12:33 p.m., with LPN-B identified they normally put a nursing order in the administration record to change oxygen tubing and bubbler water weekly. She identified the tubing should have been dated. LPN-B looked at R183's orders and identified she was not able to find an order to change the tubing but stated it should have been there.
R18's 12/20/23, admission MDS identified .
R18's 9/26/23, quarterly Minimum Data Set (MDS) assessment identified R18 was dependent on staff for cares. R18 was short of breath when lying flat and had diagnosis of heart failure, chronic respiratory failure with hypoxia (lack of oxygen), and chronic obstructive pulmonary disease.
R18's 7/27/23, care plan identified R18 used oxygen at 2 liters via nasal cannula to keep oxygen level above 90%.
Observation and interview on 12/18/23 at 5:31 p.m., of R18's oxygen tubing identified oxygen tubing was dated 11/26/23. R18 reported the staff change the oxygen tubing each week.
Based on observation, interview and document review the facility failed to have a method to identify when oxygen tubing needed to be changed for 4 of 4 residents (R18, R25, R27, and R183). The policy also failed to include documentation of the frequency for oxygen equipment changes for residents receiving oxygen.
Findings include:
R27's 12/6/23, Significant Change Minimum Data Set (MDS) assessment, identified R27 had intact cognition, and had diagnoses of malignant neoplasm of the lung (cancer), chronic obstructive lung disease (COPD), and required oxygen therapy.
R27's, required oxygen at 2 liters (L) / minute (Min) continuously via nasal cannula for hypoxemia (a low level of oxygen in the blood).
Observation on 12/18/23 through 12/20/23 identified an oxygen concentrator with a nasal cannula attached to a long tubing going from the concentrator to R27. Neither the tubing or concentrator contained a date of when it had last been changed or replaced.
Interview on 12/19/23 at 9:04 a.m. with R27 reported she always needed her oxygen on, and she did not know when staff had last changed the tube.
Interview on 12/19/23 at 9:08 a.m. with nursing assistant (NA)-H reported R27 used her oxygen all the time. She reported nursing took care of changing the tubing and she was not aware of when it had last been changed.
Interview and document review on 12/19/23 at 10:02 a.m. with licensed practical nurse (LPN)-A confirmed she was not able to find documentation of the frequency for oxygen tubing changes, nor when it had last been changed. LPN-A reported oxygen tubing was supposed to be changed weekly on Sunday, and a tag placed on the tubing with the date and initials. She confirmed there was no documentation in either the MAR or TAR that R27's tubing had been changed.
12/19/23 at 10:14 a.m., interview with DON confirmed her expectation for oxygen orders to be included in the care plan and upon review of R27's care plan confirmed it was not present. The DON confirmed the O2 tubing had not been dated when it was last changed, and it should have been changed weekly and dated with initials on the MAR/TAR.
Review of the November 1, 2021, Med-Pass Oxygen Administration policy identified the purpose to provide safe oxygen administration. The facility was to verify there was an order for oxygen administration. The policy failed to identify the need to document the frequency of tubing changes, and application of a date and initial of when the tubing was last changed on either the tubing and/or medical record.
CONCERN
(E)
📢 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 F0725
(Tag F0725)
Could have caused harm · This affected multiple residents
6) Interview on 12/18/23 at 5:10 p.m., with R25 revealed she had to wait 15 to 30 minutes for staff response to the call light when needing assistance to the bathroom. R25 stated she didn't feel impor...
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6) Interview on 12/18/23 at 5:10 p.m., with R25 revealed she had to wait 15 to 30 minutes for staff response to the call light when needing assistance to the bathroom. R25 stated she didn't feel important when having to wait for assistance from staff.
R25's 9/22/23, quarterly Minimum Data Set (MDS) identified R25 had mildly impaired cognition. R25 had diagnosis of hemiplegia (total or complete paralysis on one side of the body). R25 was dependent on staff for toileting and cares. R25 had impairment bilaterally in lower extremities. R25 had no toileting program and was frequently incontinent of bladder and always incontinent of bowel and took scheduled pain medication in the last 5 days.
Interview and document review on 12/21/23 at 8:21 a.m., with the director of nursing (DON) identified her expectation for the staffing level in the facility was for it to be in accordance with the listed facility staffing pattern identified in the Facility Assessment noted above. Review of the reported staffing data report (PBJ) identified the DON agreed staffing had not been provided according to the Staffing Plan documented in the current Facility Assessment.
Review of the October 2023, Facility Assessment identified the facility was to have the following nurse aides on duty each shift:
1.) Days-AM's 4 nursing assistants (NA)s
2.) PMS-4 NAs
3.) Nights-2-3 NAs
Staffing was to be evaluated and adjusted by the DON, dietary manager, activity manager, housekeeping manager, and the administrator, along with the charge nurse's oversight for direct care (nurse aides). After classification and staffing requirements were completed, targets were to be established and variances managed by moving staff, or calling in potential relief staff (agency staff) or extra facility staff.
Review of the documented staffing on weekends for the months of October and November 2023, and 12/1/23 through 12/20/23 identified:
1.) 10/7/23 and 10/20/23 through 10/22/23, 1 NA was scheduled for night shifts. On 10/7/23 and 10/28/23, 3 NAs for PM shift.
2.) 11/11/23, staffing showed only 1 NA night shift. On 11/4/23, 11/5/23, and 11/26/23, there were only 3 NAs on PM shifts.
3.) 12/1/23, there were 3 NAs on PM shift
Interview on 12/20/23 at 5:26 p.m., with the administrator identified he had not had time to review all the documents since he was new to the facility but he would expect the staffing plan noted in the Facility Assessment was to be followed. He reported he would be working to identify problems and develop processes for monitoring in upcoming Quality Assurance Process Improvement (QAPI) meetings.
5) R8's 10/21/23, annual Minimum Data Set (MDS) identified R8 had moderately impaired cognition. R8 was dependent on staff for toileting and other activities of daily living, in addition, R8 had impairment of bilateral lower extremities. R8 had no toileting program and was frequently incontinent of bladder and always incontinent of bowel.
R8's 5/5/23, care plan identified R8 preferred to use bedpan for toileting and refused to sit on a commode most of the time. R8 required 1 staff assist with bed mobility.
Interview on 12/18/23, at 12:06 p.m., with R8 identified she had to wait a long time for her call light to be answered, she stated 30 minutes to an hour. R8 identified that she felt that wait time was too long.
Review of R8's call light log identified the following:
12/1/2023, call light engaged at 3:50 p.m., call light was answered at 5:20 p.m.
12/2/2023, call light engaged at 6:43 a.m., call light was answered at 8:15 a.m.
12/2/2023, call light engaged at 8:38 a.m., call light was answered at 9:20 a.m.
12/2/2023, call light engaged at 12:55 p.m., call light was answered at 3:06 p.m.
12/2/2023, call light engaged at 5:50 p.m., call light was answered at 7:26 p.m.
Interview on 12/20/23 at 1:51 p.m., with the administrator identified he was not comfortable with his understanding of how the call light log worked but would have expected staff to answer call lights within 10 minutes. He had not used the call light log to audit call light wait times, and to his knowlege the facility had not completed any call light training and was unaware of the long call light times during the above time period.
Review of the undated facility policy Answering the Call Light identified staff should answer call lights promptly, turn off the call light, and complete the task requested within 5 minutes if possible. If staff were uncertain whether they could complete the task they were to notify the nurse manager.
Based on interview and document review, the facility failed to ensure sufficient staffing to provide routine assistance with activities of daily living (ADLS) and timely response to call lights for 9 of 31 residents (R2, R8, R10, R13, R15, R23, R24, R25 and R28) with concerns for sufficient staffing.
Findings include:
Interview on 12/19/23 at 3:09 p.m., during a resident council meeting, R2, R10, R13, R23 and R24 expressed concerns for sufficient staffing especially at night and on the weekends when at times there were only two nursing assistants (NA)s on duty. They voiced agreement that call light wait times got really long and they had to wait up to an hour at times for someone to respond. R2, R13, R15 agreed with the above concerns however, never voiced specific incidents. During the meeting R10, R23, and R24 voiced specific examples of their sufficient staffing concerns as follows:
1) R10 reported she did not feel it was related to specific times of the day or night, but she had experienced accidents due to having to wait for staff to respond to her call light. She stated, it was embarrassing for her to have a staff member clean her up. She reported the nursing assistants (NA)s were often busy helping someone else, and other staff persons were not always willing to help when the aides were busy.
R10's 11/15/23, annual Minimum Data Set (MDS) assessment identified her cognition was intact, and she required extensive assistance of one staff for ADLs and used a wheelchair for mobility. R10 had diagnosis of cerebral palsy, paraplegia and was occasionally incontinent of bladder and frequently incontinent of bowel.
R10's current undated care plan identified she required extensive assistance from staff for all ADLs, needed assistance to transfer, sit up and lie down, required bilateral AFO (ankle-foot Orthoses) braces applied when she got up and off when she went to bed and used a wheelchair for mobility.
2) R24 reported the facility had a lot of new staff that were temporary, and they did not always know what to do, but she voiced she was concerned because she didn't feel she should have to direct them on how to provide care.
R24's 10/29/23, Quarterly MDS assessment identified her cognition was intact and she was dependent on staff for ADLs due to physical limitations. R24 had diagnosis of functional quadriplegia, arthritis of multiple sites and was occasionally incontinent of bladder and always continent of bowel.
R24's current undated care plan identified she required limited to extensive assistance with ADLs, needed a walker with assistance or a wheelchair for mobility. She was at high risk for falls due to weakness and attempts to self transfer. Staff were to anticipate and meet her needs, ensure her call light was within reach, and respond promptly to all requests for assistance.
3) R23 reported her call light response was usually fifteen minutes to a half hour, but there had been times when it took a lot longer. R23 voiced there was never enough staff right away in the morning, but her care was provided, she just had to wait for staff. She also stated sometimes she waited to get her medication, but she was not able to give any specific instances.
4) Interview on 12/18/23 at 4:29 p.m., with R28 identified his usual wait for his call light to be answered was usually ten to fifteen minutes, but it was sometimes longer on weekends because there were not as many staff working. R28 verbalized he did not know the longest amount of time he had waited for a response to his call light, but he knew staff were busy and he was located at the end of the hall, so it took longer to get to him.
Review of R28's October - December 2023, call light log identified wait times averaged 20 - 43 minutes and one incident of 52 minutes was noted at 8:05 a.m. on 12/1/23.
R28's 9/18/23, admission MDS assessment identified he had moderate cognitive impairment but was able to respond appropriately to interview questions. He required extensive assistance from staff for dressing, toileting, and transfers and had diagnoses of problems with balance and gait disturbances, and bilateral leg and foot wounds which restricted R28's mobility.
R28's current, undated care plan identified he required extensive assistance from 2 staff for ambulation of short distances, and extensive assistance of one staff for all ADLS. R28 was at high risk for falls do to balance and gait disturbances. Staff were to anticipate and meet his needs, ensure his call light was within reach, encourage him to use it, and respond promptly to all requests for assistance.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Medical Records
(Tag F0842)
Could have caused harm · This affected multiple residents
Based on observation and interview the facility failed to ensure privacy of resident medical information for 1 of 2 facility medication carts which involved 10 of 31 residents (R2, R24, R22, R11, R28,...
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Based on observation and interview the facility failed to ensure privacy of resident medical information for 1 of 2 facility medication carts which involved 10 of 31 residents (R2, R24, R22, R11, R28, R15, R1, R26, R183, and R19). This had the potential to be viewed by any resident and visitor passing by on the C wing unit.
Findings include:
Observation on 12/18/23 at 4:54 p.m., of 1 of 2 facility medication cart located on the C wing unit, displayed personal and medical information of the following residents: R2, R24, R22, R11, R28, R15, R1, R26, R183, and R19. The facility medication cart was left unattended with no staff personnel on the unit.
Observation and interview on 12/18/23 at 4:59 p.m., with director of nursing (DON)-A stated her expectations would be for all residents information to be secured at all times. DON-A then closed the computer screen of the C wing medication cart.
Interview on 12/20/23 at 10:01 a.m., with administrator (ADM-A) stated his expectations would be for the employees to keep residents' electronic medical records confidential and private when not in use.
Review of December 2021, Confidentiality of Information and Personal Privacy policy indicated personal and medical records of residents would be protected and kept confidential.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Food Safety
(Tag F0812)
Could have caused harm · This affected most or all residents
Based on observation, interview, and document review the facility failed to ensure expired foods were disposed of, ensure staff followed their process to log cooked food temperatures to ensure appropr...
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Based on observation, interview, and document review the facility failed to ensure expired foods were disposed of, ensure staff followed their process to log cooked food temperatures to ensure appropriate oversight of cooked foods, and monitor refrigerator and freezer temperatures as indicated per policy. The facility also failed to log the results of their chemical test strips and dishwasher per policy to ensure dishes were sanitized correctly. In addition, the facility failed to ensure the dry storage area was maintained in a clean, sanitary manner and in was in good repair. This had the potential to affect all 31 residents.
Findings include:
Observation on 12/18/23 at 11:20 during the initial kitchen tour with the dietary manager (DM) identified the following:
1. The walk in refrigerator had a container of potato salad with a use by date of November 2023 and a bag with sliced ham leftovers that was undated.
2. The 3 compartment sink was visibly dirty, with a black unknown substance and food particles scattered throughout the bottom of the sink. A tin can containing grease was sitting in the sink, and a bucket with dirty water and a scoop and serving spoon were observed lying in the bucket inside the sink.
3. A clip board was observed hanging in the dishwashing room with 1 logged entry for the 4th day of the month (December). No other logs were observed in the kitchen area.
4. The dry storage area had broken tiles on the floor around the storage rack. There were missing tiles along the wall beneath a rack, and an area of missing tile was observed with the underside surface exposed. The floor was visibly dirty with pieces of cardboard, a hairnet, a package of [NAME] crackers, a black and gray dirt-like substance, cobwebs hanging from the bottom rack extending to the floor, and a dirty dish rag was observed lying on the rack.
Interview on 12/18/23 at 11:20, with the DM agreed during the initial kitchen tour identified she agreed with the above concerns and identified staff were to check for expired foods on Tuesdays. She noted there were no dishwasher logged temperatures to review to ensure dishes washed in the facility had been appropriately sanitized. Staff were also expected to log temperatures for refrigerator and freezers to ensure temperatures were within appropriate ranges, and log cooked food temperatures when removed from the oven. Staff were to log the results of the chemical test strips for the 3 compartment sink and dishwasher but revealed she had no logs for anything available for review for the current month or 4 months prior. The sinks were to be cleaned after each meal and the dry storage was to be swept daily and mopped weekly.
Interview on 12/19/23 at 9:28 a.m., with Cook-(B) identified staff checked for expired food on Tuesdays. He had not worked the last Tuesday. He noted staff had no logs for refrigerator or freezer temperature checks or if staff had signed off they performed their weekly checks for expired foods, so he had no way to know if those tasks had been performed or were within acceptable ranges. He started employment about 6 months prior to survey at the facility. At that time, staff had lists of tasks to be performed and were to sign off they were completed and logs to monitor temperatures. He was unaware how long it had been since the logs and sign off sheets were no longer available for staff use.
Interview on 12/19/23 at 1:00 p.m., with the maintenance director identified he was aware of the missing and broken tiles in the dry storage area. They were old asbestos tiles. It would be expensive to have them removed and new tiles installed and had been this way for a long time. He stated he may be able to put new tiles over the old tiles to ensure a smooth, cleanable surface vs replace the existing tiles that had been missing.
Review of undated, facility provided policies for food handling, dish machine sanitization, and kitchen cleaning identified all areas were to be kept clean and sanitary. Foods were to be dated, left over foods were be used within 7 days or discarded, refrigerator and freezer temperatures were to be monitored 2 times each day and logged on a monthly tracking sheet, and the DM was to post a log near the dish machine for the staff to document temperatures and test strip results at each meal.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
QAPI Program
(Tag F0867)
Could have caused harm · This affected most or all residents
Based on interview and document review, the facility's Quality Assurance and Performance Improvement (QAPI) committee failed to identify facility specific concerns, implement action plans for improvem...
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Based on interview and document review, the facility's Quality Assurance and Performance Improvement (QAPI) committee failed to identify facility specific concerns, implement action plans for improvement, or ensure the committee participated in the development and oversight of implementation of systems, to ensure quality of life and quality of care were maintained for 31 of 31 residents residing in the facility.
Findings include:
Review of the QAPI meeting minutes from January 2023, February 2023, March 2023, April 2023, May 2023, June 2023, and November 2023. No QAPI meetings documented as taking place for July 2023, August 2023, September 2023, and October 2023. The minutes failed to identify facility specific concerns, action plans for improvement, and/or analysis of any actions taken previously.
Interview on 12/20/23 at 5:26 p.m., with the administrator reported he was not certain how frequently QAPI meetings were held prior to his starting at the facility, but he did not find evidence of meetings for July through October 2023. He identified the facility needed to identify problems, develop plans for areas to monitor and develop a system for tracking and/or monitoring of processes put into place. He reported he was not aware of any Process Improvement Projects (PIP's) in place at the present time and the facility needed to develop systems for monitoring and identifying areas for improvement and include them in future meetings.
Review of the December 5, 2019, QAPI policy identified the committee was to monitor and sustain performance in both clinical and non-clinical system by identifying and improving areas identified. Elements to demonstrate compliance with the guidelines included:
1.) Monthly meetings with documentation
2.) designated member attendance
3.) Pips developed and implemented for identified areas of improvement.
4.) Additional QAPI meetings as needed to address and improve critical areas in need of improvement between the monthly meetings.
The QAPI Committee was to use a template to guide data collection and committee discussion. The template was to include review of systems related to care, management practices, clinical care, quality of life, resident choice, and any unique care, services or changes as identified.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0944
(Tag F0944)
Could have caused harm · This affected most or all residents
Based on interview and document review, the facility failed to provide mandatory training on the facility's Quality Assurance Program Improvement (QAPI) Program that included facility specific goals, ...
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Based on interview and document review, the facility failed to provide mandatory training on the facility's Quality Assurance Program Improvement (QAPI) Program that included facility specific goals, elements of the program, how the facility intended to implement the program, in addition to the staff's role in the facility QAPI program. The facility also failed to provide education on how staff could communicate concerns, problems, or opportunities for improvement to the facility's QAPI program. In addition, the current December 5, 2019, facility policy failed to identify the mandatory component of providing staff education on the facility specific QAPI program.
Findings include:
Interview on 12/20/23 at 9:38 a.m., with trained medication aide (TMA)-B reported she had been employed at the facility for 4 years and reported she had not received any QAPI training or recalled any facility specific programs, such as a performance improvement project (PIP).
Interview on 12/20/23 at 9:42 a.m., with licensed practical nurse (LPN)-A reported she was aware the facility had a QAPI program but was not aware of any current PIP that might be in place. LPN-A identified she had not received any education on a facility specific program and reported she was not aware of any education being provided on the facility's QAPI program to either the facility employed staff or the temporary staff.
Interview on 12/20/23 at 9:56 a.m., with the social services designee (SSD) reported she was aware of the QAPI program and was not aware of any education provided to staff on the facility specific program. She reported she was not aware of any current PIP or designated methods for staff to communicate ideas or suggestions.
Interview on 12/20/23 at 5:26 p.m., with the administrator identified the facility needed to identify problems, develop plans for areas to monitor and develop a system for tracking and/or monitoring of processes put into place. He was not aware of any PIP in place at the present time. He agreed the facility needed to develop systems for monitoring and identifying areas for improvement and include them in future meetings. The administrator identified he was not aware of education provided to staff on the QAPI program, or methods to communicate suggestions.
Interview on 12/21/23 at 8:28 a.m., with the director of nursing reported the facility had one QAPI meeting since she started in September 2023. The DON reported the facility had department meetings in the morning 5 days/week and concerns were identified and discussed at that time. She was not aware of a formalized process for staff input concerns, ideas, or commentary to the QAPI team. There was no facility specific QAPI education provided to staff that she was aware of.
Review of the December 5, 2019, QAPI policy identified the committee was to monitor and sustain performance in both clinical and non-clinical system by identifying and improving areas identified. Elements to demonstrate compliance with the guidelines included:
1.) Monthly meetings with documentation
2.) Designated member attendance
3.) Pips developed and implemented for identified areas of improvement.
4.) Additional QAPI meetings as needed to address and improve critical areas in need of improvement between the monthly meetings.
The QAPI Committee was to use a template to guide data collection and committee discussion. The template was to include review of systems related to care, management practices, clinical care, quality of life, resident choice, and any unique care, services or changes as identified. The policy failed to identify the facility needed to provide mandatory training on the facilities QAPI program, have a PIP, or educate staff on those specifics.
Mar 2023
3 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0676
(Tag F0676)
Could have caused harm · This affected 1 resident
Based on observation, interview and document review the facility failed to provide a method to communicate effectively with a non-English speaking resident, and educate staff on identified communicati...
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Based on observation, interview and document review the facility failed to provide a method to communicate effectively with a non-English speaking resident, and educate staff on identified communication needs for 1 of 1 resident (R27) reviewed for communication.
Findings include:
R27's 1/10/23 Significant Change Minimum Data Set (MDS) identified that R27 needed or wanted an interpreter to enable communication with her doctor or health care staff. She required supervision with oversight or cueing for bed mobility, transfers, and toileting, and required extensive assist of 1 staff for dressing.
R27's undated care plan, identified a communication problem related to a language barrier as the resident spoke Laotian. The care plan identified staff were to communicate with R27 by use of the language line, her daughter, or by using a picture board located in R27's room.
Interview on 3/27/23 at 5:40 p.m., with family member (FM)-A reported R27 neither spoke or understood the English language. Her primary language was Laotion and that made it difficult for her to communicate her needs or preferences to staff. FM-A reported R27 had expressed that she did not want male caregivers and that she would like to take more frequent baths. Due to her communication barrier she had not been able to communicate these preferences with staff.
Interview on 3/29/23 at 7:46 a.m., with R27 using the assistance of the Language Line she communicated she was neither able to understand staff nor were they able to understand her. R27 reported she would prefer staff to use an interpreter to clarify communication. R27 also repeated that she preferred to not have a male caregiver.
Interview on 3/29/23 at 10:33 a.m., with NA-C reported that she communicated with R27 by pointing and using hand gestures. NA-A also reported a communication binder was located in R27's room but she had not used it and or been trained on how she should communicate with R27.
Interview on 3/29/23 at 10:39 a.m., NA-B reported that she communicated with R27 by pointing and making hand gestures and agreed it would have been helpful to have an interpreter. She further reported R27 would ask a second Laotian speaking resident to relay information for her when staff had not been able to understand her.
Interview on 3/29/23 at 2:56 p.m., with the administrator reported the facility had an interpreter available through a language line and it was his expectation for staff to utilize the language line for communication with non-English speaking residents.
Review of the undated facility policy Translation and/or Interpretation of Facility Services identified neither family members or friends were to be relied on for interpretation services of residents that are non-English speaking. The facility policy further identified that providing meaningful access to services provided by the facility required the individual with limited English proficiency (LEP) resident's needs and questions are accurately communicated. Oral interpretation services therefore include interpretation from the LEP resident's primary language back to English. It is understood that in order to provide meaningful access to services provided by this facility, translation and/or interpretation must be provided in a way that is culturally relevant and appropriate to the LEP individual.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Comprehensive Assessments
(Tag F0636)
Could have caused harm · This affected multiple residents
Based on interview and document review the facility failed complete a comprehensive and/or quarterly nutritional assessment for 4 of 4 residents (R5, R10, and R25).
Findings include:
R5 had a signific...
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Based on interview and document review the facility failed complete a comprehensive and/or quarterly nutritional assessment for 4 of 4 residents (R5, R10, and R25).
Findings include:
R5 had a significant change Minimum Data Set (MDS) scheduled with an assessment reference date (ARD) of 1/6/23. R5 had no nutritional data assessment completed that identified if food intake had declined, weight loss had occurred, mobility status identified, if resident suffered psychological stress, and neuropsychological problems were identified, or the current Body Mass Index (BMI) had been determined to identified malnutrition or risk of malnutrition. There had been no documented assessment to answer section K swallowing/national status and section L oral/dental status of the MDS.
R10 had the following MDS's scheduled: significant change MDS with ARD of 5/12/22. A quarterly MDS with ARD of 11/23/22. A significant change MDS with ARD of 12/19/22. A significant change MDS with ARD of 1/12/23. There were no national data assessments completed for the scheduled MDS's that identified if food intake had declined, weight loss had occurred, mobility status identified, if resident suffered psychological stress, if neuropsychological problems were identified, or the current Body Mass Index (BMI) had been determined to identified malnutrition or risk of malnutrition. There had been no documented assessment to answer section K swallowing/national status and section L oral/dental status of the MDS. Further identified was a quarterly MDS with ARD of 2/3/23 however, the national data assessment had been completed after the assessment reference date (ARD) on 2/8/23.
R25 had the following MDS's scheduled: Annual MDS with ARD of 12/18/22. Significant change MDS with ARD of 12/20/22. Significant change MDS with ARD of 1/10/22. There were no national data assessments completed for the scheduled MDS's that identified if food intake had declined, weight loss had occurred, mobility status identified, if resident suffered psychological stress, if neuropsychological problems were identified, or the current Body Mass Index (BMI) had been determined to identified malnutrition or risk of malnutrition. There had been no documented assessment to answer section K swallowing/national status and section L oral/dental status of the MDS.
Interview on 3/29/23 at 10:39 a.m., with assistant director of nursing (ADON) identified she was responsible for scheduling the MDS's and once she had a schedule, she would email that schedule out to all departments. She reported if there was a change and a significant change MDS was scheduled, she would send out an email with the updated information. She reported all department managers had the MDS schedule so they are aware of when the assessments were due and the MDS had to be completed. She confirmed that the dietary department manager was included in email with the MDS schedule.
Interview on 3/29/23 at 12:27 p.m., with certified dietary manager (CDM) confirmed that there was an email that notified all departments of the MDS schedule for the month and when assessments are due. She reported she tries to complete on the day they are due or the next day. She revealed she worked at both facilities and had been short staffed and needed to work in the kitchen so she was be behind. She confirmed she should have completed an assessment for the above-mentioned residents with each scheduled MDS and was unaware she had missed that many. She identified when completing an assessment for a significant change MDS she does a more detailed assessment and reviews more information than she does on a quarterly assessment but the national data assessment questions on the form were the same. She confirmed that the information that she entered was obtained from the assessment she completed.
Interview on 3/29/23 at 2:16 p.m., with director of nursing (DON) identified that the ADON sends out the MDS schedule every month to all the department managers. The ADON updates the MDS schedule and re-sends with any changes such as scheduling a significant change MDS. The expectation was that each department manager completes their required assessments in order to complete the MDS. She further identified that the schedule was emailed each month to ensure that all departments know the ARD and when their assessments are due to ensure timely completion of the MDS. She confirmed that dietary department had been behind with working both buildings and covering the cook position for a while.
Interview on 3/29/23 at 2:27 p.m., with administrator who agreed that assessments should be completed and completed timely in order to complete the MDS. He reported that the CDM worked both facilities and as a cook which pushed some things to the back burner. The CDM had recently hired a cook which he felt should help. He further, revealed the facility was in between dieticians with a consulting dietician covering until the new dietician was able to start in May. He revealed he suspected things had been missed during this transition and was not surprised that assessments had been missed.
Review undated, Resident Assessment policy identified that comprehensive assessments of each residents needs are made at intervals designated by OBRA and PPS requirements. The interdisciplinary team conducts timely and appropriate resident assessments and reviews.
Review of undated, Medicare Reimbursement Resource Manual Team Processes and Documention policy identified each discipline completes assessments prior to or on ARD of the MDS. Each quarter or as needed the care plan should be updated to be consistent with the assessments to ensure the development of a resident specific care plan.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Food Safety
(Tag F0812)
Could have caused harm · This affected most or all residents
Based on observation and interview the facility failed to ensure food products with an expiration date or use by date were disposed of after expiration date. This had the potential to affect all 32 re...
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Based on observation and interview the facility failed to ensure food products with an expiration date or use by date were disposed of after expiration date. This had the potential to affect all 32 residents who consumed food products from the kitchen.
Findings include:
Observation and interview on 3/27/23 at 11:00 a.m., with dietary cook-A during initial tour of the kitchen identified in the walk- in cooler:
1) a box with receive date of 2/7/23, that contained 2 packages of beef patties with the label of the box damaged so no identified expiration date.
2) a box with receive date of 3/2/23 that contained two 5 pound packages of hamburger that identified a use date or freeze date of 3/22/23.
3) a box with a receive date of 2/7/23., that contained 3 packages of sliced corn beef that identified use date or freeze date of 2/26/23.
4) 1 package of sliced ham sitting on shelf with expiration date of 11/30/22, that contained a white milky substance within the package.
5) a box with a receive date of 3/7/23, that contained 1 package of roast beef sandwich meat with a use by or freeze by date of 3/19/23.
6) 3 gallons of chocolate milk with expiration date of 3/1/23.
7) Also observed in the walk-in cooler was a 5 gallon bucket catching water leaking from the sprinkler head located on ceiling when you first enter the walk-in cooler with water standing on the floor around the bucket. Towards the back of the walk-in cooler was more standing water on the floor with a second sprinkler leaking water from the ceiling.
Interview with dietary cook-A revealed that the product came in, it was dated when received, and was placed in the walk-in cooler. She revealed that the meat should have been frozen when delivered and that staff should only be taking out what was needed for the menu to thaw for use. She confirmed the expired ham sandwich meat contained a white milky substance and was not editable. She confirmed the products were expired and should not be used since all identified products had pasted there use by date and had not previously been frozen. She reported that the Maintenance director and administrator were aware of the leaking sprinklers in the walk-in cooler.
Interview on 3/28/23 at 10:12 a.m., with certified dietary manager (CDM) confirmed that the meat should have been frozen when delivered and not been left in the cooler. She further confirmed that only what was needed for the menu should have been thawing in the cooler. She revealed there was no process or policy to monitor for expired foods but would be creating a process.
Interview on 3/28/23 at 2:43 p.m., with consulting dietician identified staff should be checking for expired products each time and using first in products first. He confirmed any item that was found to be expired should be eliminated. He revealed staff should be able to see by the menu what is needed and have that in the cooler thawing. He confirmed products that are able to be frozen and come in bulk supply should be frozen and staff should only be thawing what is needed for the menu.
Interview on 3/29/23 at 2:16 p.m., with director of nursing (DON) revealed her expectation would be that there was a process for monitoring for for expired foods to ensure no expired foods were served.
Interview on 3/29/23 at 2:27 p.m., with administrator agreed that there should be a process for monitoring for expired foods. He revealed that the dietary manager should be providing oversight to ensure no expired foods were served.
Review of 8/3/22, Food Storage policy identified perishable food such as meat, must be frozen or stored in refrigerator immediately after receipt. Safe thawing for frozen meat should be defrosted in a refrigerator for 24 to 48 hours and should be used immediately after thawing.
Jan 2023
1 deficiency
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0661
(Tag F0661)
Could have caused harm · This affected 1 resident
Based on interview and document review the facility failed to include skin care and treatment needs on a discharge summary for newly developed skin issues for 1 of 3 residents (R1) prior to discharge ...
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Based on interview and document review the facility failed to include skin care and treatment needs on a discharge summary for newly developed skin issues for 1 of 3 residents (R1) prior to discharge to another care facility.
Findings include:
R1 was discharged to the AL facility on 12/21/22, and the discharge paperwork was faxed to the AL prior to R1 leaving in addition to a copy being provided to R1. The discharge paperwork and orders failed to include R1's wounds on her buttocks, or treatment that had been implemented.
R1's admission Minimum Data Set (MDS) assessment, dated 11/14/22 , identified R1's cognition was intact.
R1's care plan identified, R1 had a potential impairment of her skin integrity due to immobility and the intervention noted was application of barrier cream after each incontinent episode, keep skin clean and dry, application of lotion to dry skin, and a pressure relieving mattress and chair cushion.
R1's therapy and progress notes reported increased strength and mobility with a goal of returning to the Assisted Living (AL) facility where she had resided prior. On 12/16/22 at 6:45 p.m., R1 called the nurse to her room and complained of soreness on her buttocks. When the area was assessed two small areas were noted. The left measured 2 centimes (cm) in diameter, and the Right-side area measured 1 cm wide (W) x 3 cm long (L). The areas appeared to be a result of R1 scratching her buttocks and scratch marks were noted around the open areas. The doctor was notified by fax and the areas were cleansed with normal saline and covered with a duoderm.
On 12/18/22 a fax was sent to update the doctor, R1's wounds will be covered wish Sorbact (Surgical Dressing is a bacteria- and fungi binding wound dressing)dressing to change every 5 days and as needed until seen by the wound nurse. A fax back to the facility with the doctor's signature and dated 12/20/22.
Interview on 1/4/23 at 1:25 p.m., with the AL director of nursing (DON) who admitted R1, reported she had no knowledge R1 had wounds on her buttocks until she complained of pain during her admission. The AL DON reported she had investigated and observed two open pressure ulcers one on each buttock cheek with no dressing in place. The right-side area measured approximately. 4 cm x 5 cm and the left buttock area measured approximately 1 cm x 1 cm. R1 reported the areas developed in the nursing home, and she thought it was because she had liked to lie in her bed a lot. R1 reported the nursing home had been applying a cream to the area, but she did not know what it was. The AL director reported the transfer orders did not mention the wounds or contain orders for any treatment. The AL director reported she had contacted the nursing home director of nursing (DON) to ask about R1's wounds and received a reply via email that R1's sores were a result of scratches that had occurred on 12/16/22. The DON reported the treatment was collegian powder to areas and cover with a Sorbact dressing. The AL director reported she telephoned the doctor to request orders and stated treatment with Triad cream (a cream indicated for the treatment of pressure or venous ulcers) which she had on hand. An appointment was also arranged for follow up at the clinic with the doctor on 12/29/22.
Interview on 1/5/23 at 1:27 p.m., with the social services designee (SSD) reported she had completed R1's discharge paperwork and recapitulation of stay by obtaining the discharge orders from therapies, including orders listed on the resident record, and the medication and treatment records. She reported she had forwarded the form to the charge nurse to review and add any additional information.
Interviews on 1/5/23 at 12:58 p.m. and 3:30 p.m. with the DON identified R1 had developed two small open areas that were discovered on 12/16/22. The areas were felt to be the result of R1 scratching herself and the doctor had been updated. The initial nursing treatment was to cleanse the areas with saline and cover with a duoderm. This did not remain intact, and the treatment was changed to a Sorbact dressing. The doctor was faxed on 12/18/22 for the change in order and received signed on 12/20/22. R1 was scheduled to see the wound nurse on 12/22/22 but discharged on 12/21/22. The DON reported the information regarding R1's wounds and the treatment in place should have been included in the discharge paperwork sent to the AL facility and had been missed.
Interview on 1/5/23 at 2:18 p.m. with R1 reported the sores on her buttocks developed while she was in the nursing home and the staff were applying a cream and dressing to the areas. R1 reported she was able to reposition herself in bed and her chair and did not need staff to assist her.
Interview on 1/5/23 at 3:14 p.m. with doctors office staff, reported the doctor who had seen R1 on 12/29/22 was not available for interview at this time, but provided the notes from the visit. R1 was identified to have a superficial decubitus ulcer on her left buttock cheek.
Review of the 11/30/21 policy Transfer or Discharge Documentation identified details of discharge or transfer were to be documented in the medical record and appropriate information communicated to the receiving facility or provider.
Understanding Severity Codes (click to expand)
Life-Threatening (Immediate Jeopardy)
J - Isolated
K - Pattern
L - Widespread
Actual Harm
G - Isolated
H - Pattern
I - Widespread
Potential for Harm
D - Isolated
E - Pattern
F - Widespread
No Harm (Minor)
A - Isolated
B - Pattern
C - Widespread
Questions to Ask on Your Visit
- "What changes have you made since the serious inspection findings?"
- "Can I speak with families of current residents?"
- "What's your RN coverage like on weekends and overnight?"
Our Honest Assessment
Strengths
- • Licensed and certified facility. Meets minimum state requirements.
Concerns
- • Multiple safety concerns identified: 3 life-threatening violation(s), Special Focus Facility, 1 harm violation(s), $47,643 in fines. Review inspection reports carefully.
- • 56 deficiencies on record, including 3 critical (life-threatening) violations. These warrant careful review before choosing this facility.
- • $47,643 in fines. Higher than 94% of Minnesota facilities, suggesting repeated compliance issues.
- • Grade F (0/100). Below average facility with significant concerns.
Bottom line: This facility is on CMS's Special Focus list for poor performance. Consider alternatives strongly.
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About This Facility
What is The Shores Of Worthington's CMS Rating?
CMS assigns The Shores Of Worthington an overall rating of 1 out of 5 stars, which is considered much below average nationally. Within Minnesota, 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 The Shores Of Worthington Staffed?
CMS rates The Shores Of Worthington's staffing level at 4 out of 5 stars, which is above average compared to other nursing homes. Staff turnover is 54%, compared to the Minnesota average of 46%.
What Have Inspectors Found at The Shores Of Worthington?
State health inspectors documented 56 deficiencies at The Shores Of Worthington during 2023 to 2025. These included: 3 Immediate Jeopardy (the most serious level, indicating potential for serious harm or death), 1 that caused actual resident harm, and 52 with potential for harm. Immediate Jeopardy findings are rare and represent the most serious regulatory concerns. They require immediate corrective action.
Who Owns and Operates The Shores Of Worthington?
The Shores Of Worthington 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 EPHRAM LAHASKY, a chain that manages multiple nursing homes. With 69 certified beds and approximately 53 residents (about 77% occupancy), it is a smaller facility located in WORTHINGTON, Minnesota.
How Does The Shores Of Worthington Compare to Other Minnesota Nursing Homes?
Compared to the 100 nursing homes in Minnesota, The Shores Of Worthington's overall rating (1 stars) is below the state average of 3.2, staff turnover (54%) is near the state average of 46%, and health inspection rating (1 stars) is much below the national benchmark.
What Should Families Ask When Visiting The Shores Of Worthington?
Based on this facility's data, families visiting should ask: "What changes have been made since the serious inspection findings, and how are you preventing similar issues?" "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 facility's Immediate Jeopardy citations.
Is The Shores Of Worthington Safe?
Based on CMS inspection data, The Shores Of Worthington has documented safety concerns. Inspectors have issued 3 Immediate Jeopardy citations (the most serious violation level indicating risk of serious injury or death). The facility is currently on the Special Focus Facility watch list (a federal program monitoring the lowest-performing 1% of nursing homes nationwide). The facility has a 1-star overall rating and ranks #100 of 100 nursing homes in Minnesota. Families considering this facility should ask detailed questions about what corrective actions have been taken since these incidents.
Do Nurses at The Shores Of Worthington Stick Around?
The Shores Of Worthington has a staff turnover rate of 54%, which is 8 percentage points above the Minnesota 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 The Shores Of Worthington Ever Fined?
The Shores Of Worthington has been fined $47,643 across 5 penalty actions. The Minnesota average is $33,555. While any fine indicates a compliance issue, fines under $50,000 are relatively common and typically reflect isolated problems that were subsequently corrected. Families should ask what specific issues led to these fines and confirm they've been resolved.
Is The Shores Of Worthington on Any Federal Watch List?
The Shores Of Worthington is currently an SFF Candidate, meaning CMS has identified it as potentially qualifying for the Special Focus Facility watch list. SFF Candidates have a history of serious deficiencies but haven't yet reached the threshold for full SFF designation. The facility is being monitored more closely — if problems continue, it may be added to the official watch list. Families should ask what the facility is doing to address the issues that led to this status.