TREND HEALTH AND REHAB OF HOUSTON
For profit - Limited Liability company
66 Beds
TREND CONSULTANTS
Data: November 2025
Trust Grade
23/100
#193 of 200 in MS
Last Inspection: April 2025
Within standard 12-15 month inspection cycle. Federal law requires annual inspections.
Overview
Trend Health and Rehab of Houston has received a Trust Grade of F, indicating significant concerns regarding care quality. Ranked #193 out of 200 facilities in Mississippi, this places them in the bottom half of nursing homes in the state, and they are the second out of two facilities in Chickasaw County, meaning only one local option is available that is better. While the facility has shown some improvement, decreasing issues from 15 in 2024 to 8 in 2025, the overall picture remains troubling, with 30 total deficiencies noted during inspections, including serious failures in pain management and neglecting to assess residents properly after falls. Staffing is a positive aspect, with a 4 out of 5-star rating and a turnover rate of 0%, indicating that staff members are stable and familiar with residents. However, they also face $16,700 in fines, which is concerning and suggests repeated compliance problems. Specific incidents included a failure to manage pain for a resident after a fall and neglecting to assess another resident's needs properly, raising significant concerns about the quality of care provided.
- Trust Score
- F
- In Mississippi
- #193/200
- Safety Record
- High Risk
- Inspections
- Getting Better
- Staff Stability ○ Average
- Turnover data not reported for this facility.
- Penalties ○ Average
- $16,700 in fines. Higher than 71% of Mississippi facilities. Some compliance issues.
- Skilled Nurses ✓ Good
- Each resident gets 67 minutes of Registered Nurse (RN) attention daily — more than 97% of Mississippi nursing homes. RNs are the most trained staff who catch health problems before they become serious.
- Violations ⚠ Watch
- 30 deficiencies on record. Higher than average. Multiple issues found across inspections.
23/100
Bottom 4%
Review needed
15 → 8 violations
★☆☆☆☆
1.0
Overall Rating
★★★★☆
4.0
Staff Levels
★☆☆☆☆
1.0
Care Quality
★★☆☆☆
2.0
Inspection Score
↔
Stable
2024: 15 issues
2025: 8 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 Mississippi average (2.6)
Significant quality concerns identified by CMS
Federal Fines: $16,700
Below median ($33,413)
Minor penalties assessed
Chain: TREND CONSULTANTS
Part of a multi-facility chain
Ask about local staffing decisions and management
The Ugly 30 deficiencies on record
3 actual harm
Apr 2025
8 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
Deficiency F0561
(Tag F0561)
Could have caused harm · This affected 1 resident
Based on resident and staff interviews, record review and facility policy review, the facility failed to honor a resident bedtime choice for one (1) of 31 sampled residents. Resident #24.
Findings Inc...
Read full inspector narrative →
Based on resident and staff interviews, record review and facility policy review, the facility failed to honor a resident bedtime choice for one (1) of 31 sampled residents. Resident #24.
Findings Include:
Record review of the facility policy Resident Rights revealed 3. Our facility will make every effort to assist each resident in exercising his/her rights to ensure that the resident is always treated with respect, kindness, and dignity
An interview on 3/31/25 at 1:00PM with the Administrator (ADM) revealed that on 03/16/25, Registered Nurse (RN) #1 called her and reported that Certified Nursing Assistant (CNA) #1 made Resident #24 go to bed when she didn't want to. The ADM stated that RN #1 reported to her that CNA #1 took Resident #24 to her room from the dining room after the supper meal around 6:00 PM, put Resident #24's gown on and made her go to bed. She also revealed that Resident #24 kept telling her (CNA #1) that she didn't want to go to bed. The ADM reported that Resident #24's roommate, Resident #22 witnessed it, walked up to the nursing desk and reported to RN #1 that CNA #1 told Resident #24 that she was going to bed because she (CNA #1) had things to do. The ADM admitted that it was the residents' right to choose to get up and to go to bed when they wanted to, and Resident #24's choice to stay up longer should have been honored that evening.
An interview with Resident #22 on 03/31/25 at 1:40 PM confirmed that she was Resident#24's roommate and a couple of weeks ago, she saw a CNA make Resident #24 go to bed one night after supper. She revealed that she didn't know who the CNA was, but she hadn't been back since that night, and she was glad. Resident #22 revealed that she was in her bed watching television with her privacy curtain pulled about halfway to where she could see what was going on. She confirmed that she heard the CNA say to Resident #24, You're going to bed because I have work to do. She revealed that she heard Resident #24 tell the CNA several times that she was not ready to go to bed. Resident #22 revealed that she got up from her bed and went to the nursing desk and reported to a nurse what happened.
An interview on 03/31/25 at 2:35 PM with RN #1 confirmed that around 5:45 PM on 3/16/25 Resident #22 came to the nurse's desk and reported that CNA #1 was mistreating Resident #24 by making her go to bed when she didn't want to. RN #1 revealed that Resident #22 told her that Resident #24 told CNA #1 that she was not ready to go to bed and the CNA told her she was going to bed anyway because she had too much to do. RN #1 revealed that she went to Resident #24's room to check on her and found her sitting on the side of the bed with her gown on. RN #1 revealed that Resident #24 told her that she wanted to stay up longer and visit with friends in the dining room and wasn't ready to go to bed but that CNA #1 made her go to bed. RN #1 revealed that she made sure Resident #24 was safe, offered to put her clothes back on and help her get back up but at that time, she refused. RN #1 revealed that Resident #24 told her that she was sitting in the dining room at a table with other residents and CNA #1 came and pushed her in her wheelchair back to her room and put her to bed, even though she told her she was not ready. RN #1 confirmed that Resident #24's choice to go to bed later that evening should have been honored and this was not okay.
An interview on 04/01/25 at 10:20 AM with Resident #24 confirmed that a couple weeks ago, there was an aid who made her go to bed early against her wishes. She revealed that she thought it was around 6:00 PM and she was sitting in her wheelchair at a table in the dining room visiting with friends when the aid came and pushed her back to her room. Resident #24 revealed that she told the aid that she was not ready to go to bed, but the aide told her she was going anyway because she had a lot of work to do. Resident #24 revealed that this was her home, and she wanted to be good to the staff here and she wanted them to be good to her. Resident #24 revealed that it was important to her to make her own decisions about when to go to bed and she wanted to be respected. Resident #24 revealed that the aide did not hurt her, just made her go to bed. She revealed that sometimes she wanted to go to bed early but that was her choice. She revealed that if the aide wasn't going to do right, she didn't need to work there. Resident #24 revealed that she did not know who the aide was and that she hadn't been back to work since that happened.
Record review of Resident #24's admission Record revealed the facility admitted the resident on 09/02/22 with medical diagnoses that included Parkinson's Disease and Depression .
Record review of Resident #24's Minimum Data Set (MDS) with an (Assessment Reference Date) (ARD) of 01/13/25 under Section C revealed a Brief Interview for Mental Status (BIMS) Score of 8 which indicated that she had moderate cognitive deficits. The review of Section F-Preferences revealed that it was very important to her to choose her own bedtime.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
MDS Data Transmission
(Tag F0640)
Could have caused harm · This affected 1 resident
Based on staff interviews and record reviews the facility failed to transmit Minimum Data Set (MDS) Assessments timely for six (6) of 31 residents' MDS assessments reviewed. Residents #15, #16, #19, #...
Read full inspector narrative →
Based on staff interviews and record reviews the facility failed to transmit Minimum Data Set (MDS) Assessments timely for six (6) of 31 residents' MDS assessments reviewed. Residents #15, #16, #19, #30, #34, and #35.
Findings include:
A review of a typed statement on facility letterhead, and signed by the Administrator on 4/2/25 revealed, It is the policy of (Proper Name of the facility) to follow the RAI (Resident Assessment Instrument) manual, chapter 2, Timeliness of MDS.
A record review of the facilities MDS 3.0 Final Validation Report revealed that the following MDS Assessments were submitted late on 3/28/25:
Resident #15 last completed and submitted MDS with an Assessment Reference Date of 11/20/24.
Resident #16 last completed and submitted MDS with an Assessment Reference Date of 11/25/24.
Resident #19 last completed and submitted MDS with an Assessment Reference Date of 11/20/24.
Resident #30 last completed and submitted MDS with an Assessment Reference Date of 11/21/24.
Resident #34 last completed and submitted MDS with an Assessment Reference Date of 2/12/25.
Resident #35 last completed and submitted MDS with an Assessment Reference Date of 2/17/25.
In an interview on 4/01/25 at 1:10 PM, the Registered Nurse MDS Coordinator revealed she has only been with the facility for a week and found out when she came into the position that there were a lot of MDS Assessments that were not completed and therefore were very late. Now she is working to get things caught up and completed.
In an interview on 4/01/25 at 4:49 PM, the Administrator (ADM) confirmed that she was aware the facility had MDS assessments that were late being submitted. She stated, We knew they were late, our MDS nurse quit, and we knew we were continually getting behind. She revealed the current MDS coordinator has been here for about a week and is working to get things caught up and back on track. She revealed MDS Assessments are very important because they determine the care needed for the residents and ensure payment.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Assessment Accuracy
(Tag F0641)
Could have caused harm · This affected multiple residents
Based on staff interview and record review, the facility failed to accurately complete Section N of an Annual Minimum Data Set (MDS) Assessment for one (1) of 31 resident MDS assessments reviewed. Res...
Read full inspector narrative →
Based on staff interview and record review, the facility failed to accurately complete Section N of an Annual Minimum Data Set (MDS) Assessment for one (1) of 31 resident MDS assessments reviewed. Resident #24.
Findings Include:
Record review of the facility policy MDS (Minimum Data Set) Assessment revealed, It is the policy of this facility to follow the RAI (Resident Assessment Instrument) process as set forth by CMS (Centers for Medicare and Medicaid Services) protocol.
Record review of Resident #24's Annual MDS with an Assessment Reference Date (ARD) of 01/13/25 revealed under Section N - Medications, revealed that a hypnotic medication was coded as Yes, the resident is receiving.
Record review of Resident #24's Order Summary Report of active orders as of 01/13/25 revealed the resident did not have an order for a medication with a drug classification of hypnotic.
Record review of Resident #24's Medication Administration Record revealed that she did not receive a hypnotic during the seven day look back period from 01/07/25 through 01/13/25.
An interview on 04/02/25 at 9:15 AM with Registered Nurse (RN) MDS Coordinator revealed that she was new to the facility and that she was not working there during the time of the last completed MDS Assessment for Resident #24. She confirmed that Resident #24 was not taking a hypnotic and that Section N of Resident #24's Annual MDS with ARD of 01/13/25 was coded inaccurately. RN MDS Coordinator revealed that there was no documentation to reflect that Resident #24 was taking a hypnotic and stated, It's black and white to me, it's either there or it's not.
Record review of Resident #24's admission Record revealed the facility admitted the resident on 09/02/22 with medical diagnoses that included Parkinson's Disease and Major Depressive Disorder.
Record review of Resident #24's Annual MDS with ARD of 01/13/25 under Section C revealed a Brief Interview for Mental Status (BIMS) Score of 08 which indicated that she had moderate cognitive deficits.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Comprehensive Care Plan
(Tag F0656)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, staff interviews, record reviews, and facility policy reviews, the facility failed to implement a care pl...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, staff interviews, record reviews, and facility policy reviews, the facility failed to implement a care plan for a resident's Activities of Daily Living (ADL) care for one (1) of 31 resident care plans reviewed. Resident #9.
Findings include:
Record review of facility policy titled Following the Care Plan Policy dated 1/2011, revealed, It is the policy of this facility to follow a written and approved care plan for each resident. All employees will be trained upon hire and be required to follow the care plan.
Record review of the care plan, date initiated 7/16/24, revealed Resident #9 has an ADL self-care performance deficit related to hemiplegia, limited mobility, musculoskeletal impairment, stroke and has contractures to all extremities with associated spasticity. Interventions include oral care every shift.
On 3/30/25 at 4:25 PM, an observation revealed Resident #9 with a thick white substance covering his upper and lower lip and sides of his mouth.
On 3/30/25 at 6:25 PM, an observation and interview with Resident #9's Representative (RR) revealed she has to clean his mouth every time she visits, which is often. She admitted that she had talked to the staff about it, but it has not improved.
On 4/01/25 at 8:30 AM, during an interview, Licensed Practical Nurse (LPN) #1 admitted that she had seen white stuff on Resident # 9's mouth occasionally and had to clean it off. She revealed that it was both the CNAs and the nurse's responsibility to provide oral care to the residents.
In an interview on 4/1/25 at 1:35 PM, the Minimum Data Set (MDS) Coordinator revealed the care plans are developed so the staff will know how to take care of each resident's needs. She confirmed that Resident #9's ADL care plan regarding his oral care was not being followed and that the care plan lacked further development for Resident #9's individual needs.
During an interview on 4/01/25 at 1:45 PM, the Interim Director of Nurses (DON) revealed Resident #9's oral care should be done more than just each shift since he has a feeding tube and is probably a mouth breather. She revealed the resident's plan of care was not being followed in regard to his oral care, and it should have been.
Record review of Resident #9's admission Record revealed he was admitted to the facility on [DATE] with medical diagnoses that included Hemiplegia and Hemiparesis following Cerebral Infarction and Gastrostomy status.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
ADL Care
(Tag F0677)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, staff and resident representative interviews, record review, and facility policy review, the facility fai...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, staff and resident representative interviews, record review, and facility policy review, the facility failed to ensure a dependent resident received appropriate oral care for one (1) of 45 residents residing in the facility. Resident #9.
The scope and severity for this citation was increased to E for a repeated citation from the previous annual recertification survey.
Findings include:
Record review of the facility policy titled ADL (Activities of Daily Living) Care Policy dated 8/23 revealed, It is the policy of this facility to provide appropriate treatment and services in relation to ADL care to residents to ensure all ADL needs are met on a daily basis while attaining or maintaining the residence of highest, practicable, physical, mental, and social well-being.
An observation on 3/30/25 at 4:25 PM revealed Resident #9 with a thick white substance inside the corners of his mouth and covering his upper and lower lip.
An interview on 3/30/25 at 6:25 PM with Resident #9's Resident Representative (RR) sitting at the bedside, she stated that she visits frequently and usually has to wash his lips and mouth off when she arrives. She revealed she has told the staff about his mouth not getting cleaned. She understands that the staff can't be with him 24 hours a day but thinks they could do better by ensuring he is cleaned up. She revealed she has visited before and found him with white dried secretions on his lips, and that tells her that his sputum stayed on his lips long enough to dry up.
During an interview on 4/01/25 at 8:30 AM, Licensed Practical Nurse (LPN) #1 revealed that occasionally at the beginning of shift, the resident will have an white sputum on his mouth and lips. She stated, It doesn't happen all of the time but does occasionally. She revealed that the Certified Nursing Assistants (CNA) are responsible for his ADL care, which includes his mouth care, and that the nurses are also responsible for oral care each shift.
In an interview on 4/1/25 at 12:45 PM, with CNA #2, she stated that they clean Resident #9's mouth when they do his ADL care. She admitted that if the staff would clean his mouth each time they checked on him, then that stuff wouldn't dry on his mouth.
During an interview on 4/01/25 at 1:45 PM, the Interim Director of Nurses (DON) revealed Resident #9's oral care should be done each shift and more often since he is fed by a feeding tube and probably a mouth breather. She revealed that it is her expectation that each resident is adequately groomed and presentable in appearance.
Record review of Resident #9's admission Record revealed he was admitted to the facility on [DATE] with medical diagnoses that included Hemiplegia and Hemiparesis following Cerebral Infarction, Gastrostomy status, and Adult Failure to Thrive.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0679
(Tag F0679)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident and staff interviews, record reviews, and facility policy reviews, the facility failed to provide an ongoing a...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident and staff interviews, record reviews, and facility policy reviews, the facility failed to provide an ongoing activity program designed to meet the needs of each resident for four (4) of 14 residents interviewed during the Resident Council meeting as evidenced by a lack of group activities on weekends. Residents #20, #22, #38 and #39.
Findings include:
A record review of facility policy titled, Activity Program, dated 1/21/22, revealed, An ongoing program of activities is designed to meet the needs of each resident. Individualized and group activities are provided that: a. Reflect the schedules, choices, and rights of the residents; b. Are offered at hours convenient to the residents, including evenings, holidays, and weekends.
Record review of the March 2025 Activity Calendar revealed each Saturday in March INDIVIDUAL PURSUIT was listed as the activity. Church services were listed each Sunday morning with CHECKERS/MOVIES as the 2:00 PM activity each Sunday.
Resident #20
During an interview 03/30/25 at 4:50 PM, Resident #20 stated she loved attending group activities, but the facility did not have activities on Saturday's. She admitted that she gets bored on Saturdays and would like there to be activities.
An interview with the Administrator on 4/1/25 at 4:00 PM revealed the facility was required to provide daily group activities and other activities that interest the residents even on the weekend. She confirmed the facility failed to provide the residents with activities on Saturday for those residents that choose to attend.
During an interview on 4/2/25 at 9:50 AM, the Activity Director confirmed the residents need activities that meet their interests daily and the facility had failed to provide these on Saturdays for a while now. She stated the facility had a family council group that was extremely active and had activities for the residents every Saturday, but the president of that group had a family illness, so she was less involved. Since that time, the family group had fizzled out. She admitted that during the winter months, residents were more confined inside and this could cause them to feel a little stir crazy and bored. Then she added that she provided games and puzzles for the residents to do on their own on the weekend, but there were no scheduled group activities.
Record review of Resident #20's Annual Minimum Data Set (MDS) Section F with Assessment Reference Date (ARD) of 9/17/24, revealed the resident's response of very important to the question, How important is it to you to do things with groups of people? To the question, How important is it to you to do your favorite activities, the resident's response was, very important.
Record review of Resident #20's admission Record, revealed the resident was admitted to the facility on [DATE].
Record review of Resident #20's Quarterly MDS Section C with an ARD of 12/4/24, revealed a Brief Interview for Mental Status (BIMS) of 15 which indicated the resident was cognitively intact.
Resident #22
During an interview on 3/30/25 at 3:30 PM, Resident #22 revealed weekends are pretty boring here. They got us some games to play, but many folks don't know how to play them, and they just sit and stare at each other. She revealed that on Sundays, someone comes in and does a church service, but we are on our own after that.
In an interview on 4/01/25 at 9:37 AM, the Activities Director confirmed that Resident #22 had voiced concerns that she would like to do weekend activities. She revealed she is trying to build the activities department back up and confirmed that there were no organized group activities for the month of March. She revealed it has been quite some time since there have been weekend activities
During an interview on 4/01/25 at 10:10 AM, the Administrator confirmed that the family council members used to be very involved in weekend activities, but they haven't been there in a while.
Record review of Resident #22's admission MDS Section F with an ARD of 11/11/24 revealed the resident's response to the question, How important is it to you to do your favorite activities? was, Very important.
Record review of Resident #22's admission Record revealed the resident was admitted to the facility on [DATE].
Record review of Resident #22's MDS Section C with an ARD of 11/11/24, revealed a BIMS of 15 which indicated the resident was cognitively intact.
Resident #38
On 03/31/25 at 1:30 PM, an interview with Resident #38, Resident Council President, revealed that they attended monthly Resident Council Meetings and had several residents who attended regularly. She revealed that some of the residents had brought up in the past that there weren't enough activities planned during the week and no activities on the weekends. She revealed that they had preaching on Sunday and that's it.
Record review of Resident #38's admission Record revealed an initial admission date of 07/22/22.
Record review of Resident #38's Quarterly MDS with ARD of 12/09/24 under Section C revealed a BIMS Score of 15 which indicated that she had no cognitive deficits.
Resident #39
An interview on 3/30/25 at 3:45 PM, Resident #39 revealed he would love to have something to do on the weekend. He stated that they don't have anything to do on Saturdays, and have a preacher who comes in early Sunday, but after that, we don't have anything to do. Resident #39 stated, I mainly just stay in bed and watch TV or sleep on the weekends.
Record review of Resident #39's Annual MDS Section F with ARD of 7/30/24 revealed the resident's response of Very important to the question, How important is it to you to do things with groups of people? To the question, How important is it to you to do your favorite activities? the resident's response was, Very important.
Record review of Resident #39's admission Record revealed the resident was admitted to the facility on [DATE].
Record review of Resident #39's MDS Section C with ARD of 7/30/24 revealed a BIMS score of 8 which indicated the resident had moderate cognitive impairment.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, record review, and facility policy review, the facility failed to ensure implementation o...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, record review, and facility policy review, the facility failed to ensure implementation of infection prevention and control practices to prevent the potential transmission of communicable diseases and infections for two (2) of three (3) resident care areas observed (Resident #1 and Resident #9). Specifically, the facility failed to:
1. Post appropriate transmission-based precautions signage for a resident on contact isolation for Methicillin Resistant Staphylococcus Aureus (MRSA) (Resident #1); and
2. Ensure staff followed Enhanced Barrier Precautions (EBP), including wearing a gown, during the administration of medication via a Percutaneous Endoscopic Gastrostomy (PEG) tube (Resident #9).
These failures had the potential to contribute to the transmission of infectious organisms to other residents, staff, and visitors within the facility.
The scope/severity for this deficiency was increased to E - pattern. F880 was also cited during the last annual recertification survey.
Findings include:
A record review of the facility policy titled Enhanced Barrier Precautions, dated 10/23, revealed, It is the policy of this facility to implement enhanced barrier precautions for the prevention of transmission of multidrug-resistant organisms .Enhanced barrier precautions refer to the use of gown and gloves for use during high-contact resident care activities .(residents with wounds or indwelling medical devices) . c. Clear signage will be posted on the door or wall outside of the resident room indicating the type of precautions, required personal protective equipment (PPE), and the high-contact resident care activities that require the use of gown and gloves .
Record review of facility policy titled, Infection Prevention and Control Program, undated, revealed, It is a policy of this facility to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections.
Resident #1
During an interview on 3/30/25 at 5:25 PM, Resident #1 stated he had wounds on his lower legs. A hanging isolation organizer was noted on his door. There was no signage on his door that indicated what type of isolation the resident was in or what type of Personal Protective Equipment (PPE) was needed.
During an interview on 3/31/25 at 10:30 AM, the Infection Preventionist/Treatment Nurse stated that Resident #1 had Methicillin Resistant Staphylococcus Aureus (MRSA) in his leg wounds and was on contact isolation for this infection. She stated he was receiving antibiotics and after completing those, a repeat culture would be done. She stated the proper use of PPE helped prevent the spread of an infection. She acknowledged the resident did not have signage on his door to indicate what type of isolation the resident was on or what type of protective equipment needed to be used.
An interview with the Administrator on 3/31/25 at 11:40 AM confirmed that Resident #1 was in contact isolation due to MRSA in a wound and signage on or near the resident's door was required. She stated when a resident was placed in contact isolation, the type of precaution and the PPE to be used was required to be placed in a visible area outside of the resident's room. She stated signage was necessary to inform staff and visitors what PPE was needed to help prevent the spread of infection. She confirmed the facility failed to place proper infection control signage on or near a resident's door to identify the type precautions and the appropriate PPE to use.
Record review of Resident #1's Order Summary Report revealed an order dated 3/25/25 to Maintain contact precautions due to MRSA infection in lower leg every shift related to bacterial infection.
Record review of Resident #1's admission Record revealed the resident was admitted to the facility on [DATE]. Diagnoses included Bacterial Infection, Non-pressure Chronic Ulcer of left and right lower legs, and Venous Insufficiency.
Record review of Resident #1's Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 1/13/25, revealed a Brief Interview for Mental Status (BIMS) of 10 which indicated the resident had moderate cognitive impairment.
Resident #9
An observation on 4/01/25 at 8:25 AM revealed Licensed Practical Nurse (LPN) #1 administered Resident #9's medications through a PEG tube without wearing a gown for EBP. She confirmed she failed to wear a protective gown and revealed she knows that she should have. She revealed that EBP is supposed to be utilized when providing care to the resident since he has a PEG tube. She revealed we even discussed wearing the gown when I gave him his medications this morning, but I got nervous and forgot to do it.
During an interview on 4/01/25 at 2:24 PM, the Interim Director of Nurses (DON) confirmed that the nurse should have worn the PPE when administering his medications through the PEG. She revealed that EBP is implemented to protect the residents and the staff from spreading germs.
During an interview on 4/02/25 at 12:06 PM, the Infection Control Nurse revealed that for any residents under EBP, the facility's requirements and expectations are that the staff wear the proper PPE to reduce the possible spread of infections.
Record review of Resident #9's Order Summary Report with active orders as of 4/1/25 revealed an order for EBP related to PEG every shift.
Record review of Resident #9's admission Record revealed he was admitted to the facility on [DATE] with medical diagnoses that included Hemiplegia and Hemiparesis following Cerebral Infarction and Gastrostomy status.
MINOR
(C)
Minor Issue - procedural, no safety impact
Deficiency F0576
(Tag F0576)
Minor procedural issue · This affected most or all residents
Based on resident and staff interviews, record review and facility policy review, the facility failed to deliver resident mail on Saturdays for five (5) of 31 sampled residents. This has the potential...
Read full inspector narrative →
Based on resident and staff interviews, record review and facility policy review, the facility failed to deliver resident mail on Saturdays for five (5) of 31 sampled residents. This has the potential to affect all residents in the facility. Resident #4, Resident #20, Resident #22, Resident #35, and Resident #38.
Findings Include:
Record review of the facility policy Mail Delivery Policy dated 2/2009 revealed, The mail will be delivered to the resident Monday thru Friday by the Activity Director. If the resident receives mail on Saturday, it will be delivered to the resident by the week-end RN (Registered Nurse) Unit Manager.
During a Resident Council Meeting on 03/31/25 at 2:00 PM five of the thirteen residents in attendance revealed that they did not have mail delivered on Saturdays. Resident #38, Resident Council President, revealed that there was no one in the front office on the weekend to pass the mail out to them. Resident #4, Resident #20, Resident #22, and Resident #35 confirmed that the staff handed their mail out during the week and that they did not get mail on Saturdays.
An interview on 03/31/25 at 3:40 PM with Registered Nurse (RN) #1, revealed that she worked on the weekends and that she hadn't ever accepted mail on Saturdays. She revealed that the front office was closed on the weekends. RN #1 revealed that if mail was delivered to the facility on Saturdays, she could pass it out to the residents.
An interview on 04/01/25 at 9:10 AM with the Director of Nursing (DON), revealed that the mail carrier did not deliver mail to the facility on Saturdays because there was no one in the front office to give it to. She revealed that if the facility had any mail on Saturdays, the mail carrier delivered it the following Monday when they had someone to distribute it to. DON agreed that residents should receive their mail on Saturdays if they had any, and they should not have to wait until the following Monday to get it.
On 04/01/25 at 10:00 AM, an interview with the Administrator (ADM) revealed that there had been some inconsistencies with the mail but she was not aware that mail was not delivered on Saturdays. ADM confirmed that it was important for the residents to receive their mail and that it should be passed out on the days the mail ran.
Record review of Resident #4's admission Record revealed an admission date of 04/17/08.
Record review of Resident #4's Quarterly Minimum Data Set (MDS) with Assessment Reference Date (ARD) of 01/27/25 under Section C revealed a Brief Interview for Mental Status (BIMS) score of 15 which indicated that she had no cognitive deficits.
Record review of Resident #20's admission Record revealed an initial admission date of 12/13/18.
Record review of Resident #20's Quarterly MDS with ARD 12/4/24 under Section C revealed a BIMS Score of 15 which indicated that she had no cognitive deficits.
Record review of Resident #22's admission Record revealed an admission date of 11/04/24.
Record review of Resident #22's Quarterly MDS with ARD of 02/06/25 under Section C revealed a BIMS Score of 15 which indicated that she had no cognitive deficits.
Record review of Resident #35's admission Record revealed an admission date of 03/25/22.
Record review of Resident #35's Quarterly MDS with ARD of 11/19/25 under Section C revealed a BIMS Score of 15 which indicated that she had no cognitive deficits.
Record review of Resident #38's admission Record revealed an initial admission date of 07/22/22.
Record review of Resident #38's Quarterly MDS with ARD of 12/09/24 under Section C revealed a BIMS Score of 15 which indicated that she had no cognitive deficits.
Mar 2024
15 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0558
(Tag F0558)
Could have caused harm · This affected 1 resident
Based on observation, resident and staff interview, and facility policy review, the facility failed to ensure a resident's call light was in reach for one (1) of 57 residents residing in the facility....
Read full inspector narrative →
Based on observation, resident and staff interview, and facility policy review, the facility failed to ensure a resident's call light was in reach for one (1) of 57 residents residing in the facility. Resident #4
Findings include:
Review of the facility policy titled Call Lights: Accessibility and Timely Response with a revision date of 3/19/2024 revealed, Policy: The purpose of this policy is to assure the facility is adequately equipped with a call light at each residents' bedside, toilet, and bathing facility to allow residents to call for assistance. Also revealed under, Policy Explanation and Compliance Guidelines: . 5. Staff will ensure the call light is within reach of resident and secured, as needed.
Resident #4
An observation of Resident #4 on 3/18/2024 at 11:16 AM, revealed her lying in bed with a pillow under her left arm with the call light hanging down from the left side of the bed on the floor.
An observation and interview on 03/19/2024 at 2:02 PM, revealed Resident #4 hollering for help down the south hallway. The resident was observed sitting in a wheelchair facing a window in her room and stated she needed help and asked, Can you open my chocolate? The call light was hanging down from the left bed rail, which was positioned up against the wall and the resident could not access it. The resident stated she could use the call light to request help if she had it.
An observation and interview with Certified Nurse Aide (CNA) #1 on 3/19/2024 at 2:05 PM, revealed she was assigned to Resident # 4 and explained that she brought the resident to her room and got called away to do something else and confirmed that the call light was unreachable and should not be. CNA #1 explained that the purpose of having the call light close by was for the resident to call when she needed help.
An interview with the Director of Nursing (DON) on 3/19/2024 at 2:24 PM, confirmed Resident #4's call light should be accessible when the resident was in her room so she could call for assistance when needed.
Record review of Resident #4's Face Sheet revealed the facility admitted the resident on 5/10/2016 with medical diagnoses that included Cerebral Infarct, Type 2 Diabetes Mellitus, Epilepsy, and Paranoid Schizophrenia.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0578
(Tag F0578)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, resident and staff interview, record review, and facility policy review the facility failed to honor a res...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, resident and staff interview, record review, and facility policy review the facility failed to honor a resident's preference for end of life Advance Directives for one (1) of 24 residents sampled. Resident #57.
Findings include:
Record review of facility policy titled, Advance Directive Policy, undated, revealed, This facility recognizes the resident's right under the State Law to accept or refuse medical treatment and to formulate advance directives such as a Living Will, Durable Power of Attorney for Healthcare and decisions regarding resuscitation The facility supports the need for resident's participation in health care decisions and will make every effort to provide the resident and their family with information to enhance decision making capacity and to reasonably assure the ability to make voluntary and informed decisions.
Record review of Resident #57's Advance directives/Medical treatment decisions .I do not choose to formulate or issue any Advance Directives at this time. I want efforts made to prolong my life and I want life-sustaining treatment to be provided. Signed by Resident and dated [DATE].
Record review revealed a hospice form for Do-Not-Resuscitate (DNR) signed by daughter and dated [DATE].
Record review of Resident #57's Physician orders for the month of: [DATE] revealed Code Status: Full code.
Record review of Resident #57's Physician orders for the month of: [DATE] revealed an order dated [DATE] Code Status: Do Not Resuscitate.
An interview on [DATE] at 3:30 PM, with Resident #57 stated, I know I'm on hospice services but if I stop breathing, I want cardiopulmonary resuscitation (CPR). I want to come back. That's what I want. He revealed his daughter signed his hospice paperwork, but he wasn't aware that his code status had changed, and it hadn't been discussed with him.
An interview on [DATE] at 4:25 PM, the admission Liaison Nurse revealed when Resident #57 was admitted to the facility he signed his own Advance Directive paperwork, and his wish was to be a full code meaning he wished to have CPR performed. She confirmed that the resident had a form signed by Resident #57's daughter when he went on hospice services on [DATE], and a physician order for [DATE] for DNR by the hospice physician. She revealed, I don't think his code status was discussed with him when they admitted him to hospice services. She revealed they have no paperwork confirming the daughter is his Power of Attorney (POA) She confirmed it is his right to choose his end-of-life status and it is supposed to be according to his wishes. She revealed she wasn't aware that his end-of-life choice had changed from CPR to DNR.
An observation on [DATE] at 4:45 PM, revealed an interview between Resident #57 and the admission Liaison Nurse in which the nurse explained to the resident his end-of-life choices. The nurse explained the difference between the DNR code status and the Full code status. Resident #57 verbalized understanding of the difference and stated, If you can get my heart to beating, I want you to try, it may not get back to beating but I want you to try.
An interview on [DATE] at 2:02 PM, the Administrator confirmed that the resident had completed his own Advance Directive and had chosen a full code status when he was admitted to the facility. She revealed she wasn't aware of the change in his code status when he went on hospice services, and it wasn't communicated through the proper channels, and it should have been.
Record review of Resident #57's Face Sheet revealed he was admitted to the facility on [DATE] with diagnoses that included Chronic Obstructive Pulmonary Disease and Chronic Respiratory Failure.
Record review of Resident #57's Minimum Data Set (MDS) with Assessment Reference Date (ARD) of [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 11 which indicated the resident has moderate cognitive impairment.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Notification of Changes
(Tag F0580)
Could have caused harm · This affected 1 resident
Based on observation, resident and staff interview, record review, and facility policy review, the facility failed to notify a resident's physician of a skin concern for one (1) of 19 sampled resident...
Read full inspector narrative →
Based on observation, resident and staff interview, record review, and facility policy review, the facility failed to notify a resident's physician of a skin concern for one (1) of 19 sampled residents. Resident #216.
Cross Reference F684
Findings Include:
Record review of the facility policy titled Notification of Changes with a revision date of 12/20/2022 revealed, Policy: The purpose of this policy is to ensure the facility promptly informs the resident, consults the resident's physician; and notifies, consistent with his or her authority, the resident's representative when there is a change requiring notification .Compliance Guidelines: The facility must inform the resident, consult with the resident's physician and /or notify the resident's family member or legal representative when there is a change requiring such notification 3. Circumstances that require a need to alter treatment. This may include: a. New treatment .
An observation and interview with Resident #216 on 3/19/2024 at 2:40 PM, revealed the resident sitting in a wheelchair with his head laid over a bedside table. The resident was observed with an excessive thick layer of white buildup with patchy areas of flaking to the entire scalp (all hair) that extended to the ear lobes. The white buildup was also observed in the resident's facial beard that extended to the front of his neck. The resident stated that it did itch at times and revealed that the facility was not performing treatment to the areas.
An observation and interview with Licensed Practical Nurse (LPN) #1, on 3/19/2024 at 2:43 PM, confirmed Resident #216's skin concern. She revealed she was not aware of the skin issue and stated the resident was not getting any type of treatment and she was unsure if the physician had been notified, and confirmed he should have been.
Record review of Resident #216's Physician Orders revealed there was not a treatment order for his skin concern.
Record review of Resident #216's Departmental Notes dated 2/21/2024 through 3/11/2024, revealed the resident had dry skin to the BLE (bilateral lower extremities) with no documentation of his skin concern to the scalp and beard.
An interview with Registered Nurse (RN) #1 on 3/20/2024 at 1:40 PM, revealed the staff had not reported any skin issues to her for Resident #216. She stated the physician should have been contacted when the issue was first observed.
Record review of the Skin Inspection Report dated 2/28/2024, 3/11/2024, and 3/18/2024 revealed Skin Intact which indicated Resident #216 had no identified skin concern.
An interview with LPN #2 on 3/20/2024 at 3:55 PM, revealed she was the person responsible for completing the last two weeks of skin audits on Resident #216. She revealed she did not find any skin concerns on either of the skin audits and stated the resident was lying in bed when she conducted the audits, and she must have overlooked it.
An interview with the Director of Nursing (DON) on 3/20/24 at 4:00 PM, confirmed Resident #216's skin concern should have been caught on the weekly skin audits and stated the physician should have been notified for a treatment.
Record review of Resident #216's Face Sheet revealed the facility admitted the resident on 2/21/24 with medical diagnoses that included Chronic Systolic (congestive) Heart Failure and Type 2 Diabetes mellitus.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0583
(Tag F0583)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, resident and staff interview, facility policy review, the facility failed to ensure privacy for a resident...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, resident and staff interview, facility policy review, the facility failed to ensure privacy for a resident as evidenced by a staff member changing a residents brief next to a window with no curtain or blind for one (1) of 57 residents observed for privacy. Resident #35
Findings include:
Review of facility policy titled, Resident Rights, with a revision date of 9/22/22 revealed, The resident has the right to a dignified existence .7. Privacy and confidentiality: The resident has a right to personal privacy .
An observation on 3/18/24 at 10:35 AM revealed no curtains or blinds on the window in Resident #35's room with the resident's bed situated in front of the window with a view outside of a driveway with a trash dumpster and several parked cars.
An interview on 3/18/24 at 1:54 PM, Resident #35 revealed in a slurred speech that she would like curtains on her window and wasn't sure why she didn't have a curtain.
An interview on 03/18/24 at 2:30 PM, Certified Nurse Aide (CNA) #3 revealed the resident's window hadn't had a curtain or blind for a while but she was unsure how long it had been off. She revealed we change her briefs and do her peri care while she is standing up, we can't change her while she is in bed because her legs flail around so much.
An observation on 03/18/24 at 2:55 PM, CNA #3 entered Resident # 35's room with an incontinence disposable brief in her hand, she pulled the privacy curtain between Resident A and Resident B's bed and was changing Resident #35's brief and administering peri-care in front of the open window that lacked any covering from the outside view.
An interview on 03/18/24 at 3:05 PM, the Administrator confirmed there was no blind or curtain on the resident's window and revealed that it should be. She stated she wasn't sure how long it had been like this and confirmed this is a privacy and dignity issue.
Record review of Resident #35's Face Sheet revealed she was admitted to the facility on [DATE] with diagnoses that included Huntington's disease, Slurred Speech, and Anxiety Disorder.
Record review of the quarterly Minimum Data Set with an Assessment Reference Date of 1/20/24 revealed a Brief Interview for Mental Status (BIMS) score of 10 which indicated moderately impaired cognitive skills.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Comprehensive Assessments
(Tag F0636)
Could have caused harm · This affected 1 resident
Based on staff interview and record review, the facility failed to complete a Comprehensive admission Minimum Data Set (MDS) assessment within fourteen days for one (1) of 19 sampled residents Residen...
Read full inspector narrative →
Based on staff interview and record review, the facility failed to complete a Comprehensive admission Minimum Data Set (MDS) assessment within fourteen days for one (1) of 19 sampled residents Resident #216
Findings Include:
Record review of Resident #216's Face Sheet revealed the facility admitted the resident on 2/21/2024.
Record review of Resident #216's admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 2/28/2024, revealed under section Z, the date a Registered Nurse (RN) signed the assessment as complete was left blank. It also revealed a status of Open, which indicated the admission assessment had not been completed and closed for transmittal.
An interview with the Minimum Data Set (MDS) Nurse #2 on 3/20/2024 at 9:49 AM, confirmed Resident #216's admission MDS assessment was not completed and should have been completed within 14 days of admission. She revealed she overlooked the assessment and thought it had been completed. She explained the comprehensive assessment must be completed to develop the resident's care plans, which gave the staff a guide of how to care for the resident.
An interview with the Director of Nursing (DON) on 3/20/2024 at 3:20 PM, revealed she was not aware that Resident #216's admission MDS assessment had not been completed. She confirmed the MDS assessments should be completed and submitted per the Resident Assessment Instrument (RAI) guidelines.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Assessment Accuracy
(Tag F0641)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Resident #46
An observation of Resident #46 on 03/18/2024 at 11:14 AM, revealed him lying in bed awake. The resident was observe...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Resident #46
An observation of Resident #46 on 03/18/2024 at 11:14 AM, revealed him lying in bed awake. The resident was observed with paralysis to the left arm and contractures to the left fingers.
Record review of Resident #46's Physician Orders revealed an order dated 7/04/2023, Hand roll to Lt (left) hand during waking hours to prevent further contractures .
Record review of the MDS with an ARD of 3/11/2024 revealed, under section GG, functional limitation in Range of Motion - Upper extremity was marked as 0 (zero), which indicated Resident #46's had no impairment.
An interview with the MDS #1 on 3/20/2024 at 2:29 PM, revealed she was the person that completed Resident #46's MDS assessment and stated that she made an error by not marking limited range of motion (ROM) for the upper extremity. She revealed that she did not reference the RAI when she completed the assessment, and revealed that she should have. She revealed the MDS did not represent an accurate assessment of the resident.
Record review of the Face Sheet revealed the facility admitted Resident #46 on 4/08/2022 with medical diagnosis that included hemiplegia following Cerebral Infarction affecting the left nondominant side, Type 2 Diabetes Mellitus, Seizures, and Depression.
Based on observation, staff interview, record review, and facility policy review, the facility failed to accurately complete a Minimum Data Set (MDS) assessment for resident(s) with upper body contractures for two (2) of 19 resident assessments reviewed. Resident #34 and #46
Findings include:
Record review of facility policy titled Resident Assessment - RAI, dated 6/18/23, revealed, This facility makes a comprehensive assessment of each resident's needs, strengths, goals, life history, and preferences using the resident assessment instrument (RAI) specified by CMS (Centers for Medicare and Medicaid Services) .
Resident #34
An observation and interview with Resident #34 on 3/19/24 at 8:20 AM, revealed resident's left hand and fingers were contracted and a gauze dressing was in her palm. She stated it had been like that for a long time and she had a wound in her hand.
Record review of Resident #34's MDS with Assessment Reference Date (ARD) of 1/30/24, Section GG revealed the resident had no impairment with range of motion of upper extremities.
An interview with MDS Registered Nurse (RN) #1 on 3/20/24 at 3:40 PM, revealed she was the person that completed Resident #34's MDS assessment and made an error by not marking limited range of motion to upper extremity. She stated she was aware of the contracture to the resident's left hand and fingers, but she did not realize that contractures of the hand/fingers would be considered an upper extremity range of motion limitation, so therefore, she failed to code it correctly. She stated she reviewed the RAI and realized she should have marked the limited range of motion for this resident's upper extremities and confirmed she did not enter accurate information in the MDS assessment.
During an interview on 3/20/24 at 3:45 PM, the Director of Nursing (DON) revealed the MDS assessment should represent an accurate assessment of the resident's condition at that time. She confirmed the facility failed to code and submit an accurate MDS assessment concerning contractures for Resident #34.
Record review of the Physician Orders List for Resident #34 revealed an order dated 12/28/22 for a hand roll to left hand during waking hours as tolerated.
Record review of Resident #34's MDS with ARD of 1/30/24, revealed a Brief Interview for Mental Status (BIMS) of 8 which indicated the resident had a moderate cognitive impairment.
Record review of Resident #34's Face Sheet revealed she was admitted to the facility on [DATE] with medical diagnoses that include Parkinson's Disease and Abnormalities of gait and mobility.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Comprehensive Care Plan
(Tag F0656)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Resident #26
Record review of Resident #26's Care Plans revealed, Problem Onset: 1/08/2024, I require extensive to total assista...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Resident #26
Record review of Resident #26's Care Plans revealed, Problem Onset: 1/08/2024, I require extensive to total assistance with ADLs Approaches . Nail care to be done weekly on shower days .
An observation of Resident #26 on 3/18/2024 at 11:16 AM, revealed her lying in bed with long nails on both hands measuring three-eights (3/8) inch in length.
An observation and interview with the DON on 3/19/2024 at 2:25 PM confirmed Resident #26's long nails.
An interview with MDS Nurse #1 on 3/20/2024 at 2:26 PM confirmed Resident #26's care plan was not followed for nail care weekly. She revealed the purpose of the care plan was to be able to provide the needed care for the residents.
Record review of Resident #26's Face Sheet revealed the facility admitted the resident on 3/30/2022 with medical diagnoses that included Depression, Essential (primary) Hypertension, and Osteoarthritis.
Resident #46
Record review of Resident #46's Care Plan with a problem onset date of 3/228/22 revealed, Problem/Need: .contracture to left hand .Approaches . Hand roll to Lt (left) hand during waking hours to prevent further contracture as resident will allow .
An observation of Resident #46 on 03/18/2024 at 11:14 AM revealed him lying in bed awake. The resident was observed with paralysis to the left arm and contractures to the left fingers, with no device in use.
An observation of Resident #46 on 3/19/2024 at 1:59 PM revealed him sitting in a wheelchair at the nurse's station. No device in place to the left hand.
An interview and observation on 3/19/2024 at 2:10 PM with LPN #1 confirmed Resident #46 did not have a left hand roll in use.
An interview with MDS Nurse #1 on 3/20/2024 at 2:29 PM confirmed Resident #46's care plan was not followed for applying the left hand roll.
Record review of the Face Sheet revealed the facility admitted Resident #46 on 4/08/2022 with medical diagnosis that included Hemiplegia following cerebral infarction affecting the left nondominant side, Type 2 Diabetes Mellitus, Seizures, and Depression.
Resident #216
Record review of Resident #216's Face Sheet revealed the facility admitted the resident on 2/21/2024 with medical diagnoses that included Hyperlipidemia, Chronic Systolic (congestive) Heart Failure, Type 2 Diabetes Mellitus, Vitamin D deficiency, and Paroxysmal Atrial Fibrillation.
Record review of Resident #216's Electronic Medical Record (EMR) revealed there were not any care plans developed since admission.
An interview with MDS Nurse #2 on 3/20/2024 at 9:49 AM, confirmed she had not developed comprehensive care plans for Resident #216. She explained they overlooked completing the admission MDS assessment; therefore, the care plans had not been developed. She revealed the staff would not know how to care for the resident since he did not have care plans.
An interview with the DON on 3/20/2024 at 3:20 PM, revealed she was not aware Resident #216 did not have care plans. She revealed without the care plans, the staff would not know how to care for the resident. She confirmed the care plans should be completed within the time frame according to the Resident Assessment Instrument (RAI) guidelines.
Resident #13
Record review of the care plan with a problem onset date of 10/23/23, revealed Resident #13 requires total care with ADL needs due to immobility, chronic flexion contractures of all four extremities. An intervention was to provide with oral care every 2 hours and as needed with swabs, wipe his mouth after oral care and apply Vaseline to his lips.
An observation on 03/18/24 at 10:45 AM and again at 12:15 PM, of Resident #13 revealed a large amount of thick, white dried substance on his upper and lower lips.
An interview on 3/19/24 at 3:15 PM, the DON confirmed Resident #13 not having the proper oral care is not acceptable. She confirmed it is the responsibility of the CNA's on each shift to make sure the resident's lips and oral care are taken care of and the responsibility of the nurses to ensure the scopolamine patch is on to help reduce his oral secretions.
An interview on 3/20 at 2:45 PM, MDS Nurse #1 revealed the care plan is developed to ensure staff knows how to take care of the individual needs of each resident. She revealed Resident #13's care plan was developed due to his excessive secretion buildup and for the staff to know he is to receive oral care every two (2) hours and as needed as it is written. She confirmed Resident #13's oral care plan was not being followed and it should have been.
Record review of Resident #13's Care Plan with a problem onset date of 10/41/22 revealed I have dysphagia, I am NPO (nothing to eat or drink by mouth), I require PEG (Percutaneous Endoscopic Gastrostomy) tube for all nutrition and hydration, I am at risk for aspiration and other complications due to tube feeding. An intervention listed was PEG tube meds must be given individual.
An observation of medication administration via PEG tube on 3/20/24 at 8:45 AM, revealed Licensed Practical Nurse (LPN) #1 crushed six tablet medications together and mixed those with one liquid medication and administered through PEG tube.
Interview with the DON on 3/20/24 at 9:50 AM, confirmed that LPN #1 did not follow the physician order or the care plan and give each medication individually.
An interview with the MDS RN #1 on 3/20/24 at 4:10 PM, revealed the care plan was to inform the staff of how to take care of the residents. She stated it was a guide for the staff to follow for the needed care of each resident and confirmed this care plan for PEG medication administration was not followed.
Record review of Resident #13's Face Sheet revealed the resident was admitted to the facility on [DATE] with medical diagnoses that included Convulsions, Gastrostomy status, Dysphagia, and Hemiplegia.
Record review of MDS with ARD of 1/23/24 revealed a BIMS of 0 score which indicated the resident had severe cognitive impairment.
Based on observation, staff interview, record review, and facility policy review the facility failed to develop comprehensive care plans timely, failed to implement care plans for residents' Activities of Daily Living (ADL) care and position and mobility needs for five (5) of 19 resident careplans reviewed. Residents #1, #13, #26, #46, and #216.
Findings include:
Record review of facility policy titled Comprehensive Care Plans dated 12/15/22, revealed, It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and time frames to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment.
Resident #1
Record review of Resident #1's Care Plan with problem onset 09/12/2023, revealed the resident was unable to assist with her care and required total assistance with Activities of Daily Living (ADLs) due to cognitive impairment related to diagnosis of infantile cerebral palsy, and spastic quadriplegia. An intervention listed was oral care every shift with swabs.
On 3/18/24 at 11:20 AM, Resident #1 was observed in her wheelchair at the nurses station. Her lips were noted to be covered with a white crusty covering with a white thick secretion noted.
An interview on 3/19/24 at 2:40 PM, with the Director of Nursing (DON) confirmed the facility failed to ensure the resident's oral care was done as needed and therefore, the care plan was not followed.
An interview with the Minimum Data Set (MDS) Registered Nurse (RN) #1 on 3/20/24 at 4:10 PM, revealed the care plan was to inform the staff of how to take care of the residents. She stated it was a guide for the staff to follow for the needed care of each resident and confirmed this care plan for oral care was not followed.
Record review of Resident #1's Face Sheet revealed resident was admitted to the facility on [DATE]. Diagnoses included cerebral palsy, spastic quadriplegic cerebral palsy, convulsions, intellectual disabilities.
Record review of Resident #1's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 2/26/24, revealed in Section GG for oral hygiene, this resident was dependent. Review of the Brief Interview for Mental Status (BIMS) score of 0 indicated the resident was severely cognitively impaired.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0658
(Tag F0658)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interviews, record review, facility statement, and facility policy review, the facility failed to fo...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interviews, record review, facility statement, and facility policy review, the facility failed to follow professional standards of practice for a feeding tube as evidenced by crushing and administering multiple medications at once without the use of flushes and gravity for one (1) of four (4) residents observed during medication administration. Resident #13.
Cross Reference F759
Findings include:
Record review of statement signed by the Administrator on facility letterhead and dated 3/20/24, revealed (Proper name of facility) does not have a current policy on giving medications through the PEG (Percutaneous Endoscopic Gastrostomy) tube.
Record review of facility policy titled, Medication Set-up, Administration and Documentation Policy, undated, revealed, You must have an order to crush medications.
An observation of Licensed Practical Nurse (LPN) #1 during medication pass for Resident #13's PEG tube medication administration on 3/20/24 at 8:45 AM, revealed LPN #1 crushed Vitamin C 250 milligrams (MG), Metoprolol Tartrate 25 MG, Vitamin D3 1000 units, Zestril 5 MG, Hydrochlorothiazide 12.5 MG, and Aspirin 81 MG together and placed these into the container with the liquid Keppra medication. She stated she was hesitant to give the medications together since in nursing school she learned to give each one separately, but at the facility she was instructed to administer them together, so that was what she was going to do. She entered the resident's room and once again questioned this technique and went back to the medication cart to verify the order and stated there was an order to administer these together. She then returned to the room, checked the residual, pushed 15 milliliters of water, next pushed the seven combined medications, then flushed with 15 milliliters of water. This was all given by syringe and pushed in with plunger and not by gravity.
An interview with the Director of Nursing (DON) on 3/20/24 at 9:50 AM, confirmed that Resident #13 did not have a physician order to crush and administer the PEG medications together. She confirmed that LPN #1 did not follow the physician order for the PEG medications to be given individually. She also confirmed that PEG medications should be given by gravity for the resident's comfort and to prevent damage to the PEG tube and given individually with flush between each to ensure compatibility. She stated the facility used [NAME] and [NAME] as a nursing reference and did not have a policy for PEG medication administration. She also confirmed the facility did not meet the professional standards for nursing practice related to PEG medication administration.
During an interview on 3/21/24 at 10:50 AM, LPN #1 revealed she had misread the order that actually read that medications could be crushed and given together if taken by mouth, but had to be given individually by PEG tube. She confirmed the purpose of administering medications separately was to ensure the medications were compatible and the medications and flushes needed to be administered by gravity and she failed to do this.
Record review of Resident #13's Physician Orders List revealed an order dated 1/21/22, May administer crushed medications that are being given PO (by mouth) together. PEG tube meds must be given individual. Record review also revealed orders for Hydrochlorothiazide 12.5 mg per g-tube (gastrostomy tube), Aspirin 81 mg per PEG, Zestril 5 mg tablet per g-tube, Vitamin D3 1000 unit per g-tube, Vitamin C 250 mg per PEG, Metoprolol Tartrate 25 mg per g-tube, and Keppra 100 milligram/milliliter 7.5 ml per PEG.
Record review of Resident #13's Face Sheet revealed the resident was admitted to the facility on [DATE] with medical diagnoses that included Convulsions, Gastrostomy status, Dysphagia, and Hypertension.
Record review of Minimum Data Set (MDS) with Assessment Reference Date (ARD) of 1/23/24 revealed a Brief Interview for Mental Status (BIMS) of 0 which indicated the resident had severe cognitive impairment.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
ADL Care
(Tag F0677)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Review of the facility policy titled Nail Care with a revision date of 12/15/2023 revealed under, Policy Explanation and Complia...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Review of the facility policy titled Nail Care with a revision date of 12/15/2023 revealed under, Policy Explanation and Compliance Guidelines: . 4. Routine nail care, to include trimming and filing, will be provided on a regular schedule or as needed. Nail care will be provided between scheduled occasions as the need arises .
Resident #26
An observation and interview with Resident #26 on 03/18/2024 at 11:16 AM, revealed long fingernails on both hands measuring three-eights (3/8) inch in length. The resident's left fingers were contracted and bent inward toward the palm. She stated she would like to have her nails trimmed, but no one had offered.
An observation and interview with the DON on 3/19/2024 at 2:25 PM, revealed the aides were responsible for cutting the resident's nails during bathing or at any time they noticed the nails required trimming. She confirmed Resident #26's long nails could result in skin injury.
An interview with Registered Nurse (RN) #1 on 3/19/2024 3:45 PM, confirmed she was responsible for following up and ensuring the resident's ADL care was provided daily.
Record review of Resident #26's Face Sheet revealed the facility admitted the resident on 3/30/2022 with medical diagnoses that included Depression and Osteoarthritis.
Resident #216
Review of the facility policy titled Grooming a Resident's Facial Hair with a revision date of 12/20/2022 revealed under, Policy: It is the practice of this facility to assist residents with grooming facial hair to help maintain proper hygiene as per current standards of practice .
An observation and interview with Resident #216 on 3/18/2024 at 2:25 PM, revealed long, black facial hair (mustache and beard) measuring approximately one-half (1/2) inch in length. The resident stated he would like it shaved, but has been unable to do so due to weakness in his arm.
An interview with LPN #1 on 3/19/2024 at 2:43 PM, confirmed Resident #216 needed shaving. She stated that the aides were responsible for shaving the residents with bathing and as requested.
An interview with the DON on 3/19/2024 at 2:55 PM, revealed she expected the aides shaved the male residents on bath days and as they requested.
Record review of Resident #216's Face Sheet revealed the facility admitted the resident on 2/21/2024 with medical diagnoses that included Type 2 Diabetes Mellitus, and Paroxysmal Atrial Fibrillation.
Resident #13
An observation on 3/18/24 at 10:45 AM, of Resident #13 revealed a large amount of thick, white dried substance on his upper and lower lips.
An observation on 3/18/24 at 12:15 PM, of Resident #13 revealed a large amount of thick, white dried substance on his upper and lower lips.
An interview on 3/19/24 at 2:45 PM, CNA #2 revealed he was assigned to the resident today, and when he came in this morning the resident had a large amount of the white substance on his lips and confirmed it was the CNA's responsibility on each shift to make sure Resident #13's oral care is being done.
An interview on 3/19/24 at 2:55 PM, CNA #3 revealed the resident wears a patch behind his ear and she noticed when he doesn't have his patch on the buildup is a lot worse. She confirmed his mouth care is supposed to be done often and if it is built up then it hasn't been done in a while.
An interview on 3/19/24 at 3:05 PM, LPN #1 revealed Resident #13 is Nothing by Mouth (NPO) and wears a scopolamine patch to reduce his oral secretions. She revealed a lot of times his scopolamine patch will come off and doesn't get reported to her. She revealed his mouth gets foamy and has a white substance that dries on his lips, but his oral care is supposed to be done more often because of this.
An interview on 3/19/24 at 3:15 PM, the DON confirmed Resident #13 not having the proper oral care is not acceptable. She confirmed it is the responsibility of the aides on each shift to make sure the resident's lips are taken care of and the responsibility of the nurses to ensure the scopolamine patch is on to help reduce his oral secretions.
Record review of the Face Sheet revealed Resident #13 was admitted to the facility on [DATE] with medical diagnoses that included Unspecified Convulsions, and Hemiplegia.
Based on observations, staff, resident and resident representative interviews, record review, and facility policy review the facility failed to ensure dependent residents received appropriate oral care, nail care and shaving for four (4) of 57 residents observed. Resident #1, #13, #26 and #216.
Findings include:
Record review of facility policy titled, Activities of Daily Living (ADLs), dated 12/15/22 revealed, A resident who is unable to carry out activities of daily living will receive the necessary services to maintain good nutrition, grooming, and personal and oral hygiene.
Record review of the facility policy titled, Oral Care with a revision date of 12/20/2022 revealed, It is the practice of this facility to provide oral care to residents in order to prevent and control plaque-associated oral diseases Assist in wiping resident's mouth with towel.
Resident #1
On 3/18/24 at 11:20 AM, Resident #1 was observed in her wheelchair at the nurses's station. Her lips were noted to be covered with a white, crusty substance and a thick, white secretion.
An interview with Resident #1's Resident Representative (RR) on 3/18/24 at 2:15 PM, revealed she visited the resident frequently and assisted with her care. She stated when she arrived today, the resident's lips were covered with a thick crusty build up and so she cleaned resident's lips and put moisturizer on them for protection. She stated this had also occurred on other occasions.
During an observation on 3/19/24 at 8:20 AM, Resident #1's lips were noted to have some dry cracked skin/crusty dry secretions present.
During an observation and interview on 3/19/24 at 2:00 PM, Certified Nurses Assistant (CNA) #4 revealed Resident #1 needed frequent mouth and lip care due to her moving her lips inside her mouth and not eating or drinking by mouth. She revealed Resident #1 developed a dry crust covered with secretions on her lips that required them to be cleaned with a cloth and moisturizer applied frequently. She revealed she was responsible for oral care and did care earlier this shift, but Resident #1 needed her lips to be cleaned again to protect them from cracking.
During an observation and interview on 3/19/24 at 2:20 PM, Licensed Practical Nurse (LPN) #3 revealed she was the nurse for Resident #1. She revealed the resident was a mouth breather and she did not eat or drink by mouth, therefore, she required frequent oral/lip care. She stated the resident had a thick layer of dried and moist secretions on her lips which appeared to have been there a while, and oral care was needed.
An observation and interview with the Director of Nursing (DON) on 3/19/24 at 2:40 PM, revealed Resident #1's lips were covered with a layer of secretions and also dry/flaky skin in some areas and oral care was needed. She stated mouth care was to be done every shift and as needed and the facility failed to ensure the resident's oral care was done as needed and this could lead to tender, dry, cracked, bleeding lips.
Record review of Resident #1's Face Sheet revealed resident was admitted to the facility on [DATE]. Diagnoses included Spastic Quadriplegic Cerebral Palsy, Convulsions, and Intellectual Disabilities.
Record review of Resident #1's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 2/26/24, revealed for oral hygiene, this resident was dependent. Review of the Brief Interview for Mental Status (BIMS) score of 0 indicated the resident was severely cognitively impaired.
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, resident and staff interview, record review, and facility policy review, the facility failed to identify and treat a resident with a skin concern for one (1) of 19 residents samp...
Read full inspector narrative →
Based on observation, resident and staff interview, record review, and facility policy review, the facility failed to identify and treat a resident with a skin concern for one (1) of 19 residents sampled. Resident #216.
Cross Reference F580
Findings Include:
Review of facility policy titled, Resident Rights, with a revision date of 9/22/22 revealed, The resident has the right to a dignified existence .
Record review of facility policy titled, Activities of Daily Living (ADLs), dated 12/15/22 revealed, A resident who is unable to carry out activities of daily living will receive the necessary services to maintain good nutrition, grooming, and personal and oral hygiene.
On 3/19/2024 at 2:40 PM, an observation and interview with Resident #216, revealed the resident sitting in a wheelchair with his head laid over a bedside table. An excessive thick layer of white buildup with patchy areas of flaking to the entire scalp (all hair) extended to the ear lobes. The white buildup was also observed in the resident's beard that extended to the front of his neck. The resident stated that it did itch at times. He revealed that the facility was not performing treatment to the areas.
On 3/19/2024 at 2:43 PM, observation and interview, with Licensed Practical Nurse (LPN) #1 confirmed Resident #216's skin concern. She revealed she was not aware of the skin issue and stated the resident was not getting any type of treatment that she knew of.
Record review of Resident #216's Physician Orders revealed there was not a treatment order for his skin concern.
Record review of Resident #216's Departmental Notes dated 2/21/2024 through 3/11/2024, revealed the resident had dry skin to the BLE (bilateral lower extremities) with no documentation of his skin concern to the scalp and beard.
An interview with Registered Nurse (RN) #1 on 3/20/2024 at 1:40 PM, revealed the staff had not reported any skin issues to her for Resident #216. She stated the physician should have been contacted when the issue was first observed.
Record review of the Skin Inspection Report dated 2/28/2024, 3/11/2024, and 3/18/2024 revealed Skin Intact which indicated Resident #216 had no identified skin concern.
On 3/20/2024 at 3:55 PM, an interview with LPN #2 revealed she was the person responsible for completing the last two weeks of skin audits on Resident #216. She revealed she did not find any skin concerns on either of the skin audits that were completed. She stated the resident was lying in bed when she conducted the audits, and she must have overlooked it.
On 3/20/2024 at 4:00 PM, an interview with the Director of Nursing (DON) confirmed Resident #216's skin concern should have been caught on the weekly skin audits and stated the physician should have been notified for a treatment.
Record review of Resident #216's Face Sheet revealed the facility admitted the resident on 2/21/2024 with medical diagnoses that included Chronic systolic (congestive) heart failure, Type 2 diabetes mellitus, Vitamin D deficiency, and Paroxysmal atrial fibrillation.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0688
(Tag F0688)
Could have caused harm · This affected 1 resident
Based on observation, staff interview, record review, and facility policy review, the facility failed to apply a hand roll to a resident with a contracture for one (1) of 17 residents with contracture...
Read full inspector narrative →
Based on observation, staff interview, record review, and facility policy review, the facility failed to apply a hand roll to a resident with a contracture for one (1) of 17 residents with contractures. Resident #46
Findings Include:
Review of the facility policy titled Splint and Brace Application and Use undated, revealed under, Purpose: 1. To assure that residents who have splints or braces prescribed will use them when ordered. 2. To use splints to prevent and/or correct contractures.
Record review of Resident #46's Physician Orders revealed an order dated 7/04/2023, Hand roll to Lt (left) hand during waking hours to prevent further contractures .
Record review of Resident #46's Treatment Administration Record (TAR) for the month of March 2024 revealed an order dated 7/04/2023, Hand roll to Lt (left) hand during waking hours to prevent further contracture as resident will allow with documented signatures that the hand roll was applied on 3/18 and 3/19.
An observation of Resident #46 on 03/18/2024 at 11:14 AM revealed him lying in bed awake. The resident was observed with paralysis to the left arm and contractures to the left fingers, with no device in use.
An observation of Resident #46 on 3/19/2024 at 1:59 PM revealed him sitting in a wheelchair at the nurse's station with no device in place to the left hand.
An interview and observation on 3/19/2024 at 2:10 PM with Licensed Practical Nurse (LPN) #1 confirmed Resident #46 did not have a left hand roll. She revealed the aides were responsible for applying it, and she was responsible for ensuring it was in place. She revealed that the purpose of the hand roll was to prevent further worsening of the contracture and to prevent skin impairment from the contracted fingers.
An interview with the Director of Nursing (DON) on 3/19/2024 at 2:30 PM revealed the aides were responsible for applying the hand roll and the order was also on the TAR for the nurses to ensure it was on. She confirmed that not applying the hand roll could result in worsening contractures.
Record review of the Face Sheet revealed the facility admitted Resident #46 on 4/08/2022 with medical diagnosis that included hemiplegia following cerebral infarction affecting the left nondominant side, type 2 diabetes mellitus, seizures, and depression.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Unnecessary Medications
(Tag F0759)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, record review, and facility policy review, the facility failed to ensure the medication e...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, record review, and facility policy review, the facility failed to ensure the medication error rate was less than five percent for seven (7) of thirty-two medication opportunities. Medication error rate of 21.88%
Cross Reference F658
Findings include:
Record review of facility letterhead statement signed by the Administrator and dated 3/20/24, revealed (Proper name of facility) does not have a current policy on giving medications through the PEG (Percutaneous Endoscopic Gastrostomy) tube.
Record review of facility policy titled, Medication Set-up, Administration and Documentation Policy, undated, revealed, You must have an order to crush medications.
On 3/20/24 at 8:45 AM, an observation of Licensed Practical Nurse (LPN) #1 during medication pass for Resident #13's PEG tube medication administration revealed LPN #1 crushed Vitamin C 250 milligrams (MG), Metoprolol Tartrate 25 MG, Vitamin D3 1000 units, Zestril 5 MG, Hydrochlorothiazide 12.5 MG, and Aspirin 81 MG together and placed these into the container with the liquid Keppra medication. She stated she was hesitant to give the medications together since in nursing school she learned to give each one separately, but at the facility she was instructed to administer them together, so that was what she was going to do. She entered the resident's room and once again questioned this technique and went back to the medication cart to verify the order and stated there was an order to administer these together. She then returned to room, checked residual, pushed 15 milliliters of water, next pushed the seven combined medications, then flushed with 15 milliliters of water.
On 3/20/24 at 9:50 AM, during an interview with the Director of Nursing (DON) , confirmed that Resident #13 did not have a physician order to crush and administer the PEG medications together. She confirmed that LPN #1 did not follow the physician order for the PEG medications to give individually with a flush between each to ensure compatibility. The DON confirmed that this would be considered a medication error when the medications are all combined together in a PEG tube.
On 3/21/24 at 10:50 AM, during an interview LPN #1 revealed she had misread the order that actually read that medications could be crushed and given together if taken by mouth, but had to be given individually by PEG tube. She confirmed the purpose of administering medications separately was to ensure the medications were compatible.
Record review of Resident #13's Physician Orders List revealed an order dated 1/21/22, May administer crushed medications that are being given PO (by mouth) together. PEG tube meds must be given individual. Record review also revealed orders for Hydrochlorothiazide 12.5 mg per g-tube (gastrostomy tube), Aspirin 81 mg per PEG, Zestril 5 mg tablet per g-tube, Vitamin D3 1000 unit per g-tube, Vitamin C 250 mg per PEG, Metoprolol Tartrate 25 mg per g-tube, and Keppra 100 milligram/milliliter(ml) 7.5 ml per PEG.
Record review of Resident #13's Face Sheet revealed the resident was admitted to the facility on [DATE] with medical diagnoses that included Convulsions, Gastrostomy status, Dysphagia, and Hypertension.
Record review of Minimum Data Set (MDS) with Assessment Reference Date (ARD) of 1/23/24 revealed a Brief Interview for Mental Status (BIMS) score of 0 which indicated the resident had severe cognitive impairment.
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 and staff interview, the facility failed to ensure proper medication storage as evidenced by leaving keys for the medication cart, medication room, and controlled medication locke...
Read full inspector narrative →
Based on observation and staff interview, the facility failed to ensure proper medication storage as evidenced by leaving keys for the medication cart, medication room, and controlled medication locked box unattended on the medication cart in the resident hallway for one (1) of four (4) survey days.
Findings include:
Record review of facility's letterhead statement signed by the Administrator and dated 3/21/24, revealed, (Proper name of facility) does not have a policy on medication storage.
An observation on 03/21/24 at 10:20 AM, revealed an unattended medication cart on the south hall with a set of keys laying on top of the cart. Licensed Practical Nurse (LPN) #1 was observed in a resident's room and was not visible from the cart. After approximately four minutes, LPN #1 returned to the cart. When asked about the keys on top of the cart LPN #1 stated those were the keys to the medication cart, locked narcotic box, and medication room. She stated leaving the keys unattended was not acceptable and was a risk since anybody that wanted to get them could have, and medications need to be out of reach. She stated any resident, visitor, or staff could have obtained these since they were left unattended on top of the cart in a resident hallway.
During an interview on 3/21/24 at 10:25 AM, the Director of Nursing (DON) confirmed that by leaving the keys on a cart in an open hallway, the facility failed to ensure proper storage of medication. She stated this could have allowed an unauthorized person to have access to the medications and controlled medications. She stated the facility had no policy for medication storage.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, and facility policy review, the facility failed to decrease the likelihood of the spread ...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, and facility policy review, the facility failed to decrease the likelihood of the spread of infection as evidenced by a nurse dropping a glove on the floor in a resident's room, retrieving it off the floor, putting it on, and continuing with medication pass and insulin administration for one (1) of four (4) resident medication administrations observed.
Findings include:
Record review of facility policy titled, Infection Prevention and Control Program, dated 5/15/23, revealed, This facility has established and maintains an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections as per accepted national standards and guidelines. The policy also revealed, 4. b. Hand hygiene shall be performed in accordance with our facility's established hand hygiene procedures. c. All staff shall use personal protective equipment (PPE) according to established facility policy governing the use of PPE. d. Licensed staff shall adhere to safe injection and medication administration practices.
During an observation of medication pass on 3/20/24 at 8:20 AM, Licensed Practical Nurse (LPN) #1 prepared Resident #3's medications for administration. The medications consisted of 12 by mouth medications, one topical ointment, and one subcutaneous insulin injection. While in resident's room, LPN #1 washed her hands and preceded to put on her gloves, but one glove dropped one on the floor. She picked this glove up and placed it on her hand and began to prepare for the medication administration by opening the alcohol prep for the insulin injection. After administration was completed the nurse stated I shouldn't have put it on. I should have washed my hands and started with new gloves for the meds. She stated this could spread infections especially since one medication was an injection.
An interview with the Director of Nursing (DON) on 3/20/24 at 9:50 AM, revealed proper infection control techniques were not used when a glove that had been on the floor was picked up and put on by a nurse for resident care. She confirmed the facility failed to prevent the likelihood of the spread of infection and the nurse should have washed her hands and applied new gloves for the resident's medication administration.
Record review of Resident #3's Face Sheet revealed the resident was admitted to the facility on [DATE]. Diagnoses included Type 2 diabetes mellitus, Chronic Obstructive Pulmonary Disease, Epilepsy, Hypertension, and Schizophrenia.
MINOR
(B)
Minor Issue - procedural, no safety impact
Deficiency F0582
(Tag F0582)
Minor procedural issue · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview and facility record review, the facility failed to provide the Notice of Medicare Non-Coverage to two (...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview and facility record review, the facility failed to provide the Notice of Medicare Non-Coverage to two (2) of three (3) residents discharged from Medicare Part A services with service times remaining. Resident #3 and Resident #7
Findings include:
Record review of facility letterhead note signed by the Administrator and dated on 3/20/24 revealed: (Proper name of facility) does not have a beneficiary notification policy.
An interview with the Administrator on 3/19/24 at 11:08 AM, revealed she was aware of the requirement for the Notice of Medicare Non-Coverage to be provided to the resident or the resident representative and was aware that it was not being done due to staff turnover and it just fell through the cracks. She confirmed the facility failed to complete the Notice of Medicare Non-Coverage for residents who were discharged with time remaining on their Part A coverage.
Record review of Resident #3's Face Sheet revealed he was admitted to the facility on [DATE] with diagnosis of displaced fracture of base of neck of right femur.
Record review of Resident #3's Beneficiary Protection Notification Review revealed the resident's Medicare Part A skilled services episode start date of 10/3/23 and last covered day of Part A service was 11/15/23. This form revealed the facility/provider initiated the discharge from Medicare Part A Services when benefit days were not exhausted. Review of this form revealed the Notice of Medicare Non-Coverage form was not provided to the resident.
Record review of Resident #7's Face Sheet revealed she was admitted to the facility on [DATE] with diagnoses that include Unspecified Combined Systolic and Diastolic Congestive Heart Failure and Acute Kidney Failure.
Record review of Resident #7's Beneficiary Protection Notification Review revealed the resident's Medicare Part A skilled services episode start date of 8/23/23 and last covered day of Part A service was 10/21/23. This form revealed the facility/provider initiated the discharge from Medicare Part A Services when benefit days were not exhausted. Review of this form revealed the Notice of Medicare Non-Coverage form was not provided to the resident.
May 2023
3 deficiencies
3 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
Free from Abuse/Neglect
(Tag F0600)
A resident was harmed · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy reviews, interviews, and record reviews the facility neglected to properly assess Resident #1 and manag...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy reviews, interviews, and record reviews the facility neglected to properly assess Resident #1 and manage pain after a fall with injury and delay of treatment for one (1) of four (4) residents reviewed for falls. Resident #1
Finding include:
Review of the facility policy and procedure titled Abuse Neglect and Exploitation dated 9/19/2022 revealed .Neglect means failure of the facility, its employees, or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress .
The facility provided on letterhead dated 5/16/23 a statement that read: We do not have a policy on lifting after a fall. signed by the facility Administrator (ADM).
Record review of the facility policy Fall Prevention Program dated 11/10/2022 revealed, Each resident will be assessed for fall risk and will receive care and services in accordance with their individualized level of risk to minimize the likelihood of falls . 9. When any resident experiences a fall, the facility will: : a. Assess the resident. b. Complete a post -fall assessment. c. Complete an incident report. D. Notify physician and family f. Document all assessments and actions
During a telephone interview on 05/15/23 at 10:00 AM, with the Ombudsman revealed that she had received a call from the family of Resident #1 on 03/11/2023. The family reported concerns of neglect and reported that the facility did not timely call for an ambulance to transport their mother to be evaluated and treated. The family did not think that the Resident should have been put in a wheelchair and taken to the dining room to eat breakfast while in pain and possibly with a fracture. The family stated that they had to insist that the facility call 911 after resident had been left sitting in a wheelchair in the dining room for hours after a fall in which the resident stated she thought her right hip was broken and that she was in pain. The family stated that an ambulance should have been called immediately after the fall and that Resident #1 should have been placed in the bed and given pain medications.
In an interview on 03/15/23 at 1:30 P.M. with the Administrator (ADM) revealed that Resident #1 was severely cognitively impaired and had a Brief Interview for Mental Status (BIMS) score of 2 or 3. ADM stated that the resident was verbal and ambulatory without assistance and was able to verbalize to the staff that she had lost her balance and her leg gave way as she was standing at her dresser, and she fell to the floor. ADM stated that Resident #1 did complain of pain immediately after the fall and the staff called the family to report the fall and the family came to the facility and waited with the resident until the ambulance came to transport her to the emergency room (ER) for evaluation. The ADM stated that there was no local hospital near the facility and that there was no local ambulance service in the town where the facility was located. The ADM revealed that the town had a contract with neighboring towns ambulance services and the closest ambulance service was approximately 30 miles away and the closest ER for treatment of injuries was approximately 30 miles away. The ADM confirmed that the ambulance had to come from approximately 30 miles away to transport the resident to an ER which was another 30 or more miles away from the facility. The ADM revealed that the incident of the fall of Resident #1 occurred on 03/11/23 at approximately 7:00 AM during the change of shifts on a Saturday morning. Resident #1 did have an un-witnessed fall which resulted in a broken hip. Res #1 had hip surgery and spent three (3) nights in the hospital prior to her return to the facility on [DATE].
In an interview on 05/15/23 at 3:00 PM, with Registered Nurse (RN #2) who works the first shift on weekends 7:00 AM-7:00 PM, stated that she did not give any pain medications to Resident #1 on 03/11/23. RN #2 stated that she did not witness any pain medications given to Res #1 on 03/11/23 and RN #2 did not call the physician or the nurse practitioner (NP) to obtain orders for pain medications. RN #2 stated that the family came to the facility early on that Saturday morning of 03/11/23 shortly after they were contacted that the resident had fallen which was approximately 6:45 AM. The family (3-4 people) were at the facility with the resident, and they were upset that an ambulance had not been called to transport Resident #1. The on-call x-ray technician had been called to come do a bed-side portable x-ray, but she had not answered her phone and a voicemail message was left on her phone. At approximately 9:30 AM the x-ray technician called back to the facility, but the ambulance had been called to transport Res #1 to the ER for x-ray and evaluation. Res #1 did complain of pain, but the pain was mild at 7:00 AM and no orders were obtained for pain medications. The pain scale of 1-10 was used and Res #1 stated at 7:00 AM that her pain was a 4 on the pain scale. RN #2 stated that she did not reassess her pain after the initial complaint of pain at 7:00 AM. The ambulance was not called until approximately 9:00 AM on 03/11/23 after the family had requested that 911 be called. It took the ambulance approximately 20 minutes to arrive at the facility. The ambulance left the facility with Res #1 at approximately 9:32 AM.
During an interview on 05/15/23 at 3:15 PM, with Licensed Practical Nurse (LPN) #2 she revealed she was the medication nurse on the 7 AM - 7 PM shift on 03/11/23. LPN#2 stated that the resident was sitting in her wheelchair in the dining room with two (2) daughters and one (1) son when they asked LPN #2 for some pain medication for Res #1. LPN#2 stated that she told the family that the only thing that was ordered for Res #1 was Tylenol and that was all that she could give Res #1. LPN #2 stated that Res #1 was complaining of pain and that she gave the Tylenol to Res #1 in the dining room while she sat in her wheelchair. LPN #2 stated that she documented the giving of the Tylenol in the EMAR (electronic Medication Administration Record). LPN #2 stated that she gave Res #1 two (2) 325 mg Tylenol because that was all that she had orders to give. LPN #2 stated that the family was insisting that the staff call an ambulance to transport Res #1 to the ER for an x-ray. LPN #2 stated that she had been told that the x-ray technician that was on call had not answered and the facility had left a message on the voicemail for a bedside x-ray. The family expressed that they were tired of waiting on the on-call x-ray technician to respond. The family wanted the staff to call 911 and have an ambulance to take Res #1 to the ER for evaluation and x-ray.
An interview on 05/15/23 at 3:30 PM, with Certified Nursing Assistant (CNA) #1 revealed that he was walking down the hall at shift change on Saturday morning at approximately a little before 7:00 AM when he passed Res #1's room and saw her on the floor in front of her dresser. He turned around and went back to check on Res #1 and she stated that she had fallen, and her leg had given out and it was hurting. CNA #1 stated that he was not assigned to Res #1 that morning, but he immediately went and got the nurse and the CNA assigned to Res #1. CNA #1 and CNA #2, RN #1 and LPN #1 all went into Resident #1's room, and she told them all that her leg was hurting and that it had given way and she fell to the floor. CNA #1 stated that the right leg did look shorter than the left leg and when the nurse touched her, she stated that it hurt. CNA #1 stated that the resident did verbalize pain to him and to the nurses. He said the Charge Nurse (RN#1) told us to pick up Res #1 off the floor and place her in her wheelchair and push her to the dining room for breakfast. I did not see any medications given to Res #1 after the fall on 03/11/23 at 6:50 AM. I left the facility at 7:00 AM on 3/11/23. We physically picked the resident up off of the floor and placed her in a wheelchair at the request of the charge nurse RN #1 and took her to the dining room. CNA #1 confirmed that Resident #1 did complain of pain while we were putting her in the wheelchair. We did not use a lift to pick the resident up off the floor.
In an interview on 05/15/23 at 4:10 PM, with RN #1 stated that she was the charge nurse on 03/11/23 on the 7:00 PM-7:00 AM shift. She confirmed that they picked up Res #1 off the floor and did not use a lift. They put Resident #1 in a wheelchair and took her to the dining room so there would be eyes on her. I did not want to leave her (Res #1) alone in her room after the fall because I thought that there was too much going on during shift change and she may try to get up again if she was left alone. Things were very busy at the change of shift. RN#1 confirmed that the resident sat in a wheelchair in the dining room at the breakfast table. Her family was contacted, and 3-4 family members came to the facility to be with her at approximately 7:45 AM. RN#1 stated that Resident #1 did complain of pain and stated, I did not give her any pain medications and I did not obtain an order from the NP for any pain medications. RN#1 stated, To my knowledge there were no pain assessments documented for the resident on 3/11/23.
In an interview on 05/15/23 at 4:25 PM, with the two (2) daughters of Resident #1 revealed that they along with their brother had all come to the facility to be with their mother after they were notified that she had a fall. Upon arriving at the facility at approximately 7:40 AM on 03/11/23, they found her sitting in the dining room in a wheelchair at the breakfast table and she was complaining of pain in her right hip and leg. The nurse told the children that they were going to get an x-ray but that the clinic did not open until 10:00 AM and they were waiting for the x-ray person to arrive at the clinic to get the x-ray at that time. Resident #1 told the family that she thought her right hip and leg may be broken and she was having pain. The daughter stated that she was yelling out in pain as she sat in her wheelchair, and we all thought that she should be in her bed lying down and not sitting up. She was asking us to please put her in the bed. We asked the nurse if we could have pain medication given to her and the nurse told us she would give her some Tylenol and she left and never came back with the medication. The daughter confirmed no pain medications were given to Res #1 on 03/11/23 at the facility while the family was there. We asked if we could put her in her bed and the nurse told us she needed to sit up and wait for the x-ray. We waited until after 9:00 AM and nothing was done for our mother so we asked if they could call 911 and have her sent to for x-ray and evaluation. We all were not happy with how little consideration the staff gave her and they did not put her to bed. They left her in a wheelchair crying out in pain and never gave her any pain medications. We do not want to get anyone in trouble, but we do not think that any resident should be treated with such disregard. We want proper procedures to be executed for all residents and no one deserved to be treated like they treated our mother. We finally took her to her room, and we put her to bed where she was requesting to be placed. It was hurting her sitting up on that hip in that wheelchair. When we got to the ER, we found that our mother had a broken right hip, and she went to surgery the next day. We also do not feel that the facility gave us an explanation of how the entire incident occurred. The facility did nothing to address her pain after the fall. She should never be placed in a wheelchair to sit on a broken hip.
During an interview on 05/16/23 at 10:30 AM, with the Director of Nurses (DON) revealed that Resident #1 should not have been physically picked up off the floor and placed in a wheelchair. She should have been placed in bed and assessed. The DON stated that Resident #1 should have been put in the bed and her pain should have been assessed and monitored until she left the facility for the ER. We teach this in our employee training, but we have no written training records and no written policies and procedures for the monitoring of pain. We do not have any pain assessments on this resident, and we should have done them. The DON confirmed that the Standing Orders for pain medication of Tylenol was not given after Resident #1 fell and confirmed that the Medication Administration Record (MAR) had not been documented on 03/11/23 for the administrating of pain medications to Resident #1.
On 05/16/23 at 12:20 PM, in an interview with the NP she revealed that she does not recall the details of the incident with Resident #1 on 03/11/23 but she does remember that she was asked if they could get a bed side portable x-ray ordered. NP stated that this was early on a Saturday morning when she was called, and she does not have any notes from the call, so she does not recall the details. The details of Resident #1's pain were not relayed to the NP by the facility staff, and she confirmed that the Standing Orders should have been implemented and the nurses at the facility could have called for an ambulance or for additional orders as soon as the fall occurred.
On 05/16/23 at 2:30 PM, an interview with CNA #2, revealed that she was assigned to Res #1 on the third shift on 03/11/23. She was on her way out of the facility when she was notified that one of her assigned residents had fallen. Upon entering the room there were two (2) nurses and another CNA (CNA #1) in the room with Res #1 on the floor. The nurse told them to pick up the resident and put her in the wheelchair and take her to the dining room to eat breakfast. CNA #2 did not witness the fall of Res #1 and she did not witness any pain assessments or pain medications given to Res #1.
Record review of the facility Resident Incident Report dated 3/11/23 at 06:50 AM, revealed that the incident was Non-Witnessed Type of Injury: Pain. Narrative of incident and description of injuries: (CNA #1) Reported resident was found sitting on floor in her room. No injuries noted resident has c/o (complaint of) pain to rt. (right) leg. Immediate Actions Taken: Resident was assessed for injuries and assisted up to wheelchair . Pain Scale: 4 .Family notified, and Nurse Practitioner notified 3/11/23. Exam by Physician: No. Taken to Hospital: No. Report prepared by RN#1.
Record review of the facility Departmental Notes dated 03/11/23 at 7:14 AM revealed, 0650- (CNA #1) reported to nurse that resident was found sitting on the floor in her room. Resident reported that she did fall, she stated My Leg gave out, resident was assessed for injuries. Has c/o (complaint of) pain to Rt (right) leg when touch or moved/lifted. Resident stated, that's the leg I hit when I fell. 0655-Fall with c/o rt. leg pain was reported to FNP- (Family Nurse Practitioner) Order was obtained for x-ray of RT/hip/leg. 0709-Fall with c/o rt. leg pain was reported to son -he was informed that x-ray was ordered. Nurses note signed by the third shift Charge Nurse (RN #1). The nursing note 3/11/23 9:32 AM Leaving via ambulance to ER for eval and treatment. Signed by the first shift Charge Nurse (RN #2). 3/11/2023 9:50 AM Called report to ER. Signed by (RN#2). The nursing note dated 3/11/2023 at 10:46 AM read: Late charting for 9:07 AM: Resident had started yelling out in pain, radiology not available at this time. Family agreed that this nurse should call 911. Called FNP and received order to call (EMS) Emergency Management Services. Signed by (RN #2). Nursing note dated 3/11/2023 at 1:43 PM Late charting for 8:20 AM: Resident sitting up in wheelchair in the dining room and has eaten breakfast with her family. Family then transported resident back to her room in her wheelchair. Asked by her son and CNA if she should go to bed. This nurse advised against putting her back to bed due to resident needed an x-ray of her right hip, right femur and right knee. Came back to check on resident later and family member had put her in bed. Resident had started yelling due to pain because she was lying on the affected side. This nurse then called FNP to get order to send resident to the ER. Signed by RN#2.
Record review of the Electronic Medication Administration Record (eMAR) for March 2023 revealed no documentation that Resident #1 had not been given pain medications on 03/11/23 including Tylenol from the Standing Orders.
Record review of the undated facility Standing Orders revealed Pain: Tylenol 500 mg (milligrams) PO (by mouth) Q (every) 4HRS (hours) PRN (as needed). Notify Provider within 24 hours if pain persists or worsens. The facility did not implement the facility's standing orders for the PRN pain medications of Tylenol 500 mg PO Q 4 HRS PRN.
Record review of the Emergency Department report dated 03/11/23 at 1009 revealed: RN/Triage Created: 3/11/23 1009 Last Entry: 1011 EMS (Emergency Medical Services) enroute with a 89 yo (year old) F (female) with fall. Additional Information: Fall, unwitnessed. C/O Right Hip pain. Denies LOC (loss of consciousness), no blood thinners. Alert but confused. 20ga(gauge) IV(intravenous) RAC (right antecubital). 100mcg (micrograms) fentanyl given. FSBG( Fingerstick blood glucose) 203. Emergency Alert: Alert Called: Pre-Hospital Care: Patient was not medicated for pain . HPI: Fall: Occurred at 2 hours ago. Fall from standing height onto floor approx.(approximately) 0 feet injuring RLE (right lower extremity) . Chief Complaint: Fall, leg pain HPI: Patient complaining of prior to arrival of the following symptoms: Patient presents the emergency room from nursing home and apparently an unwitnessed fall confused at baseline with dementia but complaining of right hip leg pain no other evidence of trauma. 3/11/23 at 1151 doctor wrote: Provider Note: I reviewed x-ray finding fracture with family. Patient was given pain medications she has a right femoral neck fracture I consulted orthopedics. Patient will be admitted to the hospital service .
Record review of the Face Sheet of Resident #1 revealed that she was admitted to the facility on [DATE] and was discharged on 03/30/2023. Resident #1 had diagnoses of Type I Diabetes, Alzheimer's Disease, Dementia unspecified severity and Poly osteoarthritis unspecified.
Record review of the Minimum Data Set with an Assessment Reference Date (ARD) of 03/21/23 revealed a Brief Interview for Mental Status (BIMS) score of 99, indicating that the resident was unable to complete the interview.
The record review of the nursing notes for 03/11/2023 documented that Res #1 was found on the floor of her room at 6:50 AM and she complained of pain upon discovery at 6:50 AM and Resident was yelling out in pain at 9:07 AM. The record review of the nursing notes revealed that the nursing staff did not address Res #1's pain upon her first complaint at 6:55 AM or assess and address Res #1's pain at 9:07 AM when she began yelling out in pain. There was no written documentation that the facility staff had given Res #1 Tylenol as per the facility's Standing Physician's Orders.
The facility did not assess or provide pain management for Res #1's voiced pain from 0650-9:32 AM which was a minimum of two (2) hours and 42 minutes prior to leaving in the ambulance to travel 30 plus miles away to the emergency room (ER). The facility neglected to obtain an order for pain management for Res #1. The record review also revealed that the facility nursing staff placed Res #1 in a wheelchair to sit rather than place her in the bed for assessment and there was no pain management issued for Res #1. The record review documented that Res #1 was voicing pain for over two hours, and the staff did not obtain orders for pain management.
The record review of the ER reports dated 3/11/23 confirmed that (Res #1) was not medicated or given pain medications prior to leaving the nursing home for evaluation at the ER. The ER reported that Resident #1 was complaining of right hip and leg pain at the nursing home following the unwitnessed fall. The ER report confirmed that the resident had a fracture of the right hip and leg and that pain medications were given.
SERIOUS
(G)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Actual Harm - a resident was hurt due to facility failures
Comprehensive Care Plan
(Tag F0656)
A resident was harmed · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy reviews, interviews, and record reviews the facility failed to implement approaches and interventions related to...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy reviews, interviews, and record reviews the facility failed to implement approaches and interventions related to pain and control pain for one (1) of four (4) residents reviewed for care plans and pain management. Resident #1
Fndings include:
Review of the facility policy and procedure titled Abuse Neglect and Exploitation dated 9/19/2022 revealed .Neglect means failure of the facility, its employees, or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress .
Record review of a statement on facility letterhead dated 5/16/23 and signed by the Administrator revealed,We do not have a policy on pain management.
Record review of the Care Plan for Resident #1 revealed Problem Onset: 11/07/2022 I am at risk for Pain R/T (related to) DX (diagnosis) Chronic Pain Due, Osteoarthritis and Diabetic Neuropathy, Osteoporosis Goal & Target Date: My pain will be controlled by use of PRN (as needed) pain medication and non- pharmac (pharmacological) Approaches: Attempt non-pharmaceutical interventions, observe for sign and symptoms (S/S) adverse reactions . Contact physician as needed, Report any S/S of pain to nurse, Administer my pain medication as ordered, observe for effectiveness and s/e (side effects) of medication, Observe for worsening of resident's pain symptoms and report to physician.
On 05/15/23 at 10:00 AM, the Ombudsman reported via a telephone interview that she had received a call from the family of Resident #1 on 03/11/2023. They wanted to issue concerns that the resident had been left sitting in a wheelchair in the dining room for hours after a fall in which the resident stated she thought her right hip was broken and that she was in pain. The family stated that an ambulance should have been called immediately after the fall and that Resident #1 should have been placed in the bed and given pain medications.
The Administrator (ADM) revealed during an interview on 05/15/23 at 1:30 PM, that Resident #1 did complain of pain immediately after the fall. The family came to the facility and waited with the resident until the ambulance came to transport her to the emergency room (ER) for evaluation.
During an interview on 05/15/23 at 3:00 PM, with Registered Nurse (RN) #2 that was working the first shift and came in at 7:00 AM immediately after Resident #1 had fallen, stated that she did not give any pain medications to Resident #1 on 03/11/23 and stated that she did not witness any pain medications given to the resident on 03/11/23 by the previous nurse who was leaving her shift at 7:00 AM. RN #2 stated that she did not call the physician or the Nurse Practitioner (NP) to obtain orders for pain medications. RN #2 confirmed that the resident did complain of pain, but the pain was mild at 7:00 AM and no orders were obtained for pain medications. The pain scale of 1-10 was used and Resident #1 stated at 7:00 AM that her pain was a 4 on the pain scale. RN #2 stated that she did not assess her pain again after the initial complaint of pain at 7:00 AM.
On 05/15/23 at 3:15 PM, in an interview with Licensed Practical Nurse (LPN) #2 who was the medication nurse on first shift on 03/11/23, stated that Res #1 was sitting in her wheelchair in the dining room with two (2) daughters and one (1) son when they asked LPN #2 for some pain medication for Resident #1. LPN #2 stated that the resident was complaining of pain, and she told the family that all that was ordered for Resident #1 was Tylenol and that was all that she could give her. LPN #2 confirmed that she gave the Tylenol to the resident in the dining room while the resident was sitting in her wheelchair and the family watched her give the medication to the resident. LPN #2 stated that she documented that she gave Tylenol in the EMAR (Electronic Medication Administration Record). LPN #2 stated that she gave the resident two (2) 325 milligrams (mg) Tylenol because that was all that she had orders to give. The family expressed that they were tired of waiting and wanted the staff to call 911 and have an ambulance to take the resident to the ER for evaluation and x-ray because the resident was in pain
During an interview on 05/15/23 at 3:30 PM, with Certified Nursing Assistant (CNA) #1 revealed that he was walking down the hall at shift change on Saturday morning at approximately a little before 7:00 AM when he passed Resident #1's room and saw her on the floor in front of her dresser. He turned around and went back to check on her and she stated that she had fallen. She stated her leg had given out and it was hurting. CNA #1 stated that he was not assigned to Res #1 that morning, but he immediately went and got the nurse and the CNA assigned to Resident #1. CNA #1, CNA #2, RN #1, and LPN #1 all went into the resident's room, and she told them all that her leg was hurting and that it had given way and she fell to the floor. CNA #1 stated that the right leg did look shorter than the left leg and when the nurse touched her, she stated that it hurt. CNA #1 stated that Resident #1 did verbalize pain to him and to the nurses. I did not see any medications given to Resident #1 after the fall on 03/11/23 at 6:50 AM. The resident did complain of pain in her leg while we were putting her in the wheelchair.
On 05/15/23 at 4:10 PM,during an interview with RN #1, revealed that she was serving as the charge nurse on 03/11/23 on the 7:00 PM-7:00 AM shift on the weekends and confirmed Resident #1 did complain of pain and stated, I did not give her any pain medications and I did not obtain an order from the Nurse Practitioner for pain medications and to my knowledge there were no pain assessments documented for her on 3/11/23.
In an interview on 05/15/23 at 4:25 PM, with the two (2) daughters of Resident #1 revealed that they along with their brother had all come to the facility to be with their mother after they were notified that she had a fall. Upon arriving at the facility at approximately 7:40 AM on 03/11/23 they found their mother sitting in the dining room in a wheelchair at the breakfast table and she was complaining of pain in her right hip and leg. Resident #1 told the family that she thought her right hip and leg may be broken and she was having pain. The daughter stated that Resident #1 was yelling out in pain as she sat in her wheelchair in the dining room. We asked the nurse if we could have pain medication given to her and the nurse told us she would give her some Tylenol and she left and never came back with the medication. The daughter stated that no pain medications were given to Resident #1 on 03/11/23 at the facility. They did not put her to bed, and they left her in a wheelchair calling out in pain and never gave pain medications. It was hurting her sitting up on that hip in that wheelchair.
Interview on 05/16/23 at 10:30 AM, with the Director of Nurses (DON) revealed that the Res #1 should have had her pain assessed and monitored until she left the facility for the ER. We teach this in our employee training, but we have no written training records and no written policies and procedures for the monitoring of pain. We do not have any pain assessments on this resident, and we should have done them. The DON confirmed that the Standing Orders for pain medication of Tylenol was not given after the resident fell. DON confirmed that the MAR had not been documented on 03/11/23 for the administrating of pain medications to Resident #1. The DON confirmed that the resident's care plan was not followed for the pain management as outlined in her care plan.
Record review of the facility Resident Incident Report dated 3/11/23 at 06:50 AM, revealed that the incident was Non-Witnessed. Type of Injury: Pain. Narrative of incident and description of injuries: (CNA #1) Reported resident was found sitting on floor in her room. No injuries noted resident has c/o (complaint of) pain to rt. (right) leg. Immediate Actions Taken: Resident was assessed for injuries and assisted up to wheelchair . Pain Scale: 4
Record review of the facility Departmental Notes dated 03/11/23 at 7:14 AM revealed, 0650- (CNA #1) reported to nurse that resident was found sitting on the floor in her room Has c/o (complaint of) pain to Rt (right) leg when touch or moved/lifted. Resident stated, that's the leg I hit when I fell. 0655-Fall with c/o rt. leg pain was reported to FNP- (Family Nurse Practitioner) . 0709-Fall with c/o rt. leg pain .3/11/2023 at 10:46 AM: Late charting for 9:07 AM: Resident had started yelling out in pain . Nursing note dated 3/11/2023 at 1:43 PM : Late charting for 8:20 AM . Resident had started yelling due to pain because she was lying on the affected side
Record review of the undated facility Standing Orders revealed Pain: Tylenol 500 mg (milligrams) PO (by mouth) Q (every) 4HRS (hours) PRN (as needed). Notify Provider within 24 hours if pain persists or worsens. The facility did not implement the facility's standing orders for the PRN pain medications of Tylenol 500 mg PO Q 4 HRS PRN.
Record review of the Emergency Department report dated 03/11/23 at 1009 revealed: RN/Triage Created: 3/11/23 1009 Last Entry: 1011 EMS (Emergency Medical Services) enroute with a 89 yo (year old) F (female) with fall. Additional Information: Fall, unwitnessed. C/O Right Hip pain 20ga(gauge) IV(intravenous) RAC (right antecubital). 100mcg (micrograms) fentanyl given. Pre-Hospital Care: Patient was not medicated for pain . HPI: Fall: Occurred at 2 hours ago. Fall from standing height onto floor approx.(approximately) 0 feet injuring RLE (right lower extremity) . Chief Complaint: Fall, leg pain HPI: Patient complaining of prior to arrival of the following symptoms: Patient presents the emergency room from nursing home . complaining of right hip leg pain no other evidence of trauma. 3/11/23 at 1151 doctor wrote: Provider Note: I reviewed x-ray finding fracture with family. Patient was given pain medications she has a right femoral neck fracture .
Record review of the Face Sheet of Resident #1 revealed that she was admitted to the facility on [DATE] and was discharged on 03/30/2023. Resident #1 had diagnoses of Type I Diabetes, Alzheimer's Disease, Dementia unspecified severity and Poly osteoarthritis unspecified.
Record review of the Minimum Data Set with an Assessment Reference Date (ARD) of 03/21/23 revealed a Brief Interview for Mental Status (BIMS) score of 99, indicating that the resident was unable to complete the interview.
SERIOUS
(G)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Actual Harm - a resident was hurt due to facility failures
Deficiency F0697
(Tag F0697)
A resident was harmed · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy reviews, interviews, and record reviews the facility failed to treat pain for Resident #1 after a fall ...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy reviews, interviews, and record reviews the facility failed to treat pain for Resident #1 after a fall with vocalization of pain. The facility did not assess or provide pain management for the resident after voiced pain from 6:50-9:32 AM which was a minimum of two (2) hours and 42 minutes prior to leaving in the ambulance to travel 30 plus miles away to the emergency room (ER). Resident #1 was one (1) of four (4) residents reviewed for pain management.
Findings include:
Review of the facility policy and procedure titled Abuse Neglect and Exploitation dated 9/19/2022 revealed .Neglect means failure of the facility, its employees, or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress .
Record review of a typed statement on letterhead dated 5/16/23 and signed by the Administrator (ADM) revealed, We do not have a policy on pain management.
Record review of the facility policy Fall Prevention Program dated 11/10/2022 revealed, Each resident will be assessed for fall risk and will receive care and services in accordance with their individualized level of risk to minimize the likelihood of falls . 9. When any resident experiences a fall, the facility will: : a. Assess the resident. b. Complete a post -fall assessment. c. Complete an incident report. D. Notify physician and family f. Document all assessments and actions
Interview on 05/15/23 at 10:00 AM, with the Ombudsman via telephone revealed that she had received a call from the family of Resident #1 on 03/11/2023. The family reported that they wanted to issue concerns of neglect and report that the facility did not timely call for an ambulance to transport the resident to be evaluated and treated. The family did not think that the Resident should have been put in a wheelchair and taken to the dining room to eat breakfast while in pain and possibly with a fracture. The family stated that they had to insist that the facility call 911 after the resident had been left sitting in a wheelchair in the dining room for hours after a fall in which the resident stated she thought her right hip was broken and that she was in pain. The family stated that an ambulance should have been called immediately after the fall and that Resident #1 should have been placed in the bed and given pain medications.
Interview on 05/15/23 at 1:30 PM, with the ADM stated that Resident #1 was severely cognitively impaired and had a Brief Interview for Mental Status( BIMS) score of two (2) or three (3). ADM stated that the resident was verbal and ambulatory without assistance. She was able to verbalize to the staff that she had lost her balance and her leg gave away as she was standing at her dresser, and she fell to the floor. The ADM stated that Resident #1 did complain of pain immediately after the fall. The staff called the family to report the fall and the family came to the facility and waited with the resident until the ambulance came to transport her to the emergency room (ER) for evaluation. The ADM confirmed that there was no local hospital or local ambulance service near the facility. The ADM confirmed that the town had a contract with the neighboring town for ambulance services and the closest ambulance service was approximately 30 miles away and the closest ER for treatment of injuries was approximately 30 miles away. The ADM confirmed that the incident of the fall for Resident #1 occurred on 03/11/23 at approximately 7:00 AM during the change of shifts on a Saturday morning. Resident #1 did have an un-witnessed fall which resulted in a femoral fracture of the hip and that the resident had hip surgery at the hospital on [DATE]. Resident #1 spent three (3) nights in the hospital prior to her return to the facility on [DATE].
Interview on 05/15/23 at 3:00 PM, with Registered Nurse (RN) #2 that was working the first shift and came in at 7:00 AM immediately after Resident #1 had fallen, stated that she did not give any pain medications to Resident #1 on 03/11/23 and stated that she did not witness any pain medications given to the resident on 03/11/23 by the previous nurse who was leaving her shift at 7:00 AM. RN #2 stated that she did not call the physician or the Nurse Practitioner (NP) to obtain orders for pain medications. RN #2 stated that the family came to the facility early on that Saturday morning of 03/11/23 shortly after they were contacted that Resident #1 had fallen at approximately 6:45 AM. The on-call x-ray technician had been called to come do a bedside portable x-ray. At approximately 9:30 AM the x-ray technician called back to the facility, but the ambulance had been called to transport the resident to the ER for x-ray and evaluation. RN #2 confirmed that the resident did complain of pain, but the pain was mild at 7:00 AM and no orders were obtained for pain medications. The pain scale of 1-10 was used and Resident #1 stated at 7:00 AM that her pain was a 4 on the pain scale. RN #2 stated that she did not assess her pain again after the initial complaint of pain at 7:00 AM.
Interview on 05/15/23 at 3:15 PM, with Licensed Practical Nurse (LPN) #2 who was the medication nurse on first shift for 03/11/23. LPN #2 stated that Res #1 was sitting in her wheelchair in the dining room with two (2) daughters and one (1) son when they asked LPN #2 for some pain medication for Resident #1. LPN #2 stated that the resident was complaining of pain, and she told the family that all that was ordered for Resident #1 was Tylenol and that was all that she could give her. LPN #2 confirmed that she gave the Tylenol to the resident in the dining room while the resident was sitting in her wheelchair and the family watched her give the medication to the resident. LPN #2 stated that she documented that she gave Tylenol in the EMAR (Electronic Medication Administration Record). LPN #2 stated that she gave the resident two (2) 325 milligrams (mg) Tylenol because that was all that she had orders to give. LPN #2 stated that the family was insisting that the staff call an ambulance to transport Resident #1 to the ER for an x-ray. LPN #2 confirmed that she had been told that the x-ray technician that was on call had not answered and the facility had left a message on the voicemail for a bedside portable x-ray but that they had not arrived at the facility yet at this point. The family expressed that they were tired of waiting on the on-call x-ray technician to respond and wanted the staff to call 911 and have an ambulance to take the resident to the ER for evaluation and x-ray because the resident was in pain.
Interview on 05/15/23 at 3:30 PM, with Certified Nursing Assistant (CNA) #1 revealed that he was walking down the hall at shift change on Saturday morning at approximately a little before 7:00 AM when he passed Resident #1's room and saw her on the floor in front of her dresser. He turned around and went back to check on her and she stated that she had fallen. She stated her leg had given out and it was hurting. CNA #1 stated that he was not assigned to Res #1 that morning, but he immediately went and got the nurse and the CNA assigned to Resident #1. CNA #1, CNA #2, RN #1, and LPN #1 all went into the resident's room, and she told them all that her leg was hurting and that it had given way and she fell to the floor. CNA #1 stated that the right leg did look shorter than the left leg and when the nurse touched her, she stated that it hurt. CNA #1 stated that Resident #1 did verbalize pain to him and to the nurses. The Charge Nurse told us to pick the resident up off the floor and place her in her wheelchair and push her to the dining room for breakfast. I did not see any medications given to Resident #1 after the fall on 03/11/23 at 6:50 AM. I left the facility at 7:00 AM on 3/11/23 and I have not worked at the facility since 03/24/23. We physically picked the resident up off the floor and placed her in a wheelchair at the request of the charge nurse RN #1 and the resident did complain of pain in her leg while we were putting her in the wheelchair. CNA #1 confirmed that they did not use a lift to pick her up off the floor.
Interview on 05/15/23 at 4:10 PM, with RN #1 revealed that she was serving as the charge nurse on 03/11/23 on the 7:00 PM-7:00 AM shift on the weekends and confirmed that they picked Resident #1 up off the floor and did not use a lift. They put Resident #1 in a wheelchair and took her to the dining room so there would be eyes on her. I did not want to leave her (Res #1) alone in her room after the fall because I thought that there was too much going on during shift change and she may try to get up again if she was left alone. Things were very busy at the change of shift. RN #1 confirmed that the resident sat in a wheelchair in the dining room at the breakfast table and her family was contacted and they came to the facility to be with the resident at approximately 7:45 AM. Resident #1 did complain of pain and stated, I did not give her any pain medications and I did not obtain an order from the Nurse Practitioner for pain medications. An order was placed for an in-house x-ray. The neurological assessments were completed by the first shift nurse (RN#2) and to my knowledge there were no pain assessments documented for her on 3/11/23.
Interview on 05/15/23 at 4:25 PM, with the two (2) daughters of Resident #1 revealed that they along with their brother had all come to the facility to be with their mother after they were notified that she had a fall. Upon arriving at the facility at approximately 7:40 AM on 03/11/23 they found their mother sitting in the dining room in a wheelchair at the breakfast table and she was complaining of pain in her right hip and leg. The nurse told us that they were going to get an x-ray but that the clinic did not open until 10:00 AM and they were waiting for the x-ray person to arrive to get the x-ray at that time. Resident #1 told the family that she thought her right hip and leg may be broken and she was having pain. The daughter stated that Resident #1 was yelling out in pain as she sat in her wheelchair in the dining room. We all thought that she should be in her bed lying down and not sitting up and she was asking us to please put her in the bed. We asked the nurse if we could have pain medication given to her and the nurse told us she would give her some Tylenol and she left and never came back with the medication. The daughter stated that no pain medications were given to Resident #1 on 03/11/23 at the facility. We asked if we could put her in her bed and the nurse told us she needed to sit up and wait for the portable x-ray. We waited until after 9:00 AM and nothing was done for our mother, so we asked if they could call 911 and have her sent to the hospital for x-ray and evaluation. We all were not happy with how little consideration the staff gave our mother. They did not put her to bed, and they left her in a wheelchair calling out in pain and never gave pain medications. We do not want to get anyone in trouble, but we do not think that any resident should be treated with such disregard. We want proper procedures to be executed for all residents and no one deserves to be treated like they treated our mother. We finally took our mother to her room, and we put her to bed where she was requesting to be placed. It was hurting her sitting up on that hip in that wheelchair. When we got to the ER, we found that she had a broken right hip, and she went to surgery the next day on a Sunday. We also do not feel that the facility gave us an explanation of how the entire incident occurred. The facility neglected to properly care for her after the fall and they should never place her in a wheelchair to sit on a broken hip.
Interview on 05/16/23 at 10:30 AM, with the Director of Nurses (DON) revealed that Res #1 should not have been bodily picked up off the floor and placed in a wheelchair. DON stated that the Res #1 should have been put in the bed and her pain should have been assessed and monitored until she left the facility for the ER. We teach this in our employee training, but we have no written training records and no written policies and procedures for the monitoring of pain. We do not have any pain assessments on this resident and we should have done them. The DON confirmed that the Standing Orders for pain medication for Tylenol was not given after the resident fell. The DON confirmed that the MAR had not been documented on 03/11/23 for the administration of pain medications to Resident #1.
Interview on 05/16/23 at 12:20 PM, with the NP revealed that she does not recall the details of the incident with the resident on 03/11/23 but she does remember that she was asked if they could get a bed side portable x-ray ordered because the resident had fell. The NP stated that this was early on a Saturday morning when she was called, and she does not have any notes from the call, so she does not recall the details. The NP confirmed that the facility did not let her know that the resident was in pain, or she would have given them an order to treat the pain. The NP stated that the Standing Orders should have been implemented and the nurses at the facility could have called for an ambulance or for additional orders as soon as the fall occurred.
Interview on 05/16/23 at 2:30 PM with CNA #2, revealed that she was assigned to the resident on the third shift (11-7) on 03/11/23. She stated that she was on her way out of the facility when she was notified that one of her assigned residents had fallen. Upon entering the room there were (2) nurses and CNA #1 in the room with Resident#1 and she was on the floor. The nurse told them to pick up the resident and put her in the wheelchair and take her to the dining room to eat breakfast. CNA #2 did not witness the fall of Resident #1 and she did not witness any pain assessments or pain medications given to resident. CNA #2 stated that she had never had a resident to fall during her shift prior to this fall on 3/11/23. CNA #2 stated that a lift should be used for picking the resident up after a fall, but they picked her up according to the charge nurse's (RN #1) instructions.
Record review of the facility Resident Incident Report dated 3/11/23 at 06:50 AM, revealed that the incident was Non-Witnessed Type of Injury: Pain. Narrative of incident and description of injuries: (CNA #1) Reported resident was found sitting on floor in her room. No injuries noted resident has c/o (complaint of) pain to rt. (right) leg. Immediate Actions Taken: Resident was assessed for injuries and assisted up to wheelchair . Pain Scale: 4 .Family notified, and Nurse Practitioner notified 3/11/23. Exam by Physician: No. Taken to Hospital: No. Report prepared by RN#1.
Record review of the facility Departmental Notes dated 03/11/23 at 7:14 AM revealed, 0650- (CNA #1) reported to nurse that resident was found sitting on the floor in her room. Resident reported that she did fall, she stated My Leg gave out, resident was assessed for injuries. Has c/o (complaint of) pain to Rt (right) leg when touch or moved/lifted. Resident stated, that's the leg I hit when I fell. 0655-Fall with c/o rt. leg pain was reported to FNP- (Family Nurse Practitioner) Order was obtained for x-ray of RT/hip/leg. 0709-Fall with c/o rt. leg pain was reported to son -he was informed that x-ray was ordered. Nurses note signed by the third shift Charge Nurse (RN #1). The nursing note 3/11/23 9:32 AM Leaving via ambulance to ER for eval and treatment. Signed by the first shift Charge Nurse (RN #2). 3/11/2023 9:50 AM Called report to ER. Signed by (RN#2). The nursing note dated 3/11/2023 at 10:46 AM read: Late charting for 9:07 AM: Resident had started yelling out in pain, radiology not available at this time. Family agreed that this nurse should call 911. Called FNP and received order to call (EMS) Emergency Management Services. Signed by (RN #2). Nursing note dated 3/11/2023 at 1:43 PM Late charting for 8:20 AM: Resident sitting up in wheelchair in the dining room and has eaten breakfast with her family. Family then transported resident back to her room in her wheelchair. Asked by her son and CNA if she should go to bed. This nurse advised against putting her back to bed due to resident needed an x-ray of her right hip, right femur and right knee. Came back to check on resident later and family member had put her in bed. Resident had started yelling due to pain because she was lying on the affected side. This nurse then called FNP to get order to send resident to the ER. Signed by RN#2.
Record review of the Electronic Medication Administration Record (eMAR) for March 2023 revealed no documentation that Resident #1 had not been given pain medications on 03/11/23 including Tylenol from the Standing Orders.
Record review of the undated facility Standing Orders revealed Pain: Tylenol 500 mg (milligrams) PO (by mouth) Q (every) 4HRS (hours) PRN (as needed). Notify Provider within 24 hours if pain persists or worsens. The facility did not implement the facility's standing orders for the PRN pain medications of Tylenol 500 mg PO Q 4 HRS PRN.
Record review of the Emergency Department report dated 03/11/23 at 1009 revealed: RN/Triage Created: 3/11/23 1009 Last Entry: 1011 EMS (Emergency Medical Services) enroute with a 89 yo (year old) F (female) with fall. Additional Information: Fall, unwitnessed. C/O Right Hip pain. Denies LOC (loss of consciousness), no blood thinners. Alert but confused. 20ga(gauge) IV(intravenous) RAC (right antecubital). 100mcg (micrograms) fentanyl given. FSBG( Fingerstick blood glucose) 203. Emergency Alert: Alert Called: Pre-Hospital Care: Patient was not medicated for pain . HPI: Fall: Occurred at 2 hours ago. Fall from standing height onto floor approx.(approximately) 0 feet injuring RLE (right lower extremity) . Chief Complaint: Fall, leg pain HPI: Patient complaining of prior to arrival of the following symptoms: Patient presents the emergency room from nursing home and apparently an unwitnessed fall confused at baseline with dementia but complaining of right hip leg pain no other evidence of trauma. 3/11/23 at 1151 doctor wrote: Provider Note: I reviewed x-ray finding fracture with family. Patient was given pain medications she has a right femoral neck fracture I consulted orthopedics. Patient will be admitted to the hospital service .
Record review of the Face Sheet of Resident #1 revealed that she was admitted to the facility on [DATE] and was discharged on 03/30/2023. Resident #1 had diagnoses of Type I Diabetes, Alzheimer's Disease, Dementia unspecified severity and Poly osteoarthritis unspecified.
Record review of the Minimum Data Set with an Assessment Reference Date (ARD) of 03/21/23 revealed a Brief Interview for Mental Status (BIMS) score of 99, indicating that the resident was unable to complete the interview.
Dec 2022
4 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Comprehensive Care Plan
(Tag F0656)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Resident # 52
A record review of the facility's policy titled Resident Mobility and Range of Motion, revised July 2017, Policy ...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Resident # 52
A record review of the facility's policy titled Resident Mobility and Range of Motion, revised July 2017, Policy Statement .2 Residents with limited range of motion will receive treatment and services to increase and/or prevent a further decrease in ROM.3 Residents with limited mobility will receive appropriate services, equipment and assistance to maintain or improve mobility unless reduction in mobility is unavoidable. This review revealed under Policy Interpretation and Implementation .4) The care plan will be developed by the interdisciplinary team based on the comprehensive assessment and will be revised as needed.5) The care plan will include specific interventions, exercises, and therapies based on the comprehensive assessment and will be revised as needed.
Record review of Resident #52's comprehensive care plans found no care plan addressing the resident's left-hand contracture.
Record review of Resident #52's Physician's Order dated 11/7/22 revealed Hand roll to left hand during waking hours to prevent further contracture.
During an interview and observation with Resident # 52's sister on 12/12/22 at 11:05 AM, revealed her brother is supposed to have a hand roll in his left hand to prevent his contracture from getting worse. An observation revealed there was no hand roll in the residents left hand.
An observation on 12/12/22 at 3:45 PM, revealed Resident #52 with no hand roll to the left hand.
An observation on 12/13/22 at 9:39 AM, revealed no left-hand roll to Resident # 52's hand.
An observation and interview at 12/13/22 at 10:47 AM, with Registered Nurse (RN)#1 revealed Resident # 52 was not wearing a hand roll.
An interview with the Director of Nursing (DON) at 12/13/22 10:58 AM, confirmed the use of the hand roll was not on the comprehensive care plan for Resident #52.
An interview with the Minimum Data Set (MDS) nurse RN #2 on 12/14/22 at 9:00 AM, revealed the MDS department is responsible for reviewing orders Monday thru Friday and updating the care plans with any changes needed and confirmed she failed to update resident #52's care plan to include the resident's left-hand contracture and order for a hand roll.
Record review of Resident #52's Face Sheet revealed the resident was admitted to the facility on [DATE] with diagnoses of Hemiplegia following cerebral infarction affecting left nondominant side.
Record review of the MDS section C with an Assessment Reference Date (ARD) date of 10/10/22 revealed that Resident #52 had a Brief Interview of Mental Status (BIMS) score of 13 which indicated that he was cognitively intact.
Based on record review, staff interview and facility policy review the facility failed to develop and/or implement a comprehensive person-centered care plan for two (2) of 19 resident records reviewed. Resident #24 and Resident #52
Findings include:
Record review revealed the facility does not have a Comprehensive Care Plan policy.
Record review revealed a care plan dated 03/23/22: I require extensive assist with my Activity of Daily Living (ADLS) due to pain in my knees, Limited Range of Motion (LROM) in my shoulders shortness of breath with and without exertion, safety and weakness with a goal of I will improve my current level of function through 03/05/23 and interventions that include: I need assist with sponge baths on non-shower days, I need a shower 3 times per week, prepare shower with needed items, I need assist with washing my back, feet. Legs and I need help shaving on shower days and as needed.
Record review of the facilities Shower/Sponge Off Schedule revealed Resident #24 in room [ROOM NUMBER] is scheduled for a shower on Monday, Wednesday, and Friday on the 7 AM-3 PM shift and a sponge off on Tuesday, Thursday and Saturday on the 7 AM-3 PM shift.
Record review of Resident #24's Completed Care Details for the last two weeks revealed the resident had one bath on 12/5/22 with documentation for 12/06/22, 12/10/22 and 12/11/22 that indicated the activity did not occur.
On 12/12/22 at 10:24 AM, an observation revealed Resident #24 lying in bed with eyes closed, wearing a brief and a t-shirt with a strong smell of urine in the room.
At 4:40 PM on 12/12/22 an observation revealed Resident #24 sitting in his recliner with a smell of urine and facial hair stubble noted on his face.
On 12/13/22 at 10:55 AM, an observation revealed Resident #24 had facial hair covering his cheeks, chin and above his lip that was approximately 1/8th of an inch long.
During an interview on 12/13/22 at 2:20 PM, with the Director of Nurses (DON) confirmed that according to Resident #24's bath documentation, the resident has only had one bath in the past two weeks. She revealed the (Certified Nursing Assistant) CNAs were supposed to notify their charge nurse when a resident refused a bath and then the nurse should make a documentation. She confirmed that Resident #24 had documentation for 12/6/22, 12/10/22 and 12/11/22 that Activity Did Not Occur under the bathing documentation. She confirmed that there was no corresponding progress note from the nurse that would confirm that the resident had refused a bath for those days. She revealed if something is not documented then it did not occur.
In interview on 12/13/22 at 2:30 PM, with the Administrator revealed the CNAs should be documenting the resident's baths and should not have trouble doing so, because we provide tablets for them to document on. She revealed that she understands if something is not documented then you cannot prove that it was done. She revealed that Resident #24 is getting a shower and a shave right now but confirmed it should have already occurred.
On 12/14/22 at 9:38 AM, during an interview with Resident #24 revealed it is hard to get a shower in this place. He revealed the staff will come ask him if he is ready for a shower, he will lay out his clothes and then they will never come back. He revealed he does like getting a shower regularly and thinks he usually gets one or two a week.
CNA #1 confirmed during an interview on 12/14/22 at 9:45 AM she shaved Resident #24 and gave him a shower yesterday. She confirmed that the resident did need to be shaved because his hair grows fast, and she had shaved him last Thursday. She revealed she is not aware that the resident is supposed to get a shower three times per week and a shave with every shower, but confirmed she is able to see his care plans.
Record review of the Face Sheet revealed Resident #24 was admitted to the facility on [DATE] with medical diagnoses that included Chronic Ischemic Heart Disease/unspecified, weakness and other abnormalities of gait and mobility.
Record review of Resident #24's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/5/22 revealed in Section G that the resident needed physical help in part of bathing activity and in Section C a Brief Interview for Mental Status (BIMS) of 11 which indicates the resident is moderately cognitively impaired.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
ADL Care
(Tag F0677)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, staff and resident interviews, record review and facility policy review the facility failed to provide sh...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, staff and resident interviews, record review and facility policy review the facility failed to provide showers and shaving to a resident that was dependent on staff for one (1) of 19 residents reviewed.
Resident #24
Findings include:
Record review of the facility policy titled Shower/Tub Bath with a revision date of October 2010 revealed under Purpose .The purpose of this procedure is to promote cleanliness, provide comfort to the resident and to observe the condition of the residents' skin. This review revealed under Documentation #5 .If the resident refused the shower/tub bath, the reason(s) why and the intervention taken.
An observation on 12/12/22 at 10:24 AM, revealed Resident #24 lying in bed with eyes closed, wearing a brief and a t-shirt with a strong smell of urine in the room.
An observation on 12/12/22 at 4:40 PM, revealed Resident #24 sitting in his recliner with a smell of urine and facial hair stubble noted on his face.
An observation on 12/13/22 at 10:55 AM, revealed Resident #24 had facial hair covering his cheeks, chin and above his lip that was approximately 1/8th of an inch long.
An interview on 12/13/22 at 1:55 PM, with Certified Nurse Assistant (CNA) #1 revealed that Resident #24 occasionally refuses a bath but does want to be shaved. She revealed that when a resident refuses, then the CNA is supposed to let her supervising nurse know. She revealed that when a resident refuses a bath then the CNA should document the bath was refused.
An interview on 12/13/22 at 2:10 PM with Registered Nurse (RN) #3 revealed it is the responsibility of the CNAs to notify the nurse when a resident refuses a bath. She revealed it has been an issue with the CNA's not notifying the nurse when the resident refuses a bath. She revealed that Resident #24 sometimes refuses, but we hate to document it as an actual refusal because sometimes he is just confused and then gets agitated with us.
An interview on 12/13/22 at 2:20 PM, with the Director of Nurses (DON) confirmed that according to Resident #24's bath documentation, the resident has only had one bath in the past two weeks. She revealed that one of Resident #24's CNAs revealed she was having trouble documenting but did not make anyone aware. She revealed the CNAs were supposed to notify their charge nurse when a resident refused a bath and then the nurse should make a documentation. She confirmed that Resident #24 had documentation for 12/6/22, 12/10/22 and 12/11/22 that Activity Did Not Occur under the bathing documentation. She confirmed that there was no corresponding progress note from the nurse that would confirm that the resident had refused a bath for those days. She revealed if something is not documented then it did not occur.
An interview on 12/13/22 at 2:30 PM, with the Administrator revealed the CNAs should be documenting the resident's baths and should not have trouble doing so, because we provide tablets for them to document on. She revealed that she understands if something is not documented then you cannot prove that it was done. She revealed that Resident #24 is getting a shower and a shave right now but confirmed it should have already occurred.
An interview on 12/14/22 at 9:38 AM, with Resident #24 revealed it is hard to get a shower in this place. He revealed the staff will come ask him if he is ready for a shower, he will lay out his clothes and then they will never come back. He revealed he does not like getting a shower regularly and thinks he usually gets one or two a week.
An interview on 12/14/22 at 9:45 AM, with CNA #1 confirmed she shaved Resident #24 and gave him a shower yesterday. She confirmed that the resident did need to be shaved because his hair grows fast, and she had shaved him last Thursday. She revealed she is not aware that the resident is supposed to get a shower three times per week and a shave with every shower, but confirmed she is able to see his care plans.
Record review revealed Resident #24 was admitted to the facility on [DATE] with medical diagnoses that included Chronic Ischemic Heart Disease/unspecified, weakness and other abnormalities of gait and mobility.
Record review of the facilities Shower/Sponge Off Schedule revealed Resident #24 is scheduled for a shower on Monday, Wednesday, and Friday on the 7 AM-3 PM shift and a sponge off on Tuesday, Thursday and Saturday on the 7 AM-3 PM shift.
Record review of Resident #24's Completed Care Details for the last two weeks revealed the resident had one bath on 12/5/22 with documentation for 12/06/22, 12/10/22 and 12/11/22 that indicated the activity did not occur.
Record review of Resident #24's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/5/22 revealed in Section G that the resident needed physical help in part of bathing activity and in Section C a Brief Interview for Mental Status (BIMS) score of 11 which indicates the resident has moderate cognitive impairment.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0688
(Tag F0688)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff and resident representative interview, record review and facility policy review the facility failed ...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff and resident representative interview, record review and facility policy review the facility failed to provide services to prevent a further decline in range of motion for one (1) of four (4) residents reviewed for limited range of motion. Resident #52
Findings include:
A record review of the facility's policy titled Resident Mobility and Range of Motion', revised July 2017 revealed under the Policy Statement .2) Residents with limited range of motion will receive treatment and services to increase and/or prevent a further decrease in ROM.3) Residents with limited mobility will receive appropriate services, equipment and assistance to maintain or improve mobility unless reduction in mobility is unavoidable.
A record review revealed the facility has no policy titled Physician's Orders.
An observation and interview with Resident # 52's sister on 12/12/22 at 11:05 AM, revealed her brother is supposed to have a hand roll in his left hand to prevent his contracture from getting worse. An observation revealed there was no hand roll in the residents left hand.
An observation on 12/12/22 at 3:45 PM, revealed Resident # 52 with no hand roll to his left hand.
An observation on 12/13/22 at 9:39 AM, revealed there was no left-hand roll to Resident # 52's hand.
Record review of Resident #52's Physician's Order dated 11/7/22 revealed Hand roll to left hand during waking hours to prevent further contracture.
Record review of the Electronic Treatment Administration Record (E-TAR) for December 2022 revealed staff documented hand roll to left hand at 6 AM and 2 PM on 12/12/22 and 12/13/22.
An observation and interview on 12/13/22 at 10:47 AM, with Registered Nurse (RN) #1 revealed that Resident #52 should be wearing a left-hand roll and confirmed it was not on. An observation revealed RN #1 removed the hand roll from the resident's drawer and placed it in Resident #52's left hand and confirmed that worsening of the contracture is a possible complication from not wearing the hand roll.
An interview with the Director of Nursing (DON) on 12/13/22 at 10:58 AM, confirmed Resident #52 had an order for a left-hand roll and is being signed off on the Treatment Administration Record as wearing the hand roll and confirmed that worsening contractures are a possible problem if the device is not applied.
An interview with the Administrator on 12/13/22 at 11:00 AM, revealed that worsening of the contracture and pressure injury was a possible problem from not wearing hand roll.
Record review of Resident #52's Face Sheet revealed that the resident was admitted to the facility on [DATE] with diagnoses of Hemiplegia following cerebral infarction affecting left nondominant side.
Record review of Resident #52's admission Minimum Data Set (MDS) with an Assessment Reference Date of 4/19/22, Section G, revealed Impairment on one side to upper and lower extremity.
The MDS section C with an ARD of 10/10/22 revealed that Resident #52 had a Brief Interview of Mental Status (BIMS) score of 13 which indicated that he was cognitively intact.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected 1 resident
Based on observation, staff interview and facility policy review the facility failed to prevent the likelihood of the spread of infection as evidenced by not wearing a mask or performing hand hygiene ...
Read full inspector narrative →
Based on observation, staff interview and facility policy review the facility failed to prevent the likelihood of the spread of infection as evidenced by not wearing a mask or performing hand hygiene during meal tray pass and feeding assistance for one (1) of three (3) survey days.
Findings include:
Record review of the facility policy titled, Hand Hygiene with a revision date of 12/01/22 revealed under Policy .All staff will perform proper hand hygiene procedures to prevent the spread of infection to other personnel, residents and visitor. This applies to all staff working in all locations within the facility.
An observation on 12/12/22 at 11:45 AM, revealed approximately 24 residents in the dining room with four (4) staff present. This observation revealed Certified Nurse Assistant (CNA) #1, and CNA #2 did not perform hand hygiene prior to setting up multiple resident lunch trays. This observation revealed CNA #1 and #2 did not perform hand hygiene prior to leaving the dining room, delivering, and setting up a lunch tray in two resident rooms. This observation revealed CNA #2 returned to the dining room did not perform hand hygiene, pulled her mask down below her chin and assisted in feeding a resident.
An interview on 12/12/22 at 12:20 PM, with CNA #2 confirmed she did not perform hand hygiene before she set up lunch trays, delivered a lunch tray to a resident's room or before assisting in feeding a resident. She confirmed that she did pull her mask down below her chin while she was assisting in feeding a resident. She revealed that it is the policy of the facility that she is supposed to always wear a mask and needs to perform hand hygiene before feeding a resident. She revealed that she knows that wearing a mask and performing hand hygiene helps to decrease the spread of infections and keeps the staff from catching infections.
An interview on 12/12/22 at 12:40 PM, with CNA #1 confirmed she did not perform hand hygiene prior to or at any time during passing lunch trays. She revealed she is aware she should perform hand hygiene especially after entering a resident's room and setting up a meal tray.
An interview on 12/13/22 at 4:15 PM, with the Director of Nurses (DON) revealed that it is the policy of the facility that all staff wear a mask while working in the facility and perform hand hygiene before setting up meal trays, before and after entering a resident's room and before feeding a resident. She confirmed the purpose of the mask and performing hand hygiene is to prevent the spread of germs which can lead to infections.
An interview on 12/14/22 at 9:00 AM, with the Administrator revealed the facility is requiring everyone to wear a mask, had an in-service on 10/21/22 with all staff that informed them that mask was required, and revealed they have signs on the entrance doors that a mask is required. She revealed she expects all employees to wear a mask while at work. She revealed that all staff should be performing hand hygiene before they start passing meal trays and if they touch anything else such as a resident room door then they should perform hand hygiene after touching those things and before assisting a resident to eat to help decrease the spread of infection.
Record review of the facility policy titled Coronavirus Prevention and Response with a revision date of 09/26/22 revealed under Policy Explanation and Compliance Guidelines #5 a. Ensuring that everyone is aware of the recommended Infection Prevention and Control practices in the facility by posting visual alerts (e.g., signs, posters) at the entrance and in strategic places to include instructions about current IPC recommendations
Record review of the facility in-services revealed the facility had an in-service on 06/23/22 and 12/1/22 for nurses and CNA's titled Handwashing, an in-service on 06/28/22 topic Mandatory In-service infection control and an in-service on 10/21/22 that included infection control.
Understanding Severity Codes (click to expand)
Life-Threatening (Immediate Jeopardy)
J - Isolated
K - Pattern
L - Widespread
Actual Harm
G - Isolated
H - Pattern
I - Widespread
Potential for Harm
D - Isolated
E - Pattern
F - Widespread
No Harm (Minor)
A - Isolated
B - Pattern
C - Widespread
Questions to Ask on Your Visit
- "Can I speak with families of current residents?"
- "What's your RN coverage like on weekends and overnight?"
Our Honest Assessment
Strengths
- • Licensed and certified facility. Meets minimum state requirements.
Concerns
- • Multiple safety concerns identified: 3 harm violation(s), Payment denial on record. Review inspection reports carefully.
- • 30 deficiencies on record, including 3 serious (caused harm) violations. Ask about corrective actions taken.
- • $16,700 in fines. Above average for Mississippi. Some compliance problems on record.
- • Grade F (23/100). Below average facility with significant concerns.
Bottom line: Trust Score of 23/100 indicates significant concerns. Thoroughly evaluate alternatives.
✓ Report will be sent to your email
About This Facility
What is Trend Health And Rehab Of Houston's CMS Rating?
CMS assigns TREND HEALTH AND REHAB OF HOUSTON an overall rating of 1 out of 5 stars, which is considered much below average nationally. Within Mississippi, 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 Trend Health And Rehab Of Houston Staffed?
CMS rates TREND HEALTH AND REHAB OF HOUSTON's staffing level at 4 out of 5 stars, which is above average compared to other nursing homes.
What Have Inspectors Found at Trend Health And Rehab Of Houston?
State health inspectors documented 30 deficiencies at TREND HEALTH AND REHAB OF HOUSTON during 2022 to 2025. These included: 3 that caused actual resident harm, 25 with potential for harm, and 2 minor or isolated issues. Deficiencies causing actual harm indicate documented cases where residents experienced negative health consequences.
Who Owns and Operates Trend Health And Rehab Of Houston?
TREND HEALTH AND REHAB OF HOUSTON 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 TREND CONSULTANTS, a chain that manages multiple nursing homes. With 66 certified beds and approximately 44 residents (about 67% occupancy), it is a smaller facility located in HOUSTON, Mississippi.
How Does Trend Health And Rehab Of Houston Compare to Other Mississippi Nursing Homes?
Compared to the 100 nursing homes in Mississippi, TREND HEALTH AND REHAB OF HOUSTON's overall rating (1 stars) is below the state average of 2.6 and health inspection rating (2 stars) is below the national benchmark.
What Should Families Ask When Visiting Trend Health And Rehab Of Houston?
Based on this facility's data, families visiting should ask: "Can I visit during a mealtime to observe dining assistance and food quality?" "How do you handle medical emergencies, and what is your hospital transfer rate?" "Can I speak with family members of current residents about their experience?"
Is Trend Health And Rehab Of Houston Safe?
Based on CMS inspection data, TREND HEALTH AND REHAB OF HOUSTON has a clean safety record: no substantiated abuse findings (meaning no confirmed cases of resident harm), no Immediate Jeopardy citations (the most serious violation level indicating risk of serious injury or death), and is not on the Special Focus Facility watch list (a federal program monitoring the lowest-performing 1% of nursing homes). The facility has a 1-star overall rating and ranks #100 of 100 nursing homes in Mississippi. While no facility is perfect, families should still ask about staff-to-resident ratios and recent inspection results during their visit.
Do Nurses at Trend Health And Rehab Of Houston Stick Around?
TREND HEALTH AND REHAB OF HOUSTON has not reported staff turnover data to CMS. Staff turnover matters because consistent caregivers learn residents' individual needs, medications, and preferences. When staff frequently change, this institutional knowledge is lost. Families should ask the facility directly about their staff retention rates and average employee tenure.
Was Trend Health And Rehab Of Houston Ever Fined?
TREND HEALTH AND REHAB OF HOUSTON has been fined $16,700 across 2 penalty actions. This is below the Mississippi average of $33,246. 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 Trend Health And Rehab Of Houston on Any Federal Watch List?
TREND HEALTH AND REHAB OF HOUSTON is not on any federal watch list. The most significant is the Special Focus Facility (SFF) program, which identifies the bottom 1% of nursing homes nationally based on persistent, serious quality problems. Not being on this list means the facility has avoided the pattern of deficiencies that triggers enhanced federal oversight. This is a positive indicator, though families should still review the facility's inspection history directly.