OXFORD HEALTH & REHAB CENTER
For profit - Corporation
120 Beds
ADVANCED HEALTH CARE MANAGEMENT
Data: November 2025
1 Immediate Jeopardy citation
Trust Grade
43/100
#80 of 200 in MS
Photo by Oxford Health and Rehab Center
Photo by Oxford Health and Rehab Center
Photo by Oxford Health and Rehab Center
1 / 5 photos
Last Inspection: September 2024
Within standard 12-15 month inspection cycle. Federal law requires annual inspections.
Overview
Oxford Health & Rehab Center has received a Trust Grade of D, indicating below-average quality and some concerns about care. They rank #80 out of 200 nursing homes in Mississippi, placing them in the top half of facilities in the state, and are the only option in Lafayette County. The facility is improving, with issues decreasing from 4 in 2024 to just 1 in 2025. Staffing is a strength with a rating of 4 out of 5 stars and a turnover rate of 40%, which is better than the state average. However, there are concerning incidents, including a failure to properly clean and disinfect medical equipment used for blood glucose testing, and a serious issue with not providing adequate pain management for a resident, highlighting both strengths and weaknesses in their overall care approach.
- Trust Score
- D
- In Mississippi
- #80/200
- Safety Record
- High Risk
- Inspections
- Getting Better
- Staff Stability ○ Average
- 40% turnover. Near Mississippi's 48% average. Typical for the industry.
- Penalties ✓ Good
- No fines on record. Clean compliance history, better than most Mississippi facilities.
- Skilled Nurses ⚠ Watch
- Each resident gets only 22 minutes of Registered Nurse (RN) attention daily — below average for Mississippi. Fewer RN minutes means fewer trained eyes watching for problems.
- Violations ⚠ Watch
- 23 deficiencies on record. Higher than average. Multiple issues found across inspections.
43/100
Top 40%
Review needed
4 → 1 violations
★★★☆☆
3.0
Overall Rating
★★★★☆
4.0
Staff Levels
★★★★★
5.0
Care Quality
★★☆☆☆
2.0
Inspection Score
↔
Stable
2024: 4 issues
2025: 1 issues
The Good
-
4-Star Staffing Rating · Above-average nurse staffing levels
-
5-Star Quality Measures · Strong clinical quality outcomes
-
Full Sprinkler Coverage · Fire safety systems throughout facility
-
No fines on record
-
Staff turnover below average (40%)
8 points below Mississippi average of 48%
Facility shows strength in staffing levels, quality measures, fire safety.
The Bad
3-Star Overall Rating
Near Mississippi average (2.6)
Meets federal standards, typical of most facilities
Staff Turnover: 40%
Near Mississippi avg (46%)
Typical for the industry
Chain: ADVANCED HEALTH CARE MANAGEMENT
Part of a multi-facility chain
Ask about local staffing decisions and management
The Ugly 23 deficiencies on record
1 life-threatening 1 actual harm
Oct 2025
1 deficiency
1 Harm
SERIOUS
(G)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Actual Harm - a resident was hurt due to facility failures
Deficiency F0697
(Tag F0697)
A resident was harmed · This affected 1 resident
Based on resident representative and staff interview, record review, and facility policy review, the facility failed to ensure pain management was provided for a resident that had diagnoses that inclu...
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Based on resident representative and staff interview, record review, and facility policy review, the facility failed to ensure pain management was provided for a resident that had diagnoses that included pain and chronic pain for one (1) of six (6) residents sampled. Resident #1Findings include:Record review of facility policy titled, Pain Management with a revised date of 3/10/25, revealed, The facility must ensure that pain management is provided to residents who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences .During a phone interview on 10/1/25 at 12:17 PM, Resident #1's representative revealed the resident had multiple wounds and was on antibiotics and was admitted to the facility from the hospital late in the evening on 7/25/25 and was sent back to the hospital on 8/6/25 and passed away on 8/25/25. She stated when the resident returned to the hospital it was determined that she had a decreased blood supply to her lower body and this caused excruciating pain. She stated that during the facility stay, the resident requested her pain medication and several times she did not receive it at all, or it was given long after it was requested. She stated it was unacceptable for the resident to have been in such severe pain and to not have the ordered medication given to her timely.A phone interview with Licensed Practical Nurse (LPN) #1 on 10/2/25 at 8:30 AM, revealed she was the nurse that admitted Resident #1 to the facility. She stated the resident had multiple wounds and complained of severe pain on admission, but she did not have pain medication available to administer to the resident. She confirmed she did not follow the process of obtaining pain medications for a resident with pain and she did not contact the pharmacy or the physician. She revealed a pain scale score was not checked or documented, but the resident had significant pain during part of her shift, and when the medication arrived around 3:00 AM, the resident was asleep. She stated the resident's condition was a sad situation and she had pain from the moment she was admitted till she left that shift. An interview with the Director of Nursing (DON) on 10/1/25 at 2:30 PM and 10/2/25 at 9:35 AM, revealed Resident #1 was admitted to the facility with multiple wounds and cellulitis of the perineum. She stated the facility had a system in place to allow medications to be obtained any time day or night through their medication dispensing system which could be accessed prior to medications delivered by their pharmacy. She acknowledged if a pain medication was needed, the on-call pharmacy provided a code for the narcotic to be obtained from the dispensing system. If no prescription was available, the provider would be notified to send a hard copy of prescription to the pharmacy so the staff could obtain the needed medication for the residents. After Resident #1's admission Health Status Note by LPN #1 which indicated the resident was having pain and medications were not available, was reviewed by the DON, she acknowledged this should not have occurred since the medication was available in their dispensing system. She acknowledged that a pain level score was not documented by LPN #1, but the nurse had documented in the progress note that the resident was experiencing pain. She acknowledged that each resident has the right to receive the care necessary and it was her expectation that each staff member follows the process to obtain the needed medications for each resident. She confirmed the nurse, therefore the facility, failed to follow the procedure for obtaining medication for a resident experiencing pain. Record review of Resident #1's Health Status Note dated 7/25/25 at 9:30 PM, revealed, Resident is complaining of pain at this time, but no medications are on hand for her. This was signed by LPN #1.Record review of Resident #1's Order Summary Report revealed an order dated 7/25/25 for Hydrocodone-Acetaminophen Tablet 5-325 milligram (mg) give one tablet by mouth every 8 hours as needed for pain.Record review of the Electronic Medication Administration Record (EMAR) revealed Resident #1 did not receive the ordered pain medication on 7/25/25.Record review of facility's Inventory list for medications in the dispensing system revealed that Resident #1's ordered medication, Hydrocodone/Acetaminophen 5-325 mg was available in the facility's medication dispensing system.Record review of Resident #1's admission Record revealed an admission date of 7/25/25, with diagnoses that included cellulitis of perineum, pressure ulcer, pain, and chronic pain.Record review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 8/1/25 revealed a Brief Interview for Mental Status (BIMS) score of 13 indicating Resident #1 was cognitively intact.
Sept 2024
4 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, the facility failed to ensure a resident had a properly fitting wheelchair for one (1) of 20 sampled residents. Resident #83
Findings Include:
Recor...
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Based on observation, resident and staff interview, the facility failed to ensure a resident had a properly fitting wheelchair for one (1) of 20 sampled residents. Resident #83
Findings Include:
Record review of a typed statement on facility letterhead and signed by the Administrator, revealed This facility does not have a policy related to resident equipment, including wheelchairs.
An observation and interview on 9/3/2024 at 11:20 AM, with Resident #83 revealed, she was sitting in a wheelchair in her room. The resident's feet were dangling down of the seat of the wheelchair and did not touch the floor. The resident revealed she propelled herself throughout the facility in the wheelchair and admitted it was difficult to do this because her feet did not touch the floor.
An interview with Certified Nurse Aide (CNA) #2 on 9/4/2024 at 11:05 AM, confirmed Resident #83 used her wheelchair to propel herself about the facility and this was her method of mobility.
An interview with Resident #83, on 9/4/2024 at 11:40 AM, revealed she would like a better fitting wheelchair so that her feet could touch the floor and it would be more comfortable.
An observation and interview, on 9/4/2024 at 11:45 AM, with Registered Nurse (RN) # 2, confirmed Resident #83's wheelchair was too tall for her and acknowledged the resident would have trouble with foot propulsion since her feet did not contact the floor.
An interview with the Occupational Therapist (OT) on 9/4/2024 at 11:54 AM revealed, when a resident admits to the facility, someone usually goes and gets an available wheelchair from inside the facility. He revealed the wheelchair was not customized to fit Resident #83 and stated her feet should reach the floor to safely self-propel.
An interview with the Administrator on 9/4/2024 at 1:50 PM, confirmed Resident #83 should have a proper fitting wheelchair to meet the resident's needs.
Review of the admission Record revealed the facility admitted Resident #83 on 8/1/2024 with medical diagnoses that included Unspecified fracture of the left femur.
Record review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 8/9/2024 revealed, under section C, a Brief Interview for Mental Status (BIMS) summary score of 14, which indicates Resident #83 was cognitively intact.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Safe Environment
(Tag F0584)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff and resident interview, record review, and facility policy review, the facility failed to ensure the...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff and resident interview, record review, and facility policy review, the facility failed to ensure the residents rooms were clean and in good repair for three (3) of 90 resident's rooms observed during survey. Resident #12, #17 and #28.
Findings Include:
Review of the facility policy titled, Room and Restroom Daily Cleaning Duties with a revision date of 4/9/2020 revealed .Procedure .7. The third rag should be used to clean the bed. Wipe down all bed rails, head and foot boards .
Review of the facility policy titled, Resident Room and Bathroom Complete/Deep Cleaning Policy with no revision date, revealed, It is the policy of Proper Name Services to Complete/Deep Clean all resident rooms on a monthly basis .Procedure .2. Beds .Headboards and rails will be included . 6. Cubicle Curtain .each cubicle curtain will be checked for cleaning. If needed, it will be replaced, and the old one will be washed in the laundry .
Record review of a typed statement on facility letterhead, undated and signed by the Administrator revealed This facility does not have a policy related to environmental cleaning.
Resident #12
An observation on 9/3/24 at 11:12 AM, of Resident #12's room revealed, the privacy curtain at the foot of the resident's bed had approximately 8 brown stains about 1-2 inches wide scattered over the curtain.
Review of Resident #12's admission Record revealed the resident was admitted to the facility on [DATE] with medical diagnoses that include Cerebral Infarction.
Review of Resident #12's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 7/15/24 revealed in section C, a Brief Interview for Mental Status (BIMS) score of 14, which indicated the resident was cognitively intact.
Resident #17
An observation and interview on 9/3/24 at 2:38 PM, with Resident #17 revealed, her closet door on one side had been broken for a long time and maintenance knew about it. She stated the nurses and aides must get my clothes out of the closet daily, so they see that only one side works. This observation revealed the resident's closet had double sliding doors and one door was off the track and propped against the clothes that were hung in the closet.
Review of Resident #17's admission Record revealed the resident was admitted to the facility on [DATE] with medical diagnoses that included Multiple Sclerosis.
Review of Resident 17's MDS with an ARD of 6/18/24 revealed in section C, a BIMS score of 15, which indicated the resident was cognitively intact.
Review of the List of Rooms to be done by Maintenance did not include Resident #17's room.
An interview on 9/3/24 at 2:45 PM, with Licensed Practical Nurse (LPN) #2 revealed, they do Angel Rounds at the beginning of their shifts. She revealed these rounds were done to make sure the rooms were clean and there were no repairs needed in each room.
An interview on 9/4/24 at 8:41 AM, with LPN #1, revealed all office nurses have assigned rooms that they make Angel Rounds on one time per week. She revealed they make these rounds to make sure the rooms were clean and there were not any needed repairs. She stated if they find something that maintenance needs to repair then they just call him.
A review of the schedule for Angel Rounds revealed that all resident rooms were assigned to an administrative nurse.
An interview on 9/4/24 at 10:21 AM, with the Maintenance Director confirmed that staff usually send him a text or a group email when repairs need to be made. He confirmed there was a maintenance log at the nurse's desk, but text and email were the best communication. He revealed the list of rooms that needed to be repaired was on the list that he provided and that was all the repairs that he was aware of.
An interview and observation on 9/4/24 at 10:48 AM, with the Administrator, confirmed Resident #17's closet door was off track and should have been found on the Angel Rounds and maintenance should have been notified to keep the resident's room in good repair. The Administrator confirmed Resident #12's dirty privacy curtain. The Administrator acknowledged the privacy curtain needed to be changed out because it was dirty.
An interview on 9/4/24 at 2:28 PM, with Housekeeping #2 revealed, that if she found a dirty privacy curtain, she would notify her supervisor and she would resolve it.
An interview on 9/4/24 at 3:10 PM, with the District Manager for Housekeeping confirmed that if a housekeeper noticed that a privacy curtain was dirty then they can replace it. She said the rooms get deep cleaned one time monthly and curtains also get replaced then if they are dirty.
Review of the Monthly Calendar for Deep Cleaning resident rooms revealed that Resident #12's room was due for a deep cleaning on 8/29/24 and Resident #28's room was due on 8/30/24.
Resident #28
An observation on 9/3/24 at 11:35 AM, revealed dirty bilateral one-quarter length bed rails in Resident #28's room. The right bed rail had three areas approximately one inch long by one-quarter inch wide of brownish yellow substance on the interior part next to the mattress. The left bed rail had two areas of brown substance approximately one inch by one-half inch on the inner left bed rail and had a gray substance scattered along the entire length of the top bar of the quarter-sized bed rail.
An observation on 9/4/24 at 7:38 AM, of Resident #28's room, revealed the right interior bed rail with brownish yellow substance scattered in three places approximately one inch by one-quarter inch. The left bed rail had two areas of brown substance approximately one inch by one-half inch on the inner left bed rail and had a grayish substance along the entire top edge of the quarter-sized bed rail.
An interview on 9/4/24 at 11:18 AM, with District Housekeeping Supervisor, revealed that they cleaned resident rooms every day and that the staff deep cleaned the rooms once a month. She revealed that the daily resident room cleaning included spot checking the walls, cleaning the bathrooms, sweeping, mopping, and wiping down all high contact surfaces. She confirmed that cleaning the bed rails was part of the daily cleaning tasks and stated It is our responsibility. The District Housekeeping Supervisor revealed that the young ladies in housekeeping were new, and she was working on retraining them on things she had noticed that they needed to improve on. She also revealed that she would make sure the bed rails were cleaned from now on.
An interview on 9/4/24 at 10:20 AM, with Registered Nurse (RN) Unit Manager confirmed that Resident #28's bedrails had the brownish yellow substance and the grayish substance on both bilateral rails. She revealed that dirty side rails could cause the spread of germs and stated, I will get them cleaned right now. The RN Unit Manager also revealed that it was everyone's responsibility to clean the side rails if they noticed them to be dirty.
An interview on 9/4/24 at 10:25 AM, with Licensed Practical Nurse (LPN) #3, revealed that the Housekeeping Department was responsible for cleaning the bed rails. She observed and confirmed that Resident #28's bilateral side rails were dirty and stated, We don't know what it is.
Record review of Resident #28's admission Record revealed an admission date of 6/17/2024 and diagnoses that included Need for assistance with personal care, Cerebral infarction, and Anxiety disorder.
Record review of Resident #28's MDS with ARD of 6/24/2024 revealed under section C, a BIMS score of 10 which indicates Resident #28 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
Based on observation, staff interview, record review, and facility policy review, the facility failed to implement a comprehensive care plan related to personal hygiene for one (1) of 20 sampled resid...
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Based on observation, staff interview, record review, and facility policy review, the facility failed to implement a comprehensive care plan related to personal hygiene for one (1) of 20 sampled residents. Resident #31.
Findings Included:
Review of the facility policy titled, Comprehensive Plan of Care, dated 10/10/22 revealed Policy: It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident
Record review of Resident #31's Care Plan with a date initiated 2/27/24 revealed Focus: Resident requires staff assistance with ADL's (Activities of Daily Living) related to Dysphagia and History of CVA (Cerebrovascular Accident) with left sided hemiparesis. Goal: .will be provided with ADL's according to daily needs through next review .
On 9/3/24 at 10:34 AM, an observation revealed Resident #31 lying in his bed and he wearing a short-sleeved shirt. The resident's shirt had an area of white, crusty substance on the right anterior sleeve and a quarter-sized, dried, brown substance on the upper, anterior chest area of the shirt.
On 9/3/24 at 11:50 AM, an observation revealed Resident #31 lying in his bed and he had the same short-sleeved shirt on with the dried substance.
On 9/4/24 at 7:40 AM, an observation revealed Resident #31 lying on his left side in his bed with the same short-sleeved T-shirt he had on the day before on 09/03/24.
On 9/4/24 at 3:06 PM, an observation and interview with Certified Nursing Assistant (CNA) #1, revealed that Resident #31 was assigned to her today. She confirmed it is in his care plan to receive hygiene care.
On 9/4/24 at 3:40 PM, an interview with Minimum Data Set (MDS) Coordinator, revealed that the comprehensive care plan was developed to provide patient-centered, individualized care for each resident. MDS Coordinator agreed that Resident #31's care plan was not followed when the staff failed to assist him with his ADL needs.
Record review of Resident #31's admission Record revealed an admit date of 01/21/2021 with diagnoses that included Need for Assistance with Personal Care, Cerebral Infarction with Hemiplegia and Hemiparesis affecting left non-dominant side.
Record review of Resident #31's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 08/26/24 under Section C revealed a Brief Interview for Mental Status (BIMS) Score of 03 which indicated that he had severe cognitive deficits.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
ADL Care
(Tag F0677)
Could have caused harm · This affected multiple residents
Based on observation, staff interview, record review, and facility policy review, the facility failed to provide Activities of Daily Living (ADL) care for a resident dependent on staff for care for on...
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Based on observation, staff interview, record review, and facility policy review, the facility failed to provide Activities of Daily Living (ADL) care for a resident dependent on staff for care for one (1) of 20 sampled residents. Resident #31
Findings Included:
Review of the facility policy, Activities of Daily Living (ADL) with revised date of 09/15/2022 revealed , Care and services will be provided for the following activities of daily living: 1. Bathing, dressing, grooming, and oral care .
An observation on 9/03/24 at 10:34 AM, revealed Resident #31 lying in his bed and he wore a red short-sleeved T-shirt. Resident #31's shirt had an area of white, crusty substance on the right anterior sleeve and also a quarter-sized area of dried, brown substance on the upper center front of the shirt.
An observation on 09/03/24 at 11:50 AM, revealed Resident #31 lying in his bed and he had the same red short-sleeved shirt on.
An observation on 09/04/24 at 7:40 AM, revealed Resident #31 lying on his left side in his bed with the same red short-sleeved shirt he had on the day before on 09/03/24.
An observation and interview on 09/04/24 at 3:06 PM, with Certified Nursing Assistant (CNA) #1, revealed that Resident #31 was assigned to her today. She revealed that this resident was on hospice services, and their CNAs came to the facility three times a week to bathe him. CNA #1 revealed that Resident #31 was on a pureed diet and would often drop food on his clothes or in his beard. She revealed that on the days that hospice didn't come, the facility CNAs were responsible for changing the residents' clothes and bathing them if needed. CNA #1 confirmed the dried white and brown substance on Resident #31's red shirt and stated, It looks like food. She revealed that she had been in and out of his room and had not noticed his dirty shirt and that she would change his clothes now.
On 09/04/24 at 3:10 PM, an interview with Licensed Practical Nurse (LPN) #3 revealed that Resident #31 was assigned to her today and she had been in and out of his room all day. She revealed that she had not noticed that he had on the same shirt as yesterday or that it was dirty. LPN #3 revealed that she should have paid more attention to him and not been in a hurry and stated, There's no excuse for this. LPN #3 revealed that resident care was supposed to be the same whether hospice staff came in or not and stated, This falls on us, we should have already changed him. She also revealed that residents' clothes should be changed every day whether they were scheduled to have a bath or not. LPN #3 revealed that this facility was their home and stated, These residents should be treated like we want to be treated and we get to change our clothes every day.
An interview on 09/04/24 at 3:25 PM, with Registered Nurse (RN) Unit Manager, revealed that she failed to check the shower book this morning to make sure that Resident #31 received his ADL care. She revealed that she fed Resident #31 earlier, had put a clothing protector on him, and had not noticed the dirty shirt he had on.
Record review of Resident #31's admission Record revealed an admit date of 01/21/2021 and that he had diagnoses that included Need for Assistance with Personal Care, Cerebral Infarction with Hemiplegia and Hemiparesis affecting his left non-dominant side.
Record review of Resident #31's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 08/26/24 under Section C revealed a Brief Interview for Mental Status (BIMS) Score of 03 which indicated that he had severe cognitive deficits.
Aug 2023
2 deficiencies
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0602
(Tag F0602)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review and facility policy review, the facility failed to ensure that one (1) of three (...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review and facility policy review, the facility failed to ensure that one (1) of three (3) residents reviewed was free from misappropriation of property, Resident #1.
Findings Include:
Record review of facility policy titled: Abuse, Neglect, and Exploitation with revised date of 10/10/2022 documented under Policy: This facility's policy is to protect each resident's health, welfare, and rights by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation, and misappropriation of resident property.
Record review of Administrator statement on facility letterhead documented on August 22, 2023, the following:
RE: Allegation of Narcotic Diversion
The allegation was made on August 17, 2023, at approximately 2:00pm, that RN (Registered Nurse proper name), RN could have possibly taken resident (proper name) 5mg (milligrams) Percocet while administering her 2pm medication .Upon conclusion of the investigation, on Monday August 21, 2023, the employee was terminated, and the MS Board of Nursing and the Attorney General's (AG) office were notified. The final investigation was sent into the MSDH on 08/22/23. This statement was signed by Administrator.
On 08/22/23 at 10:00 AM, an observation and interview with Resident #1 revealed her sitting in her wheelchair in her room with her head and neck positioned slightly forward and she was unable to raise her head upright. Resident #1 revealed that there was a situation last week that happened with her medication. Resident #1 revealed that on 08/17/23, she went up to the Nurse's desk between 1:00 PM and 2:00 PM and asked for her pain medicine and afternoon medicines. Resident #1 revealed that Licensed Practical Nurse (LPN) #1 was her nurse that day, but she (LPN) was busy at the computer, so the Registered Nurse (RN) #1 offered to help, she took the medication cart keys from LPN, and went and got her medicine. Resident #1 revealed that she looked at her medication that was handed to her by RN, and stated to her, Where's my Percocet? Resident #1 revealed that the pain pill she had given her looked like a Tylenol and said, I know what that looks like. Resident #1 revealed that RN told her that sometimes the suppliers change, and the medicine can sometimes come in different shapes and colors. Resident also revealed that she took the Tylenol; but this didn't help with the pain. Resident #1 revealed that she told LPN #1 that she didn't get her Percocet and the LPN went to the Director of Nursing (DON) and reported this, the staff came in to talk to her, and the RN got fired. Resident #1 said, I don't' think she's (RN) mean and tried to withhold it from me; I have no idea what happened to the Percocet. Resident #1 revealed that the Assistant Director of Nursing (ADON) came in and checked on her a little later, the doctor came in to see her and they brought her a Percocet. She revealed that she had a lot of pain issues and had to have her pain medication and she was familiar with what it looked like.
On 08/22/23 at 10:35 AM, an interview with LPN #1, revealed that on 08/17/23 at 1:30 PM, she was sitting at the desk updating doctors' orders when Resident #1 walked up to the desk using her rollator walker and asked for her 2:00 PM medications. LPN revealed that RN #1 was the Unit Manager that day, offered to get the medications for Resident #1 and brought Resident #1's pills to her in a medication cup. LPN #1 revealed that a couple minutes later, Resident #1 asked where her Percocet was, and she witnessed RN #1 point to the oval white pill in the cup and proceeded to tell her that Percocet comes in different shapes and sizes. LPN #1 revealed that this threw up a red flag to her because she identified the white pill as a Tylenol because it was white and oval shaped. She revealed that she reported this immediately to the DON. LPN #1 revealed that she and RN #1 then counted the entire cart, and a Percocet was missing from the Resident's drug card and had been signed out by RN #1; but was not in Resident #1's cup. LPN #1 stated, I would recognize it, because I have been giving it to her on a regular basis. She revealed that Resident #1 was concerned that her medications were wrong, and she was assured by LPN #1 that it would be taken care of. LPN #1 revealed that the Percocet was the same shape, size and color as before which was a round white pill and it had been signed out of the Narcotic book; but had not been signed off on the Medication Administration Record (MAR).
On 08/22/23 at 2:20 PM, a phone interview with the DON, revealed that last Thursday, August 17, 2023, LPN #1 had reported to her that she was afraid that RN #1 had taken Resident #1's Percocet. DON revealed that LPN #1 had reported to her that resident had walked up to the nursing station and asked for her 2:00 PM medications, and RN #1 offered to help and took the medication cart keys and gave resident her medications. DON revealed that LPN #1 had told her that she didn't see the Percocet in the medication cup, that she saw what looked like a Tylenol. The DON revealed that she, LPN #1, and RN #1 went immediately and completed a narcotic count, and she sent out a message to the ADM and ADON for an emergency meeting. DON revealed that when ADM arrived back at the facility, they looked at surveillance camera footage and saw suspicious activity on the video footage with RN#1. She stated that RN #1 shuffled her hands back and forth with the Percocet in her hand, turned the medication cup upside down in her hand and clenched her fist closed and threw the medication cup in the trash can. DON stated that when they interviewed RN #1 that she denied the allegation, and told them that she put Resident #1's Tylenol in one medication cup and put the Percocet and other scheduled medications in a second medication cup. RN #1 revealed that Resident #1 had refused the Tylenol, so she gave her the cup of pills and threw the Tylenol in the trash. DON revealed that they looked through all trash bags and could not find any medication. The DON revealed that they had RN #1 do a urine drug screen and she tested positive for Oxycodone, Benzos, and Amphetamines. RN #1 had informed DON that she had taken an oxycodone on Monday night, 08/14/23 but did not have a prescription for it. The DON revealed that they reported this to the Attorney General's Office and to the Mississippi State Board of Nursing on 08/21/23.
On 08/22/23 at 3:50 PM, a phone interview with RN #1, revealed that on 08/17/23, she was asked to give Resident #1 her 2:00 PM medications because LPN #1 was busy. She stated that Resident #1 was very serious about her medications, and she came up to the desk asking for her Percocet and her other scheduled medications and that Resident #1 normally asked for Tylenol as well. She revealed that she pulled her regular medications and put in one medication cup and put her Tylenol in a different medication cup. She revealed that Resident #1 refused the Tylenol and she put the Tylenol in the trash. She stated that she handed the resident her medications, left the med cart, and went into the break room to get her coffee and then returned to the nursing station. She then revealed that Resident#1 came up to the nursing station and questioned whether she got her Percocet, and I pointed it out to her in the cup. She stated that she was required to take a drug test and it was positive for opioids; but she had taken an oxycodone on Monday night from her family member's bottle. She also revealed that the next day on 08/18/23, she went to Urgent Care and had another drug screen and results were negative. RN stated, I did not take the Percocet.
Record review of Resident #1's Controlled Drug Record was documented that RN #1 signed out an Oxycodone/Apap tablet 5-325 mg on 08/17/23 at 1:30 PM.
Record review of Daily Staff Roster dated 08/17/23 revealed that RN #1 was B-Unit Manager, and that LPN #1 was B Unit Nurse.
Record review of Employee Timecards revealed that RN#1 was working on 08/17/23 with start time of 7:21 AM and a stop time of 4:57 PM.
Record review of Employee Timecards for LPN #1, revealed that she was working on 08/17/23 with start time of 6:32 AM and stop time of 6:49 PM.
Record review of Facility Investigation documented that the allegation was reported to the Mississippi Board of Nursing and confirmation was received on August 21, 2023, at 3:44 PM. Record review also revealed that RN #1 was terminated on 08/21/23 at approximately 4:30 PM by phone call from ADM with DON as witness to the conversation.
Record review of Resident #1's Face Sheet revealed that she was admitted to the facility on [DATE] with the following diagnoses to include: Conversion disorder with seizures or convulsions, Polyneuropathy, Age-related Osteoporosis without current pathological fracture, Other Muscle Spasm, Repeated Falls, Sciatica, left side, Chronic Pain, and Dystonia.
Record review of Resident #1's Minimum Data Set (MDS) with Assessment Reference Date (ARD) of 06/20/23 documented under Section C a Brief Interview for Mental Status (BIMS) Score of 15 which indicated that resident was cognitively intact.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Report Alleged Abuse
(Tag F0609)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review and facility policy review, the facility failed to report an allegation of misappropriation of...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review and facility policy review, the facility failed to report an allegation of misappropriation of resident property to the proper authorities for one (1) of three (3) resident reviewed for misappropriation. Resident #1.
Findings include:
Record review of facility policy titled: Abuse, Neglect, and Exploitation with revised date of 10/10/2022, revealed, Policy: This facility's policy is to protect each resident's health, welfare, and rights by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation, and misappropriation of resident property . Reporting/Response A. The facility will report all alleged violations and all substantiated incidents to the state agency and to all other agencies as required and take all necessary corrective actions depending on the results of the investigation .C. When suspicion of abuse/neglect/exploitation or reports of abuse/neglect/exploitation occur, the following procedure will be initiated .2. The Administrator or designee will: a. Notify the appropriate agencies Immediately, but not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury
Record review of Administrator statement on facility letterhead documented on August 22, 2023, the following:
RE: Allegation of Narcotic Diversion The allegation was made on August 17, 2023, at approximately 2:00pm, that RN #1 (Registered Nurse proper name), RN could have possibly taken resident (proper name) 5mg (milligrams) Percocet while administering her 2pm medication .Upon conclusion of the investigation, on Monday August 21, 2023, the employee was terminated, and the MS Board of Nursing and the Attorney General's (AG) office were notified. The final investigation was sent into the MSDH on 08/22/23. This statement was signed by Administrator.
Record review of Facility Investigation documented that the allegation was reported to the Mississippi Board of Nursing and confirmation was received on August 21, 2023, at 3:44 PM. Record review also revealed that RN #1 was terminated on 08/21/23 at approximately 4:30 PM by phone call from ADM with DON as witness to the conversation.
During an interview with Resident #1 on 08/22/23 at 10:00 AM, she stated that on 08/17/23, she went up to the Nurse's desk between 1:00 PM and 2:00 PM and asked for her pain medicine and afternoon medicines. Resident #1 revealed that Licensed Practical Nurse (LPN) #1 was her nurse that day, but she was busy at the computer, so Registered Nurse (RN) #1 offered to help and went and got her medicine. Resident confirmed that she looked at her medication that was handed to her by RN #1, and stated to her, Where's my Percocet? I know what that looks like. Resident #1 confirmed that the pill in the cup looked like a Tylenol, and it was oblong and white, and her pain pills were white and round. She stated that she told LPN #1 that she didn't get her Percocet. Resident #1 revealed that the Assistant Director of Nursing (ADON) came in and checked on her a little later, and the doctor came in to see her and they brought her a Percocet. She confirmed that she had a lot of pain issues and had to have her pain medication and she was familiar with what it looked like, and she knew that what RN #1 gave her was not her Percocet.
An interview with LPN #1 on 08/22/23 at 10:35 AM, revealed that on 08/17/23 at 1:30 PM, she was sitting at the desk updating doctors' orders when Resident #1 walked up to the desk using her rollator walker and asked for her 2:00 PM medications. LPN revealed that RN #1 was the Unit Manager that day and she offered to get the medications for Resident #1 and brought Resident #1's pills to her in a medication cup. LPN #1 revealed that a couple minutes later, Resident #1 asked where her Percocet was, and she witnessed RN #1 point to the oval white pill in the cup and proceeded to tell her that Percocet comes in different shapes and sizes. LPN #1 revealed that this threw up a red flag to her because she identified the white pill as a Tylenol because it was white and oval shaped. She revealed that she reported this immediately to the DON. LPN #1 revealed that she and RN #1 then counted the entire cart, and a Percocet was missing from the Resident's drug card and had been signed out by RN #1; but was not in Resident #1's cup. LPN #1 stated, I would recognize it, because I have been giving it to her on a regular basis. She revealed that Resident #1 was concerned that her medications were wrong, and she was assured by LPN #1 that it would be taken care of. LPN #1 revealed that the Percocet was the same shape, size, and color as before which was a round white pill and it had been signed out of the Narcotic book; but had not been signed off on the Medication Administration Record (MAR).
A phone interview with the DON on 08/22/23 at 2:20 PM, revealed that last Thursday, August 17, 2023, LPN #1 had reported to her that she was afraid that RN #1 had taken Resident #1's Percocet. DON revealed that she immediately contacted the ADM and Assistant DON for an emergency meeting. She stated that when the ADM arrived back at the facility, they looked at surveillance camera footage and saw suspicious activity on the video footage with RN#. She stated that RN #1 shuffled her hands back and forth with the Percocet in her hand, turned the medication cup upside down in her hand and clenched her fist closed and threw the medication cup in the trash can. She stated that RN#1 denied the allegation and told them that she put Resident #1's Tylenol in one medication cup and put the Percocet and other scheduled medications in a second medication cup. RN #1 revealed that Resident #1 had refused the Tylenol, so she gave her the cup of pills and threw the Tylenol in the trash. DON revealed that they looked through all trash bags and could not find any medication. The DON revealed that they had RN #1 do a urine drug screen and she tested positive for Oxycodone, Benzos, and Amphetamines. RN #1 had informed DON that she had taken an oxycodone on Monday night, 08/14/23 but did not have a prescription for it. The DON revealed that they reported this to the Attorney General's Office and to the Mississippi State Board of Nursing on 08/21/23 but they failed to report the allegation of misappropriation to the State Agency office.
On 08/22/23 at 3:10 PM, an interview with the ADM, revealed that with this situation she felt like they didn't have enough evidence gathered to report it and was planning on reporting this once the investigation was completed. Administrator confirmed that she failed to report the allegation to the State Agency according to the federal requirements.
Record review of Resident #1's Controlled Drug Record was documented that RN #1 signed out an Oxycodone/Apap tablet 5-325mg on 08/17/23 at 1:30 PM.
Record review of Daily Staff Roster dated 08/17/23 revealed that RN #1 was B-Unit Manager, and that LPN #1 was B Unit Nurse.
Record review of Resident #1's Face Sheet revealed that she was admitted to the facility on [DATE] with the following diagnoses to include: Conversion disorder with seizures or convulsions, Polyneuropathy, Age-related Osteoporosis without current pathological fracture, Other Muscle Spasm, Sciatica, left side, Chronic Pain, and Dystonia.
Record review of Resident #1's Minimum Data Set (MDS) with Assessment Reference Date (ARD) of 06/20/23 documented under Section C a Brief Interview for Mental Status (BIMS) Score of 15 which indicated that resident was cognitively intact.
May 2023
9 deficiencies
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 interviews, record review and facility policy review, the facility failed to communicate a medical change in condition of a resident with edema in the hand and...
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Based on observation, resident and staff interviews, record review and facility policy review, the facility failed to communicate a medical change in condition of a resident with edema in the hand and wrist for one (1) of 23 residents reviewed. Resident #16
Findings include:
Review of the facility policy titled, PHYSICIAN VISITS AND MEDICAL ORDERS, with a revised date of 11/28/2017, revealed . POLICY: the attending physician shall prescribe the medical regimen of care for the residents he/she admits. The attending physician must directly supervise the activities leading to the treatment of the resident.
Review of the facility policy titled, NOTIFICATION OF CHANGE IN RESIDENT'S CONDITION, with a revised date of 11/28/2017, revealed POLICY: Physicians . shall be notified, as soon as possible, of any changes in the resident's condition.
An observation and interview on 05/10/23 at 12:24 PM, with Resident #16, revealed her left hand was swollen from approximately 2 inches above the wrist to the end of her fingers. She provided information about the nurse being aware of the swelling in her left hand. She noted her hand had been swollen for a few weeks, that she did not know why, and she did tell the nurse so she could get some help with getting it to go down. Resident stated that she has had a stroke on the left side of her body, but her hand hasn't swollen like this before and that she doesn ' t recall injuring it recently.
An interview on 5/10/23 at 4:17 PM, with Licensed Practical Nurse (LPN)#6, revealed he was aware of the swelling in Resident #16's left wrist and hand and that the swelling had been there for a few weeks. LPN #6 stated that the resident liked to sleep on her left side, but he wasn ' t sure what had caused the swelling because she had not had any recent injury or falls that he was aware. He revealed he had not documented the information in the medical record regarding finding the swelling, that he had not called the physician to inform him of the physical changes with Resident #16 or to request orders for follow up care needs. He revealed he was not sure what could have caused the swelling but had informed the Charge Nurse lately about it, but she was not at work today.
An observation and interview on 5/10/23 at 4:30 PM, of Resident #16's left wrist and hand, with Registered Nurse (RN) Charge Nurse #3, revealed she was not aware Resident #16 had swelling to her left wrist and hand. She noted she rounded daily on all the residents, had rounded on Resident #16 today, but did not see her swollen left wrist and hand because she did not complete a total body audit. She revealed none of the nurses that had been assigned to Resident #16 for the past few weeks had informed her that Resident #16 had a swollen left wrist and hand. She confirmed through observation that Resident #16 did have swelling noted approximately 2 inches above her left wrist and that the edema extended to the end of Resident #16's fingers on the left hand.
An interview on 5/10/23 at 5:05 PM, with the Director of Nursing (DON) revealed she was not aware that Resident #16 had edema approximately 2 inches above her left wrist, that extended down her hand to the ends of her fingers. She confirmed the LPN should have told each Charge Nurse about the findings of edema in Resident #16's left wrist and hand, that he should have documented the findings and that the physician should have been notified immediately to allow Resident #16 to be assessed for the possible need of follow up and/or possible new orders for care. The DON also confirmed Resident #16 did not receive treatment and care according to professional standards of practice.
Record review completed of the Departmental Notes for April 2023, and May 9, 2023, for nurses' progress notes for Resident #16, revealed no documentation regarding the edema in Resident #16's left wrist and hand, and revealed no documentation regarding the Charge Nurses, the DON, or the physician being notified of the edema in Resident #16's left wrist and hand observed by LPN #6.
Record review of the Face Sheet for Resident #16 revealed an admission date of 11/01/21, with a diagnosis of Unspecified Sequelae of Unspecified Cerebrovascular Disease.
Record review of Section C of the Significant Change Minimum Data Set (MDS) Assessment, with an Assessment Reference Date (ARD) of 03/10/2023, for Resident #16, revealed a Brief Interview for Mental Status (BIMS) score of 12, indicating the resident is cognitively intact.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Safe Environment
(Tag F0584)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, resident and staff interviews and facility policy review the facility failed to maintain and provide a cl...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, resident and staff interviews and facility policy review the facility failed to maintain and provide a clean and homelike environment for two (2) of 23 residents reviewed. Resident #13 and #38
Findings include:
Review of the facility policy titled, Resident Environment with a revision date of 11/28/2017, revealed this facility shall create and maintain a supportive environment for all residents, which preserves dignity and facilitates a positive self-image.
The facility provided documentation on letterhead dated 5/11/23 that read, This facility does not have a policy regarding the cleaning of wheelchairs.
Resident #13
An observation on 05/10/23 at 8:05 AM, revealed Resident #13 sitting in a wheelchair in the hallway. The resident's wheelchair was noted with a thick layer of dried brown substance adhering to the lower bars and frame of the wheelchair.
An interview on 05/11/23 at 8:30 AM, with Certified Nurse Aide (CNA) #3 revealed that the night shift was responsible for cleaning the residents' wheelchairs.
An interview and observation on 5/11/23 at 8:34 AM, with Registered Nurse (RN) #1, confirmed that Resident #13's wheelchair had a thick layer of dried brown substance adhering to the lower bars and the lower frame. She stated, Yes, I see what you're saying. She revealed that the night shift CNA's were responsible for cleaning the resident's wheelchairs, but they did not have a set cleaning schedule.
An interview and observation on 5/11/23 at 8:56 AM, with the Director of Nursing (DON) acknowledged that Resident #13's wheelchair had a dried brown substance adhering to the lower bars and frame. She agreed that the residents' equipment should be cleaned and stated that the night shift CNA's was responsible for the cleaning of the wheelchairs and they have a schedule to determine which wheelchairs need cleaning on which nights. However, she could not provide any documentation of a wheelchair cleaning schedule.
Record review of the Face Sheet revealed Resident #13 was admitted to the facility on [DATE] with medical diagnoses that included Unspecified Intellectual Disabilities, Down Syndrome, unspecified and Anxiety disorder.
Record review of the Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 4/14/23 revealed under Section C a Brief Interview for Mental Status (BIMS) score of 99, indicating Resident # 13 was unable to complete the BIMS.
Resident #38
An observation, on 05/09/23 at 11:33 AM, revealed Resident #38 in bed. The resident's overbed tray table had 3/4 of the brown coating scraped off the top and had the wood exposed. The upper siderails of the bed were dirty and the left side handrail was cracked approximately six to seven (6-7) inches and was rough to the touch. The side rail on the bed had a brownish substance that had run down the side rail and dried. The window blinds were broken and bent. Resident #38 was in a private room, there were no pictures, wall decorations or any other personal items observed in the room. The room was bare except for essential items, bed, overbed table and bedside table and a small television. There was an area on the wall by the bed that had an irregular one by three (1x3) foot area with the paint scuffed off the wall.
An interview on 5/10/23 at 2:30 PM, with Resident #38 revealed he would like to have some pictures on the wall and would like his bed moved in the room where he could see out the window. The resident denies any injury but stated the side rails need fixing because he could skin his arms.
An observation and interview on 5/11/23 at 2:40 PM, with the Marketing Director, who stated he is an Assistant Social Worker and the Social Service Director confirmed the resident's room was bare and the overbed tray table had most of the surface peeled off.
An observation and interview on 5/11/23 at 2:50 PM, with the Director of Nursing (DON) revealed the window blinds were bent and broken and she stated that they need to be replaced. She stated that Resident #38's overbed table needed to be replaced, his wall needed to be repaired and his side rail needed to be cleaned and the torn area needs to be repaired or replaced. She confirmed that the side rail needed to be repaired because it could cause a skin tear.
An interview with the Marketing Director revealed he should have noticed the overbed table and the side rails. He stated that he is assigned to Resident #38's room daily to make rounds and notify if repairs need to be made and stated that he needs to do better observing for these things.
Review of the facility Face Sheet for Resident #38 revealed an admission date of 1/21/21 with diagnoses that included Hemiplegia following Cerebral Infarction affecting left nondominant side and Anxiety.
Review of the MDS with an ARD of 3/24/23 revealed Resident #38 had a BIMS score of 03 which indicated severe cognitive impairment.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0637
(Tag F0637)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interviews, and facility policy review the facility failed to complete a Significant Change Minimu...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interviews, and facility policy review the facility failed to complete a Significant Change Minimum Data Set (MDS) Assessment within 14 days for a resident with a physical and mental decline for one (1) of 23 sampled residents. Resident #16
Resident #16
Review of the facility policy titled, COMPREHENSIVE ASSESSMENT AND RE-ASSESSMENT, with a revised date of 11/27/2017, revealed . POLICY: The assessment of the care or treatment required to meet the needs of the resident shall be ongoing throughout the resident's facility stay, with the assessment process individualized to meet the needs of the resident population. The facility shall comply with Resident Assessment Instrument (R.A.I.) guidelines for comprehensive assessments and re-assessments to determine significant status changes in cognitive and/or physical condition. A comprehensive reassessment shall be completed . within 14 days after it is determined that there has been a significant change in the resident's physical or mental condition.
Record review of the Significant Change Minimum Data Set (MDS) Assessment, with an Assessment Reference Date (ARD) of 3/10/23 revealed the assessment was completed related to a significant physical change that was identified in January 2023.
An interview on 5/11/23 at 12:00 PM, with Restorative Care Aid #5, revealed she did have Resident #16 admitted for Restorative Therapy in January 2023, because of a physical decline, falls, and increased confusion. She noted Resident #16 was not getting any better with the Restorative Therapy and was then placed on Physical Therapy (PT) in February 2023.
An interview on 5/11/23 at 3:30 PM, with the MDS Nurse confirmed she completed the MDS Significant Change Assessment with an ARD of 3/10/23 based on the physical decline that began in January 2023. She noted Resident #16 had restorative therapy in January 2023 and did not progress. Resident #16 was then admitted to therapy services in February 2023. The Therapy Director informed her in March 2023 of Resident #16's significant physical decline, after Resident #16 was discharged from therapy and that she had met her goals and improved. She revealed she felt the significant change assessment needed to be done since Resident #16 had a decline in January 2023 and required therapy to improve. She confirmed the MDS Significant Change Assessment, with an ARD of 3/10/23, for Resident #16, was not completed in 14 days of Resident #16's noted significant physical change/decline.
A record review and interview on 5/11/23 at 3:55 PM, with the Director of Nursing (DON) revealed Resident #16 was noted to have had a significant decline in her physical and mental independence, and that she started to require 2-3 people assist at times for Activities of Daily Living (ADLs), and that Resident #16 had been previously totally independent. She also noted Resident #16 had increased confusion during the time when she suffered her physical decline. She confirmed that there was no nursing documentation in the computer for the progression of the physical and mental decline and the periods of confusion expressed for Resident #16. The DON confirmed there was documentation of a fall in October 2022 and January 2023. The DON confirmed that the MDS Significant Change Assessment with an ARD of 3/10/23 was not submitted within 14 days of her significant physical and mental decline.
An interview on 5/12/23 at 11:30 AM, with the Rehabilitation (Rehab) Director revealed he informed the MDS Nurse that Resident #16 had a significant change of improvement, not a significant decline for the Significant Change MDS Assessment that was done on 3/10/23.
An interview on 5/12/23 at 3:15 PM, with the Administrator confirmed that the MDS Nurse did not complete a timely Significant Change MDS Assessment for Resident #16 and that it should have been completed within 14 days after her significant physical and mental decline began.
Record review of the Departmental Notes for Resident #16, revealed . 2/2/2023 1:40 PM IDT MET TO REVIEW RECENT FALLS RESIDENT HAD A FALL ON 1/31/23 AT 12:55 AM. The record review did not reveal that the fall was related to a physical or mental decline.
Record review completed of the nurses' progress notes for January 2023 and for February 2023 to March 9, 2023, for Resident #16, revealed there was no documentation regarding a physical or mental decline for Resident #16.
Record review of the Physical Therapy Plan of Care for Resident #16 revealed . MEDICAL DIAGNOSIS . Unspecified dementia, unspecified severity, with other behavioral disturbances . TREATMENT DIAGNOSIS . Unsteadiness on feet . Other abnormalities of gait and mobility . Other lack of coordination . START OF CARE 02/02/2023; END OF CARE 03/15/2023 . Reason For Referral: (Resident #16's name removed) is a 86 y/o female and long term resident who was recently referred to PT d/t pt fall on 1/31/2023 . Pt's prior level of function was: independent for functional mobility . Pt presents to physical therapy with decreased endurance (fair), decreased transfer ability (min-mod (a)) d/t weakness and decreased coordination in (B) LE, impaired gait d/t (b) LE weakness and deconditioning, and impaired balance (f-) secondary to decreased safety awareness and weakness, activity limitations, and participation restrictions of inability to bathe IND (independant), completed light room chores, completed ADLs, ambulate functional distances with in room, and completed WC (wheelchair) mobility for community.
Record review revealed that Resident #16 was admitted to the facility on [DATE] with a diagnosis which included Cerebrovascular Disease and Lack of Coordination. The resident had a most recent MDS with an ARD of 3/10/23 that revealed a BIMS score of 12 revealing that the resident was moderately impaired with cognition.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Comprehensive Care Plan
(Tag F0656)
Could have caused harm · This affected 1 resident
Based on record review, staff interviews, and facility policy review the facility failed to develop and implement a care plan for a resident providing self-care with a colostomy for one (1) of 23 resi...
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Based on record review, staff interviews, and facility policy review the facility failed to develop and implement a care plan for a resident providing self-care with a colostomy for one (1) of 23 residents care plans reviewed.
Resident #15
Findings include:
Review of the facility policy titled, COMPREHENSIVE PLAN OF CARE, with a revised date of 10/10/2022, revealed, Policy: 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 timeframe's to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment.
Record review of the care plans for Resident #15 revealed she did not have a care plan developed for self-care of her colostomy.
An interview on 05/09/23 at 10:44 AM, with Resident #15 revealed she cleaned and changed her own colostomy wafer and colostomy bag as needed. The State Agency (SA) observed two (2) new ostomy bags were on Resident #15's bedside table and noted that the staff brought ostomy supplies to her room for the resident to use as she needed.
An interview on 5/10/23 at 4:40 PM, with Registered Nurse (RN)#2, confirmed Resident #15 completed her own colostomy care that included changing the barriers and changing the colostomy bags.
An interview on 5/10/23 at 4:45 PM, with RN Charge Nurse #3 confirmed Resident #15 provided her own colostomy care with no care plan and that she was aware that Resident #15 had been doing her own colostomy care.
An interview on 5/10/23 at 4:50 PM, with the Care Plan Nurse confirmed there was not a care plan developed for Resident #15 to do self-care with her colostomy. She revealed she was aware that Resident #15 was caring for her own colostomy and thought there was a care plan for the self-care of the colostomy in the electronic health record (EHR) for Resident #15. She confirmed that a care plan should have been developed for Resident #15 regarding self-care of her colostomy.
An interview on 5/10/23 at 5:05 PM with the Director of Nursing (DON) confirmed Resident #15 was providing self-care of her colostomy. She confirmed that Resident #15 did not have a care plan developed for her to perform self-care of her colostomy. The DON also confirmed that a care plan should have been developed for Resident #15 regarding self-care of her colostomy.
Record review of the Face Sheet for Resident #15 revealed an admission date of 7/21/20, with diagnoses of Other Symptoms and Signs Involving the Digestive System and Abdomen and Encounter for Attention to Colostomy.
Record review of the Minimum Data Set (MDS) Assessment, with an Assessment Reference Date (ARD) of 03/08/2023, for Resident #15, revealed a Brief Interview for Mental Status (BIMS) score of 13, indicating Resident #15 is cognitively intact.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0660
(Tag F0660)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interviews, record review, and facility policy review, the facility failed to complete the discharge planning pro...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interviews, record review, and facility policy review, the facility failed to complete the discharge planning process for a resident that requested to transfer to another nursing facility for one (1) of four (4) residents reviewed. Resident #1
Findings include:
Review of the facility policy titled, TRANSFER AND DISCHARGE, revised 10/18/2022, revealed c. Orientation for transfer or discharge must be provided and documented to ensure safe and orderly transfer or discharge from the facility . this orientation may be provided by various members of the interdisciplinary team . e. The comprehensive, person-centered care plan shall contain the resident's goals for admission and desired outcomes and shall be in alignment with the discharge . g. Supporting documentation shall include evidence of the resident's or resident representative's verbal or written notice of intent to leave the facility, a discharge plan, and documented discussions with the resident and/or resident representative.
An interview on 5/11/23 at 9:30 AM, with Social Services revealed that Resident #1 had asked to be transferred to another nursing facility closer to his home in August 2022 but the Social Services department did not document it until March 7, 2023 She confirmed she did not document her conversation with Resident #1 regarding his discharge planning request to go to another nursing facility closer to home. She stated she did not have a discharge care plan meeting, nor had she updated his discharge care plan regarding Resident #1's request to go to another nursing facility. She also confirmed that she had not developed a discharge plan with the interdisciplinary team to work on discharge to another nursing facility and had not documented that referrals were sent out to other nursing facilities. She confirmed she had not documented the response from any of the nursing facilities regarding the referrals sent out for Resident #1. She noted she did not know she had to document responses from referrals and was not aware she had to document everything that was done for a resident's discharge planning process in the medical record. She confirmed that none of the facilities had accepted Resident #1 until March 2023 and that she waited until he was accepted by another nursing facility to fill out a Discharge Assessment Guide and plan the discharge on [DATE].
An interview on 5/11/23 at 10:00 AM, with the Director of Nursing (DON) revealed she was not involved in a care plan meeting regarding the discharge plan of Resident #1 and was not aware of any documentation regarding the discharge plan from Social Services. The DON noted there was no nursing documentation related to discharge planning.
An interview on 5/11/23 at 10:30 AM, with the Administrator confirmed Social Services had not documented regarding the discharge planning process for Resident #1 and there had not been an interdisciplinary approach for the discharge plan for Resident #1. The Administrator confirmed that there was no discharge care plan updated for Resident #1 and Social Services did not follow the discharge planning process for Resident #1.
Record review of the Departmental Notes, for Resident #1, revealed there was no documentation regarding an interdisciplinary team meeting for discharge planning for Resident #1.
Record review of the Discharge Assessment Guide and Plan, dated 3/1/23, for Resident #1 revealed . Special Instructions: DC (Discharge) to (Proper name of a facility). Community Agencies to Be Contacted: (Proper Name of facility) to follow up referral. Documentation revealed that the Discharge Assessment Guide and Plan was not fully completed.
Record review of the Physician's Orders dated 3/8/23 revealed an order Discharge to (Formal name of nursing facility) on 3/9/2023 .
Record review of the Face Sheet for Resident #1 revealed an admission date of 3/22/22, with a diagnoses that included Nicotine Dependence, Cigarettes, Uncomplicated.
Record review of Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 03/06/2023, revealed a Brief Interview for Mental Status (BIMS) score of 13, indicating Resident #1 is cognitively intact.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
ADL Care
(Tag F0677)
Could have caused harm · This affected 1 resident
Based on observation, staff interview and facility policy review the facility failed to provide adequate mouth care to a resident who is dependent on staff for care for one (1) of 108 residents observ...
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Based on observation, staff interview and facility policy review the facility failed to provide adequate mouth care to a resident who is dependent on staff for care for one (1) of 108 residents observed for personal care and hygiene. Resident #47
Findings include:
Review of the facility policy titled, Increasing Resident Independence, Provision of Care, Treatment, and Service: Resident and Family Education, with a revision date of 11/28/2017, revealed facilities shall promote an atmosphere of respect for human dignity in the provision of healthcare and services provided by the facility. Healthcare providers shall encourage resident independence to engender increased resident self-esteem and confidence. The procedures include ADL (Activities of Daily Living) shall be performed by healthcare providers for those residents who are unable to perform the activities themselves, or who do not have support from family.
An observation on 05/09/23 at 5:06 PM, revealed Resident #47 had tube feeding formula infusing. The mucous membranes of Resident #47's mouth and lips were dry with a white line around the top and bottom lips.
On 05/10/23 at 2:59 PM, an observation revealed Resident #47's lips were dry and cracked.
An observation on 5/11/23 at 8:55 AM, revealed Resident # 47 in bed with dry white flakes on her lips.
An observation on 05/11/23 at 9:30 AM, revealed the resident continued to have dry cracked lips with white flakes on her lips.
An observation and interview on 5/11/23 at 9:40 AM, with Certified Nursing Assistant (CNA) #1 revealed that she does mouth care on Resident #47 every time she makes rounds. She stated she uses lemon glycerin swabs, but the resident's lips are dry and has scabbing and rubbing them with the swabs or a bath cloth will make them bleed. CNA #1 confirmed the resident's lips should not look like they do with hard dry skin on them.
An observation and interview on 5/11/23 at 9:42 AM with the Assistant Director of Nursing (ADON) stated the Resident #47's lips did not look good and confirmed that they were dry and cracked. She stated that they need to find something else to put on her lips to keep them moistened.
Review of the facility Face Sheet for Resident #47 revealed an admission date of 5/4/2017 and a readmission date of 11/16/21 with diagnoses that included Downs Syndrome, personal history of Venous Thrombosis and Emboli, and Dysphagia.
Review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 2/26/23 revealed no Brief Interview for Mental Status (BIMS) score due to Resident #47 being severely impaired-never/rarely made decisions.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Accident Prevention
(Tag F0689)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, resident and staff interviews, facility policy review the facility failed to ensure the environment is fre...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, resident and staff interviews, facility policy review the facility failed to ensure the environment is free of potential accident hazards as evidenced by unattended medications left on bedside table for two (2) of 108 residents reviewed. Resident # 356 and
#362
Findings include:
Record review of the facility policy titled, Medication Administration with a revision date of 06/27/19 revealed Policy . No medication shall be left at the resident's bedside unless the following is available: Physician order; Self-administration of medication assessment; Care plan .The nurse administering the medication shall stay with the resident until the medication is taken .
An observation and interview with Resident #356 on 05/09/23 at 11:10 AM, revealed a light green oval capsule inside a clear medicine cup on the bedside table. The State Agency (SA) inquired whether the resident could self-administer her medications and Resident #356 stated, They bring in my medicine, sit it down on the table, and I take it. The resident confirmed that the capsule on the bedside table was her medication.
An observation on 05/09/23 at 3:45 PM, of Resident #356's bedside table revealed a light green capsule inside a clear medicine cup.
Record review of the Face Sheet revealed Resident #356 was admitted to the facility on [DATE] and re-admitted on [DATE] with medical diagnoses that included Displaced Intertrochanteric Fracture Left Femur, subsequent encounter for closed fracture with routine healing, and Aftercare Following Explanation of Hip Joint Prosthesis and Anemia, unspecified.
Record review of the 5-day Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 4/18/23, revealed under section C a Brief Interview for Mental Status (BIMS) score of 14, which indicated Resident # 356 is cognitively intact.
Resident #362
An observation on 5/9/23 at 11:40 AM, of Resident #362's bedside table revealed a bottle of nasal spray, a bottle of eye drops, an inhaler, and a bottle of roll-on Lidocaine.
Observation and interview on 05/09/23 4:35 PM, with Resident #362 revealed Flonase nasal spray, artificial tears eye drops, lidocaine roll on and an albuterol inhaler on bedside table. Resident #362 verified that the medications were hers and stated that a nurse brought the medications to her and told her the medications were left over from a previous stay at the facility. Resident stated that the lidocaine roll on belongs to her husband and he uses it during the day while he visits. She revealed she knows how to administer the albuterol inhaler and artificial tears and uses them as needed and stated she uses the Flonase nasal spray once daily.
Record review of the Face Sheet revealed Resident #362 was admitted to the facility on [DATE] with medical diagnoses that included Other Specified Disorders of Muscle, History of Falling, and Epilepsy, unspecified not intractable, without status epilepticus.
Record Review of the Minimum Data Set (MDS) admission 5-day assessment with an Assessment Reference Date (ARD) of 4/21/23 revealed under section C a Brief Interview for Mental Status (BIMS) score of 14, which indicates Resident #362 is cognitively intact.
An interview on 05/10/23 at 5:05 PM, with Licensed Practical Nurse (LPN) # 1 revealed that when she administered medication to a resident, she always stayed in the room to ensure that the resident swallowed the medication and did not choke or spit it out. She revealed that by leaving the medicine in the room, a confused person could wander into the room and take it. She confirmed that neither Resident # 356 or Resident #362 has a physician's order or a care plan to self-administer medication.
An interview on 05/10/23 at 5:15 PM, with Registered Nurse (RN) #1 acknowledged that the staff should never leave medicine in a resident room unattended. She stated that it is not safe to leave medications unattended at a resident's bedside. She revealed that neither Resident # 356 or Resident # 362 has a physician's order or a care plan to self-administer her medications.
An interview on 05/10/23 at 5:25 PM, with Certified Nurse Aide (CNA) #2 revealed that if she noticed medicine in a resident's room unattended, she immediately notified the nurse. She revealed that a confused resident could accidentally take the medicine without understanding the danger.
An interview on 05/12/23 at 9:01 AM, with the Director of Nursing (DON) acknowledged that medicine should not be left in a resident's room. She stated that the nurse should stay with the resident to ensure that the resident took the medication. She revealed by leaving the medicine in the room, the resident could miss a dose, or someone else could wander into the room and take the medicine.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Medication Errors
(Tag F0758)
Could have caused harm · This affected 1 resident
Based on staff interview, consultant pharmacy interview, record review and facility policy review the facility failed to provide a 14- day stop date on psychotropic medications for one (1) of 23 sampl...
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Based on staff interview, consultant pharmacy interview, record review and facility policy review the facility failed to provide a 14- day stop date on psychotropic medications for one (1) of 23 sampled residents. Resident #68
Findings include:
Review of the facility policy titled, Psychotropic Medication Use, revealed it is the facility's policy that each resident's drug regimen is managed and monitored to promote or maintain the resident's highest practicable mental, physical, and psychosocial well-being, free from unnecessary drugs. As needed (PRN) orders for psychotropic drugs will be limited to 14 days unless prescribing physician believes that the drug should be prescribed beyond the 14-day period. The rationale for extending the use and the indicated duration shall be documented in the resident's medical record.
Resident #68:
Record review of the physician orders for Resident #68 revealed an order dated 1/12/23 for Ativan 2 milligrams (mg)/milliliter (ml) vial, give 0.5 ml sublingual (SL) every (Q) 4 hours (H) prn (anxiety/agitation). The order does not have a stop date.
An observation and interview on 5/11/23 at 9:30 AM with Licensed Practical Nurse (LPN) #6 confirmed Resident #68 had an order for as needed Ativan and that it should have a stop date of 14 days. He stated that he had not noticed it because he had not given the medication.
An observation and interview on 5/11/23 at 9:42 AM with Assistant Director of Nursing (ADON) confirmed Resident #68 had an order for as needed Ativan sublingual. She stated that the order should have a stop order date.
A telephone interview, on 5/11/23 at 9:50 AM with the Consultant Pharmacist, revealed the Ativan as needed order should have a stop date. He stated that he reviewed the order and sent a recommendation to the physician. He stated they (the physicians) have been instructed on the need for written justification for not giving a stop date.
An interview on 05/11/23 at 10:00 AM with the Director of Nursing (DON) confirmed that orders for as needed Ativan should have a stop date and confirmed that the physician's order for Resident #68 did not have a stop date for the medication order.
Record review of the consultant pharmacist recommendation to physician revealed due to Centers for Medicare and Medicaid (CMS) requirements for (PRN) as needed psychotropic medications, consider adding a 14-day duration or consider changing to a scheduled frequency if receiving routinely. Under Physician/Prescriber Response, which included agree, disagree, and other, other was checked with a statement that revealed Patient is on hospice and close monitoring.
Review of the facility Face Sheet for Resident #68 revealed an admission date of 4/16/22 with diagnoses that included Perineural cyst and Metabolic Encephalopathy.
Review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 3/26/23 revealed a Brief Interview for Mental Status (BIMS) score of 11 which indicated Resident #68 had moderately impaired cognition.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Food Safety
(Tag F0812)
Could have caused harm · This affected most or all residents
Based on observation, staff interviews and facility policy review the facility failed to ensure items in the kitchen refrigerator and freezer were dated and labeled for one (1) of three (3) dietary ob...
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Based on observation, staff interviews and facility policy review the facility failed to ensure items in the kitchen refrigerator and freezer were dated and labeled for one (1) of three (3) dietary observations.
Findings include:
A review of the facility policy titled, Food Storage with an initial date of 2021 and a revision date of 3/22 revealed All foods should be covered, labeled, and dated, and routinely monitored to assure that foods (including leftovers) will be consumed by their safe use by dates, or frozen (where applicable), or discarded.
On 05/09/23 at 10:15 AM, observation and interview of the kitchen with the Dietary Manager (DM) and Dietary Staff #1 revealed in the standing freezer noted a manufactured bag of a food product that was unlabeled and undated. Dietary Staff #1 revealed that's Panko Chicken tenders and stated she wasn't sure of when it was opened. She confirmed that the food was not labeled and dated, and it should be. In the main standing Walk-in Cooler revealed a pie with approximately 3/4 remaining. Dietary Staff #1 revealed this an a apple pie and needed to be thrown away because it did not have a date. There was a large rectangular aluminum pan with a brown substance on the lid with no label or date. Dietary Staff #1 revealed there are hotdog's in here and I think the brown substance may have been from where it was in the oven, and something leaked on the top of it. There was a large rectangular aluminum pan with a lid was observed with no label, it had a date of 5/2 and a line drawn underneath with the date of 5/5. Dietary Staff #1 identified the food as green bean casserole and revealed that 5/2 was the date it was put in the refrigerator and 5/5 was the date it was supposed to be discarded by. There was a large rectangular aluminum pan with a lid observed with no label or date. Dietary Staff #1 identified the item as being chicken and dumplings and confirmed there were no dates and labels but there should be. Observed one (1) quart-size bag with lettuce, (1) quart-size bag with onions, and (1) quart-size bag of sliced tomatoes were unlabeled and undated. The DM identified the food items in each bag and revealed they should have been labeled and dated and that it is their policy to keep foods labeled and dated. The DM disposed of all unlabeled and undated food items from the standing freezer and walk-in cooler.
An interview on 05/09/2023 at 11:05 AM, the DM revealed the dietary staff that puts the food in the refrigerator or freezer is responsible for labeling and dating the food item and then management is responsible to check the refrigerators/freezers the first thing each morning to make sure things are labeled and dated and there are no expired foods. The DM confirmed that food items were not being labeled and dated and revealed these foods could make a resident sick.
Jan 2023
1 deficiency
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Free from Abuse/Neglect
(Tag F0600)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review and facility policy review the facility failed to ensure that one (1) of five (5)...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review and facility policy review the facility failed to ensure that one (1) of five (5) residents were protected from physical abuse. Resident #2. Based on the facility's implementation of corrective actions taken on 11/08/22, this was determined to be Past Non-Compliance.
Findings Include:
Review of the facility's policy titled, Abuse, Neglect, And Exploitation, revised date 10/10/2022, revealed, This facility's policy is to protect each resident's health, welfare, and rights by developing and implementing written policies and procedures that prohibit abuse, neglect, exploitation, and misappropriation of resident property.
Record review revealed an investigation of alleged physical abuse conducted by the facility on 11/08/22 involving Certified Nursing Assistant (CNA) #1 and Resident #2. At approximately 9:30 AM on 11/08/22, CNA #1 and CNA #2 were in Resident #2's room changing her brief when Licensed Practical Nurse (LPN) #1, who was just inside the door to Room #B95, overheard what sounded like two pops. Immediately after hearing that, Resident #2 stated, Ouch, don't hit me and CNA #1 stated, I didn't hit you, you hit me first. CNA #2 witnessed CNA #1 slap Resident #2 two times on her hand. LPN #1 checked on Resident #2, made sure that she was okay and then reported the incident to LPN #2. The incident was then reported immediately to the Administrator (ADM), the Director of Nursing (DON), Assistant Director of Nursing (ADON), and B-Unit Manager. CNA #1 was immediately pulled off the floor and interviewed. The B-Unit Manager completed a full body audit on Resident #2 and multiple x-rays were completed with no injuries found. The facility immediately began an investigation, reported the incident to the Local Police Department, the State Department of Health, and to the Attorney General's Office. CNA #1 was terminated. The Police Department arrived about five minutes after the alleged abuse was reported. CNA #1 admitted that she slapped Resident #2's hand while changing her. CNA #2 was interviewed and stated, We were changing her, and we had her legs up and she slapped at (Resident's proper name). Resident slapped her hand and said, don't be hitting me. Resident #2 was interviewed, and she confirmed that CNA #1 had slapped her hand. CNA #1 was immediately terminated, and charges were filed against her for abuse and neglect of a vulnerable adult. Resident #2's son was notified. An immediate in-service was started with all staff on abuse and neglect and reporting of abuse and neglect. Resident's Care Plan was updated. An emergency Quality Assurance (QA) Meeting was held, and interviews were started immediately with residents and staff.
On 01/09/23 at 12:45 PM, an observation/interview with Resident #2 revealed that she could talk very little due to the recent use of an oxygen face mask on at 10 liters/minute continuously.
On 01/09/23 at 5:00 PM, an interview with the DON, revealed that Resident #2 has had a recent decline in her health and was now on hospice. She also revealed that Resident #2 was able to talk and answer questions some days and not able to on other days. The Administrator revealed that on 11/08/22, two CNAs were in Resident #2's room to change her brief and had the privacy curtain pulled. ADM revealed that LPN #1 was just inside the resident's room and heard the commotion. LPN #1 had reported that she had overheard the resident state, Don't hit me again. This LPN also overheard CNA #1 reply with, Well, you hit me first. CNA #2 was assisting with the care of the resident. The ADM revealed that LPN #1 reported this to LPN #2 and the incident was immediately reported to administrator, the police were called, the AG office was contacted and so was SA office. The Administrator revealed that the local police arrived about five minutes after they were called and interviewed CNA #1. CNA #1 confessed to them that she had slapped the resident's hand and CNA #1 was given a court date. CNA #1 was terminated at this time. The DON stated that they called the Resident's son and reported all of this to him. She also stated, The resident could get a little feisty at times, but this did not justify her (CNA #1) actions.
On 01/09/23 at 5:30 PM, an interview with DON, revealed that she accompanied the local police department into the resident's room and that initially, resident denied any abuse. As the interview continued, Resident #2 stated that the aid with glasses and dark, wavy hair slapped her hand. Resident could not remember her name but stated that this aid was here all the time.
On 01/10/22 at 9:40 AM, a phone interview with CNA #2 revealed that on 11/08/22, she and CNA #1 were in Resident #2's room changing her brief. While CNA #1 was changing her brief, the resident slapped CNA #1 because she was being a little rough and was rushing to get through. CNA #2 witnessed CNA #1, pop Resident #2 on her hand twice and heard the resident say, Ouch, that hurt, don't hit me again! CNA #2 revealed that Resident #2 had no marks or red places on her hand where she was slapped. CNA #2 revealed that the resident was back to herself acting like nothing ever happened. CNA #2 revealed that this was reported immediately, investigated and that in-services on abuse, neglect was completed with all staff.
On 01/09/23 at 10:00 AM, the State Agency (SA) attempted to call CNA #1 with no answer and SA was unable to leave a voicemail. CNA #1 did not return any calls.
On 01/10/23 at 11:55 AM, a phone interview with LPN #1 revealed that she was standing just inside Resident #2's room when she heard some loud talking. She heard CNA #1 say, Quit, be still, quit yelling, we gotta change you! She then heard the resident say, You're being too rough, you're hurting me. She also revealed that she heard what sounded like two slaps but did not see it. This LPN also revealed that Resident #2 was in her right mind at this time and that if someone would rush her or get rough with her, she would sometimes be loud. LPN #1 revealed that she stayed in the room until the CNAs had finished changing the resident and then she immediately reported this. She also revealed that CNA #1 was immediately pulled off the floor and was terminated later that same day.
On 01/10/23 at 1:30 PM, an interview with the Staff Educator revealed that she had been here for 22 years and that oversaw staff education. She revealed that the staff members receive training on Abuse/Neglect/Reporting Abuse upon hire, quarterly and anytime an incident in the facility occurred. She also revealed that upon hire and yearly, staff were required to watch videos on how to deal with residents in different scenarios and stated that it is one on one in-services and each staff member was required to sign that he/she attended.
Record review of Investigation/Statement Form dated 11/08/22 revealed the following statement written by accused CNA #1: I know I don't post to hit a resident, but it was a reflex went she hit me and I am very sorry. I know I will get trouble for that. This statement was signed by CNA #1.
Record review of the acknowledgement of the Abuse Policy signed by CNA #1 on 3/2/20, revealed the following: It is the policy of this nursing facility to prohibit abuse of any kind and all residents. Any employee who is guilty of any type of abuse: mental, verbal, physical, sexual, or any other, resulting from a full investigation will be discharged without notice and could face criminal and civil penalties for failure to exercise reasonable care.
Record review of the Investigation/Statement Form dated 11/08/22 revealed the following written statement completed by CNA #2 which stated, I seen (CNA #1) hit (proper name) on her hand after (proper name) hit her. Form was signed by CNA #2.
Record review of CNA #1's Personnel Record revealed that a Criminal History Background Check had been completed prior to her employment and no violations found that would prevent her from working and she was hired on 03/02/22. Annual Employee Evaluation Forms had been completed on 03/19/21 and 03/09/22. This SA also observed in the personnel record no other write-ups or disciplinary actions were noted. The CNA License was observed with an expiration date of 07/31/23 and the CNA was terminated on 11/08/22 for Substantiated Abuse of a resident.
Record review of Employee Final Exit Job Performance Record Form on employee with date employment ended date of 11/08/2022 revealed reason as Substantiated Abuse.
Record review of Resident #2's Face Sheet revealed that she was admitted to the facility on [DATE] with the following diagnoses to include: Encounter for Attention to Colostomy, Dementia, Edema, Cellulitis, Cognitive Communication Deficit, Chronic Pain, Muscle Weakness, Lack of Coordination, Shortness of Breath, Major Depressive Disorder, and Generalized Anxiety. Record review of Resident #2's most recent Minimum Data Set (MDS) with an Assessment Reference date (ARD) of 12/27/22 revealed a Brief Interview for Mental Status (BIMS) Score of 11 indicating a moderately impaired cognitive status.
Record review revealed that on 11/08/22, the ADON conducted an interview with all residents on B-Hall who had been under the care of CNA #1 and no further issues were noted. CNA #1 was immediately terminated, and charges were filed against her for abuse and neglect of a vulnerable adult. The facility notified the Responsible party, the local police, the Attorney General, the State Agency and immediately began in-services regarding abuse and neglect until 100% of the staff had completed their in-services. Resident #2 was immediately assessed, and a body audit was completed. The Social Worker (SW) followed up with the resident for the next several weeks to ensure that she did not suffer any negative outcome, and none was evidenced by the SW visits with the resident one on one. An immediate in-service was started with all staff on abuse and neglect and reporting of abuse and neglect. Resident's Care Plan was updated. An emergency Quality Assurance (QA) Meeting was held, and interviews were started immediately with residents and staff. The SA feels that the facility completed all the requirements and cited abuse at past noncompliance.
Apr 2021
6 deficiencies
1 IJ (1 affecting multiple)
CRITICAL
(K)
Immediate Jeopardy (IJ) - the most serious Medicare violation
Infection Control
(Tag F0880)
Someone could have died · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, physicians' interview, review of the manufacturer's instructions for glucose meter (gluco...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, physicians' interview, review of the manufacturer's instructions for glucose meter (glucometer), insert for germicidal wipes used at the facility, resident record review, and facility policy review, the facility (a.) failed to ensure nursing staff cleaned and disinfected a multi-use glucometer before and after fingerstick blood glucose testing for three (3) of five (5) sampled residents observed for blood glucose fingersticks, Residents #15, #27, and #122 and (b.) failed to perform proper hand hygiene and glove use for (4) of 5 sampled residents, Residents #15, #27, #122, and #230 and (c.) failed to use a barrier and perform hand hygiene for one (1) of 5 sampled residents observed during blood glucose monitoring for Residents #230. This practice had the potential to affect 32 of 32 residents who received blood glucose monitoring, out of a total of 43 residents with Diabetes.
The facility's failure of not following standard precautions for infection control by not disinfecting the glucometer between residents, placed these and other residents who received blood glucose finger sticks (32 total residents out of 42 diabetic residents) in a situation which caused a likelihood of serious injury, harm, impairment, or death, related to the spread of blood-borne pathogens due to cross-contamination with the multi-resident use of the glucometer.
The situation was determined to be an Immediate Jeopardy (IJ), which began on 4/6/21 at 7:40 AM, when Licensed Practical Nurse #9 failed to clean and disinfect a multi-use blood glucometer per manufacturer's guidelines before and after use. The facility failed to follow standard precautions of infection control while performing blood glucose finger sticks without cleaning/disinfecting the Glucometer before use between three (3) residents.
IJ existed at:
483.80 Infection Prevention & Control CFR (s): 483.80(a)(1)(2)(4)(e)(f) - F 880 - Scope and Severity K
The State Agency (SA) notified the Administrator on 4/7/21, at 9:20 AM, of the IJ and provided the Administrator with the IJ Template. An acceptable Removal Plan was received on 4/8/21, in which the facility alleged all actions were completed on 4/8/21, and the IJ was removed as of 4/8/21. The SA validated the Removal Plan and determined the IJ was removed on 4/9/21, prior to exit. The scope and severity for CFR(s) 483.80(a)(1)(2)(4)(e)(f),was lowered from a K to a scope and severity of a E, while the facility develops and implements a plan of correction and monitors the effectiveness of systemic changes to ensure the facility sustains compliance with regulatory requirements.
Findings include:
Record review of the facility policy titled, Surveillance Plan revised date 11/28/2017, revealed . Process Surveillance reviews practices directly related to resident care, to identify compliance with established policies and procedures based on recognized guidelines. Process Surveillance determines for example if the facility has and implements procedures in place to: .b. Use appropriate hand hygiene prior to and after all procedures .h. ensure proper that reusable equipment is appropriately cleaned, disinfected, or reprocessed.
Record review of the facility policy titled, Standard Precautions, effective date 9/19/14, revealed It is the policy of (Proper Name of Management Company) facilities to provide patient care services that reflects the Standard Precautions infection control practices when interacting with residents. Standard Precautions components include, but are not limited to, the following: Hand Hygiene .
Record review of the facility policy titled Infection Prevention Program, revised date 11/28/17, revealed Education of Staff, Residents and Visitors: Education addressing the principles and practices for the preventing transmission of infectious agents shall be provided to all facility staff, as well as anyone who may have direct or indirect contact with the residents or medical equipment .
A review of the Center for Disease Control and Prevention guidelines last updated 6/8/17, regarding shared blood glucose meters, revealed if blood glucose meters were shared, the device should be cleaned and disinfected after every use, per manufacturer's instructions, to prevent carry-over of blood and infectious agents.
Record review of a policy presented by the facility related to disinfection of equipment titled Infection Control, with a revised date of 11/28/17, revealed, It is the policy of (Proper Name of Management Company) facilities to operate in compliance with Environmental Protection Agency (E.P.A.) guidelines for the management of healthcare associated infections. (H.A.I.) . Procedure: E.P.A. approved products shall be used for disinfecting in the event of H.A.I. Appropriate supplies shall be available in each resident area. The policy did not specifically address the cleaning of glucometers.
In an interview on 4/9/21 at 10:30 AM with the Risk Manager stated when asked about a policy on disinfection of equipment policy, This is the disinfection policy. RN #4 presented the policy Infection Control with a revised date of 11/28/17.
Resident #122
An observation on 4/6/21 at 7:40 AM, revealed Licensed Practical Nurse (LPN) #9 took the glucometer out of the top drawer of the medication cart and did not disinfect the glucometer. While at the medication cart, LPN #9 did not wash her hands or use hand sanitizer. LPN #9 entered Resident #122's room. LPN #9 performed the blood glucose fingerstick using the EVENCARE G3 meter, placed the meter back on the tray, then removed her gloves while in the resident room and performed hand hygiene. LPN #9 returned to the medication cart, put on gloves, and wrapped the meter in a MAGICARE Premium Alcohol wipe. LPN #9 removed her gloves and did not perform hand hygiene.
Record review of Resident #122's Face Sheet included diagnoses of Type 2 Diabetes Mellitus with hyperglycemia and Type 2 Diabetes Mellitus with diabetic neuropathy, unsp (unspecified). Resident #122's Minimum Data Sheet (MDS) with an Assessment Reference Date (ARD) dated 3/21/21 revealed a Brief Interview for Mental Status (BIMS) score of 15 indicating Resident #122 was cognitively intact. Resident #122's Electronic Medical Record (eMAR) for April 2021 revealed a blood glucose documented on 4/6/21 at 7:30 AM and signed by LPN #9.
Resident #27
An observation of a blood glucose fingerstick using the EVENCARE G3 meter on 4/6/21 at 10:05 AM, with Resident #27, revealed LPN #9 took the glucometer out of the top drawer of the medication. LPN #9 did not disinfect the glucometer, she did not wash her hands or use hand sanitizer prior to putting gloves on. LPN #9 entered Resident #27's room. LPN #9 performed the blood glucose fingerstick using the EVENCARE G3 meter and placed the meter on the tray. LPN #9 removed her gloves. She did not perform hand hygiene. LPN #9 returned to the medication cart, put on gloves, and wrapped the meter in a MAGICARE Premium Alcohol Wipe. LPN #9 removed her gloves and did not perform hand hygiene.
Record review of Resident #27's Face Sheet revealed Resident #27 was admitted to the facility on [DATE]. Resident #27 diagnoses included Type 2 Diabetes Mellitus with hyperglycemia. Resident #27's MDS with an ARD dated 1/13/21 for revealed a BIMS score of 15 which indicated Resident #27 was cognitively intact. Record review of Resident #27's Administration Record (EMAR) for dated 4/6/21 revealed a documented blood sugar at 10:09 AM.
Interview on 4/6/21 at 10:10 AM, with LPN #9 revealed she had not performed any other blood glucose fingersticks since the earlier one on Resident #122. LPN #9 stated that she used the alcohol wipes to disinfect the glucometer because this is how she was oriented when she was hired one month ago. SA asked LPN #9 if she had any other wipes in the cart, and she produced Micro-Kill Germicidal Alcohol wipes that were in the medication cart drawer. When asked what she used the Micro-Kill Germicidal Alcohol wipes for, she stated that she cleans the medication cart off with them when she finishes her medications for the shift. She was asked why she did not use the Micro-Kill Germicidal Alcohol wipes on the glucometer. She stated because they told me to use alcohol wipes and that is why they stay in the top drawer. She was asked who told her to use the alcohol wipes and she stated the supervisor. She stated I do not know her name. She is in one of the front offices, but she is not the Unit Supervisor.
Resident #15
An observation of a blood glucose fingerstick using the EVENCARE G3 meter, on 4/6/21 at 8:05 PM, with Resident #15, revealed LPN #10 gathered her supplies to include the glucometer. She did not disinfect the glucometer and did not wash her hands prior to putting on gloves. She entered Resident #15's room and placed the glucometer on the overbed table with no barrier. LPN #10 performed the blood glucose fingerstick using the EVENCARE G3 meter, removed her left glove, and held the meter in her gloved right hand. LPN #10 returned to the medication cart and placed a clean glove on her left hand. LPN #10 got a Micro-Kill Germicidal Alcohol wipe out of the container, using her left hand, and wrapped the meter up. She stated she will leave it wrapped up for two (2) to five (5) minutes. She removed her gloves and did not wash her hands.
Review of the Micro-Kill containter label, Directions For Use: Disinfecting: To disinfect hard, non porous surfaces, use one or more wipes, as necessary, to thoroughly wet the surface to be treated. Treated surface should remain visibly wet for one minute to achieve complete disinfection of all pathogens listed on this label. The label included effective disinfection of 12 Bactericidal and 11 Virucidal pathogens which included Hepatitis B, Hepatitis C and Human Immunodeficiency Virus (HIV).
Record review of Resident #15's Face Sheet revealed Resident #15 was admitted to the facility on [DATE]. Resident #15's diagnoses included Type 2 Diabetes Mellitus with hyperglycemia. Resident #15's e-MAR for April 2021 revealed a blood glucose had been obtained for 4/6/21 at 8:00 PM and was initialed by LPN #9.
During an interview with LPN#10 on 4/6/21 at 8:10 PM, the SA asked LPN #10 had she used the glucometer prior to this fingerstick and LPN #10 stated, no and that this was the first fingerstick she had done on this shift. The SA asked LPN #10 was the glucometer clean when she removed it from the drawer. LPN #10 stated that she should have cleaned it before using it. She stated she should have washed her hands before and after performing the fingerstick. LPN #10 stated that she was hired in August and completed the new hire videos and computer trainings. LPN #10 stated that she was put with random nurses for orientation to the medication cart and procedures. LPN #10 stated that she was taught to wash her hands, put gloves on, disinfect the glucometer using the Micro-Kill Germicidal Alcohol wipes and keep it wrapped up for two (2) to five (5) minutes, perform the accu-check, disinfect the glucometer, and wash her hands.
Resident #230
On 04/06/21 at 08:05 PM, an observation of a bedside fingerstick glucose for Resident # 230 performed by Licensed Practical Nurse (LPN) #1, revealed LPN #1 carried a disinfected glucometer and supplies into the room on a barrier and placed it on the bedside table. LPN #1 wore gloves into the room. She removed the glucometer from the barrier and placed in it on a chair while she performed the fingerstick. LPN #1 did not remove her gloves and perform hand hygiene when she completed the fingerstick blood glucose. With the same gloves on, LPN #1 picked up a pair of pajamas from the bed and held them in her right hand while she administered oral medications to Resident #230. She exited the room, removed her gloves at the medication cart and appropriately disinfected the glucometer with disinfectant wipes and then used hand sanitizer.
An interview, on 4/6/21 at 8:15 PM, with LPN #1, revealed that she realized she put the glucometer on the chair and should not have done that. She stated that she contaminated the monitor when she placed it on the chair. She stated she should have removed her gloves when she finished with the fingerstick, because her gloves were contaminated, and she could have spread germs by touching the other things in the room.
On 04/08/21 at 09:25 AM, an interview with LPN #2, Infection Preventionist, revealed that staff should remove gloves between procedures and perform hand hygiene. LPN #2 stated that LPN #1 should have removed her gloves when she finished the blood glucose fingerstick and performed hand hygiene before touching anything else because of possible contamination with blood. LPN #2 confirmed the glucometer should always be placed on the barrier. The purpose of the barrier is to prevent contamination of the glucometer.
Record review revealed LPN #1 performed a glucometer competency checklist on 11/19/20 with instruction to wash hands following the proper disposal of the used test strip.
An interview on 4/8/21 at 11:10 AM with RN #2, Unit Supervisor. RN #2 stated she is responsible for any of the glucometer audits for the nurses and she stated that she does random audits but, she has not had a new nurse on her unit but if she had, that she would do the audit. The SA asked RN #2 if someone failed to wash their hands or disinfectant the glucometer, what could be a concern and RN #2 stated you could take something from one resident to the next resident. RN #2 stated residents do not have their own personal glucometers, unless on isolation.
During an interview on 4/9/21 at 10:45 AM with the Corporate Nurse Consultant (CNC) reports her role is to oversee the facility is following State and Federal Regulations. She states that in the past I have discussed ways to do glucometer checks and med pass. I also help with protocols and policies. When asked about any negative outcomes of not washing hands appropriately or not cleaning and disinfecting the glucometer the CNC stated, We expect the Director of Nurses (DON) and Infection Preventionist (IP) to carry out task. It's an infection control issue. When asked about nurses following policies that had been implemented by the facility the CNC confirmed nurses should follow the established policies.
During an interview with on 4/9/21 at 11:00 AM, with the Director of Nurses, (DON) stated there were no infections in the facility. The DON reports that when a nurse is hired, they are trained during orientation on medication pass and glucometer checks, then that is validated by a preceptor. The competencies should be completed within the same month. She stated when asked about the outcome of not properly cleaning the glucometer, There would be a risk for transmission of infection from resident to resident. She further reports that hand hygiene should be used before entering the resident's room and when completing a task and gloves are supposed to be worn with any risk of coming into contact with bodily fluids. When asked about in-services on infection control the DON reports that in-services are done Quite frequently. They do audits annually and also do weekly and monthly audits. We completed a skills fair in November. The DON reports that nurses should be following CDC (Centers of Disease Control) guidelines when cleaning glucometers.
During an interview with the Facility Administrator on 4/9/21 at 11:50 AM, stated when asked should nurses clean the glucometer according to established guidelines, she stated, Yes they should be following CDC guidelines. It was a deficient practice. I don't argue it's a deficient practice. She further stated, I'm know I'm responsible to see there are people to follow the guidelines. I know it all sets with me.
During an interview with Resident # 122's primary Physician on 4/9/21 at 3:45 PM, when asked if he was aware of an issue with the facility related to glucometer cleaning. The Physician reports he was aware. When asked about negative outcomes he reports it's an infection control issue. It's unfortunate.
During an interview with the Medical Director, on 4/9/21 at 4:05 PM, when asked what a negative outcome would be if nurses did not properly clean the glucometer, the Medical Director stated, If they didn't clean it at all, blood could potentially come in contact with the nurses' gloves and get on the glucometer. It could be a blood borne pathogen hazard, it's infection control.
A review of the Manufacturer's User Guide for the EVENCARE G3 glucose monitor (used by the facility), revealed under section titled Cleaning and Disinfecting Procedures for the Meter the meter should be cleaned and disinfected between each patient. The following products have been approved for cleaning and disinfecting the EVENCARE G3 Meter:
Dispatch Hospital Cleaner Disinfectant Towels with Bleach (EPA registration #56392-8)
Medline Micro-Kill Disinfecting, Deodorizing, Cleaning Wipes with Alcohol (EPA registration #59894-10),Clorox Healthcare Bleach Germicidal and Disinfectant Wipes (EPA registration 67619-12), Medline Micro-Kill Bleach Germicidal Bleach Wipes (EPA registration #37549-1).
A review of the manufacturer's package of MAGICARE PREMIUM DISINFECTING WIPES (used by the facility in the deficient practice) revealed the ingredients are 75% alcohol and water.
Review of an untitled document on facility letterhead provided by the facility dated 4/8/21 and signed by the Administrator revealed, Prior to April 7, 2021 (proper name of facility) did not have a policy to clean glucometers. Record review of a typed statement on facility letterhead dated April 9,2021, revealed This facility does not have a specific policy on hand washing and gloves. We follow CDC guidelines. The document was signed by the Facility Administrator.
Record review of a document typed by the facility dated 4/9/21 Diabetic Residents at [NAME]revealed there were 42 resident names listed on the diabetic list. Another list provided by the facility Diabetic Residents at [NAME] with Blood Sugar Checks revealed 32 residents receive blood sugar checks.
Record review of a typed statement from LPN #2, Infection Preventionist, revealed that during the week of the annual survey, there was zero residents in the facility that had the diagnoses of Hepatitis B, Hepatitis C, Human Immunodeficiency Virus, or Clostridioides difficile.
Record review of an Inservice Attendance Record dated 3/12/21 with an attached agenda included handwashing/infection. LPN#9 or LPN#10's names were not listed as having attended the in-service.
Record review of an Inservice Attendance Record dated 3/31/21 with a brief description of the in-service revealed Glucometer check off regarding cleaning-disinfecting & proper procedure checking blood sugars. LPN #1, LPN #9 and LPN #10's names were listed as an attendees.
Record review of LPN #10's Licensed Nurse Competency dated 8/24/20 revealed LPN #10 had a check mark under Basic Nursing Skills- Capillary blood glucose with a completion date listed as 8/26/20 and under Medication Management- Glucometer checks with a completion date listed as 8/27/20
Record review of a Glucometer Competency Checklist dated 9/13/20 revealed LPN #10 had Yes marked under each skill observed and documentation indicated, Nurse Passed Competency Check -Yes.
Record review of LPN#9 Licensed Nurse Competency dated 3/1/21 revealed LPN #9 had a check mark under Basic Nursing Skills- Capillary blood glucose and under Medication Management-Glucometer checks with a completion date listed as 3/1/21.
Record review of the General Orientation Checklist dated 3/1/21 for LPN # 9 revealed General Purpose: This check list outlines the information, which new employees will want to become familiar with during his/her introduction period. The orientation checklist included, Infection Control.
Record review of a Glucometer Competency Checklist dated 3/10/21 and 4/8/21 revealed LPN #9 had Yes marked under each skill observed and documentation indicated, Nurse-Passed Competency Check -Yes.
The facility provided an acceptable Removal Plan for the IJ on 4/8/21. Review of the facilitys Removal Plan revealed the facility took the following actions to remove the IJ:
Removal Plan
The facility took the following actions to address the citation and prevent any additional residents from suffering any adverse outcome.
On 04/06/21, a licensed nurse cleaned the glucometer with a 75% alcohol [NAME] care disinfectant wipe. The facility failed to properly clean a glucometer and disinfect the multi-patient resident use glucometer (Evencare G3 meter) per Environment Protection Agency (EPA) registered disinfectant observed for Resident #15, Resident #27, and Resident #122. This nurse was previously in-serviced on March 31, 2021. She completed her competency with accuracy by using the appropriate EPA approved disinfectant wipe. Each unit manager conducted a physical assessment on all residents that have an order for glucometer checks.
1. Thirty-six (36) residents have an order for a glucometer check. They were assessed by the unit managers with no signs or symptoms of infection or adverse reactions.
2. All [NAME] wipes were removed immediately from all medication carts and supply rooms on April 7,2021 and were replaced with EPA approved wipes per manufacturer's instructions. All Glucometers were cleaned with EPA approved wipes. The facility has a total of 12 multi patient glucometers in use.
3. An Emergency QA meeting was conducted on 04/07/21 at 10:00 AM with the following: Medical Director, Nurse Practitioner, DON, Infection Preventionist, QA nurse, Administrator and ADON on the Immediate Jeopardy and removal plan for proper cleaning of glucometers. Immediately, a directive in-service began and was conducted by RN #1 and RN #2 for all Licensed Nurses on proper disinfection on glucometer check with return demonstration. Neither of these individuals are employees of this facility. The following topics were discussed in the QA meeting.
a. All diabetic residents at risk to suffering adverse outcomes
b. Removal of [NAME] care wipes from all medication carts
c. Directive in-services for all licensed nurses
d. Policy revision on Glucometer Disinfection.
4. A Directive in-service began on 04/07/21 being conducted with all Licensed nurses by RN #1 and RN #2. The in-service consists of appropriate technique, including a return demonstration on properly cleaning and disinfection glucometers before and after each use. All nurses will be educated prior to their next shift and no staff will be allowed to work until properly in-serviced. A total of 41 out of 57 nurses have been in-serviced at this time.
Facility asserts that it is in compliance on April 8, 2021 at 10:00 AM.
On 4/9/21, the SA validated the facility's Removal Plan through observation, staff interviews, record reviews, and review of in-service sign-in sheets. The SA verified the facility had implemented the following to remove the IJ:
1. Interview with the DON and Nurse Practitioner revealed that the thirty-six (36) residents with an order for a glucometer check were assessed by the unit managers with no signs or symptoms of infection or adverse reactions.
2. Observation of all medication carts verified that all [NAME] wipes were removed immediately from all medication carts and supply rooms on April 7,2021 and were replaced with EPA approved wipes per manufacturer's instructions. Interview with the DON revealed all Glucometers were cleaned with EPA approved wipes. The facility has a total of 12 multi patient glucometers in use.
3. Interview with the DON, Nurse Practitioner and Administrator and record review of the sign-in sheets revealed an Emergency QA meeting was conducted on 04/07/21 at 10:00 AM with the following: Medical Director, Nurse Practitioner, DON, Infection Preventionist, QA nurse, Administrator and ADON on the Immediate Jeopardy and removal plan for proper cleaning of glucometers. The following was discussed: All diabetic residents at risk to suffering adverse outcomes, Removal of [NAME] care wipes from all medication carts, Directive in-services for all licensed nurses, Policy revision on Glucometer Disinfection. Immediately, a directive in-service began and was conducted by RN #1 and RN #2 for all Licensed Nurses on proper disinfection on glucometer check with return demonstration.
4. Interview with the DON and eight nurses and record review of the sign-in sheets revealed a Directive in-service began on 04/07/21 being conducted with all Licensed nurses by RN #1 and RN #2. The in-service consists of appropriate technique, including a return demonstration on properly cleaning and disinfection glucometers before and after each use. All nurses will be educated prior to their next shift and no staff will be allowed to work until properly in-serviced. A total of 41 out of 57 nurses have been in-serviced at this time.
The SA validated that all corrective actions to remove the IJ had been completed as of 4/8/21, and the IJ was removed on 4/9/21, prior to exit.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0576
(Tag F0576)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview, resident interview and facility policy review, the facility failed to deliver mail unopened for two (2...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview, resident interview and facility policy review, the facility failed to deliver mail unopened for two (2) of six (6) residents interviewed in Resident Council. Residents #34 and #122.
Findings Include:
Resident Council
Record review of facility policy titled Resident's Rights Under Federal Law, undated, revealed the facility shall protect and promote the rights of each resident, including each of the following rights: the resident has a right to privacy in written communications, including the right to send and receive mail promptly that is unopened.
Review of facility policy titled Resident Rights and Responsibilities, dated 11/28/2017, revealed, facilities shall adopt the Statement of Resident Rights, in accordance with all Federal and State Regulatory requirements. This facility shall protect and promote the rights of each resident. Revealed each resident shall have the right to communicate with persons of his/her choice, and may receive mail unopened or in compliance with the policies of the home.
A Resident Council meeting was held on 04/08/21 at 11:00 AM. Resident #34 voiced concerns about some of his packages being opened by Social Worker and at times items are removed. Stated he received an electric teapot by mail and that package was not opened by staff, but they did remove this from his room. Stated he also had a leg brace he ordered, but the staff would not allow him to wear this device since it was not ordered by a doctor. Stated these items are in the social worker's office. Stated he has had other packages that were opened by SW and then he was given the items the SW thought he could have. Stated he ordered a large projector screen so he could watch movies with other residents, but he never received this item. Resident #34 stated the social worker told him the item was received in the facility but since it was too large for his room the SW sent it back. He stated he never saw the item and he has not received his refund from an online distributor (Proper Name) so he is unsure it was sent back. He stated an employee could have taken item. Resident #34 stated he notified the Postmaster General and reported his packages being opened by a staff member. Resident #34 stated he was instructed that they could issue an arrest warrant, but Resident stated he likes the social worker and would not want to do this to him.
An interview on 4/8/2021 at 3:40 PM, with Resident #122 revealed she received a package with a pair of pants and it was opened when she received it.
An interview with the Social Worker on 4/8/2021 at 4:25 PM, revealed he had opened some of Resident #34's packages. The SW stated the resident was receiving items that were not allowed into the resident's room such as lancets for finger sticks and large bottles of Aspirin. He stated the resident also had ordered an electric teapot and a leg brace and these items are being stored in the social workers office. The State Agency surveyor observed these items in the SW office. The SW stated he realizes he should not have opened the packages being delivered to the resident and he was trying to ensure safety for the Resident #34, as well as the other residents. He stated he should have had the resident open the packages and ask for permission to look at contents. The SW stated the resident ordered a one hundred inch projector screen that was delivered to the facility, but SW told delivery person to take it back since it was so large. He informed Resident #34 that item had arrived and he had sent it back but he was not aware if Resident #34 had received credit back from where it was ordered from. He stated he was unaware of Resident #75's package being opened. The SW stated he did not open this package and does not know who did.
An interview with the Administrator, on 4/8/2021 at 5:00 PM, revealed she was unaware of residents' packages being opened prior to being delivered to the residents. She stated she was also unaware of Resident #34's projector screen being sent back without the resident's permission. She stated it is each resident's right to receive their mail and packages unopened and confirmed the facility failed to follow the resident rights guidelines to ensure the residents received their mail and packages unopened.
An interview with the Administrator on 4/9/2021 at 9:30 AM, revealed she spoke with Resident #34 concerning his mail and his projector screen. Record review of the invoice for the projector screen revealed it was reordered.
Record review the Face Sheet revealed Resident #34 was admitted to the facility on [DATE] with diagnoses of Type 2 Diabetes Mellitus, Chronic Kidney Disease, Stage 3, Cardiomyopathy, Cerebral Infarction.
Record review of Resident #34's Minimum Data Set (MDS) dated [DATE], Section C, revealed the resident had a Brief Interview for Mental Status (BIMS) score of 12, indicating resident with moderate cognitive impairment.
Record review of Resident #122's Face Sheet revealed she was admitted to the facility on [DATE] with diagnoses of Type 2 Diabetes Mellitus, Fracture of right femur; Hypertensive Heart Disease. Record review of MDS dated [DATE] , Section C, revealed the Resident had a BIMS score of 15, indicating Resident is cognitively intact.
Review of Resident's Rights training revealed the SW was in-serviced on Resident's Rights on 8/17/2020.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
ADL Care
(Tag F0677)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, resident interview, staff interview and facility policy review, the facility failed to provide Activities ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, resident interview, staff interview and facility policy review, the facility failed to provide Activities of Daily Living (ADL) care for one (1) of four residents reviewed for ADL care. Resident #16.
Findings Include:
Review of facility policy titled, Restorative Program and Activities of Daily Living - Provision of Care, Treatment, and Service: Resident Care, dated 1/9/2015, revealed, it is the policy of the restorative program to provide the resident with appropriate treatment and services to maintain or improve his or her abilities. A resident who is unable to carry out activities of daily living will receive the necessary services to maintain good nutrition, grooming, and personal oral hygiene.
On 04/05/2021 at 02:45 PM, an observation of Resident #16 revealed a strong odor of urine in room. Resident was lying in bed with a large sized area of bedsheet and pants noted to be discolored and appeared to be wet with urine, from mid back to below hips.
On 4/5/2021 at 2:45 PM, an interview with Resident #16 revealed he was doing fine. Resident appears to be hard of hearing and required fairly loud voice to hear.
On 04/05/2021 at 03:10 PM, an observation of Resident #16 revealed a strong odor of urine in room and bedsheet and clothing appeared to be discolored and wet.
During an interview on 4/5/2021 at 3:10 PM, Resident #16 stated he was hard of hearing and having difficulty hearing State Agency (SA) trying to speak in a volume that the facility staff in hallway could not overhear.
An observation on 04/05/21 at 04:16 PM, revealed Resident #16 lying in bed. Strong odor in room. Resident with discolored bedsheet with large brown ring, pink incontinence pad noted underneath resident that appeared saturated and discolored and resident's right pants leg appeared to be wet from hip to below the knee.
An observation on 04/05/21 at 04:44 PM, revealed Resident #16 lying in bed with strong odor noted. Bedsheet, incontinence pad, and resident's pants appeared to be wet and discolored.
An observation on 4/5/2021 at 05:45 PM, revealed Resident #16 in bed with bedsheet, incontinence pad, and resident's pants discolored and appeared to be wet. Strong urine odor noted in room.
An observation the following morning, on 4/6/2021 at 07:55 AM, revealed resident still lying in bed with strong odor in room noted. Bedsheet, incontinence pad, and resident's pants noted to be stained and damp looking. Pants and shirt were the same clothes resident had on yesterday. A small mark noted on front of pants yesterday was present on pants this morning and made these pants recognizable.
An observation on 4/6/2021 at 8:55 AM, revealed Certified Nurse Aide (CNA) #1, picked up breakfast tray. No request offered by CNA #1 to Resident #16 for care. Resident continued to remain in soiled bed with soiled clothing as previously noted.
An interview on 4/6/2021 at 9:15 AM, with CNA #1 revealed her procedure for her resident rounds. She stated at the beginning and the end of each shift, the oncoming and off-going CNA make rounds. She stated during her initial rounds, she checks to see that the residents are breathing and dry. She stated if a resident is wet or soiled, care is done. She stated baths are started and given until breakfast and then after breakfast, the baths are completed. She stated Resident #16 often refuses to be cleaned up. She stated he was wet this morning, but she did not work this hall yesterday so she was unaware of how long he had been wet. Stated rounds are made at least every 2 hours and the residents should be cleaned as soon as noted to prevent skin irritation.
Observation on 4/6/2021 at 9:30 AM, revealed CNA #1 assisted Resident #16 into the wheelchair and taken down the hall to the shower room. Resident #16 was very cooperative. Resident #16 did not refuse bath and ADL care.
An interview in Resident #16's room, with Director of Nursing (DON) on 4/6/2021 at 9:30 AM, revealed she observed Resident #16's condition in hallway on his way to the shower and observed the resident's soiled bedding. Stated the resident should not be left in that condition. Stated rounds should be made at least every 2 hours and care should be given then. She stated this resident has often refused care. Stated if care is refused, the nurse should be notified. Stated this should be documented. She confirmed the facility failed to provide proper care in a timely manner. Stated when the resident was allowed to remain in wet clothing and bedding for an extended time, the risk of skin breakdown is increased.
An interview on 4/7/2021 at 3:40 PM, with Licensed Practical Nurse (LPN) #2, Quality Assurance Nurse revealed the facility has started Guardian Angel rounds. Stated during these rounds, the department heads periodically go to each resident's room to check on the resident as well as the room environment. Stated she had not made rounds on 4/5/2021 or 4/6/2021, so she was unaware of the condition Resident #16 was in. Stated she was unaware resident had been soiled for an extended period of time (at least 19 hours observed during this observation). Stated the resident had refused care in the past and she had seen him soiled and refusing to be changed. Confirmed the resident was not care planned for refusal of care or behaviors. Confirmed the facility failed to provide the resident adequate Activities of Daily Living (ADL) care in an acceptable time frame, and this could lead to skin issues.
Interview on 4/7/2021 at 3:55 PM, with DON. Stated the staff do bedside handoffs at the beginning and end of each shift. Stated the oncoming and off-going CNAs make rounds and the oncoming and off-going nurses make rounds. Stated the staff had mentioned Resident #16's refusal of care on several occasions. Stated some employees are able to get resident to cooperate more than others are. Stated the resident has the right to refuse care. Confirmed the resident was not care planned for refusal of care and the resident had no behaviors documented. Stated there was no documentation of refusal of care during the past several days. DON confirmed the resident did not receive timely ADL care and this could lead to skin breakdown. DON confirmed that if the resident had been refusing care, he should have been care planned for this behavior. The DON confirmed if care was refused, the nurse should have been notified to intervene and documentation concerning event should have been completed. Confirmed that by leaving the resident soiled for an extended period of time (at least 19 hours for this observed occurrence), the facility failed to meet Resident #16's ADL needs and increased the likelihood of skin breakdown.
An interview on 4/7/2021 at 4:55 PM, with CNA #2 revealed she had charted that she had given Resident #16 a shower on the evening of 4/5/2021. Stated she was just trigger happy when she was charting and Resident #16 did not receive a shower. Stated she worked on 4/5/2021 from 5 PM until 11 PM. Stated she made rounds at 6 PM, 8 PM, and 10 PM. Stated during the 8 PM rounds, she changed the resident's brief and put his dirty, wet pants back on him. Stated she took his pants off for the brief change and put soiled pants back on. Stated she did not report this to the nurse or document event, but stated she should have. Stated the negative outcome of being soiled for an extended time could lead to skin breakdown. Stated at the end of her shift at 10:30 PM, rounds were made with oncoming CNA. Stated she informed the oncoming CNA that resident and bed was soiled and resident did not want his bed to be changed.
An interview on 4/8/2021 at 7:55 AM, with Resident #16 revealed his concerns with ADL care. Stated he has been left wet at times and he does not like it. Stated there have been times the staff did not change him quickly.
On 4/29/21, at 10:03 AM, an observation of Resident #16 revealed two (2) CNAs were in his room performing incontinent care. SA introduced self and asked to come in and observe. Resident #16 and staff had no objections. Observation of Resident 's buttocks and peri area revealed no redness or skin breakdown.
On 4/29/21 at 10:15 AM an interview with the Resident revealed he did not remember being left wet for a long period of time. States his memory is not great but he is doing pretty good for his age, can still walk and chew gum at the same time. The Resident revealed he has no complaints and is getting pretty good care. Revealed they check on him and if he is wet, they will change him.
Record review of a Quarterly Minimum Data Set with an Assessment Reference Date of 4/6/21, Section C, revealed a Brief Interview for Mental Status (BIMS) score of 12, indicating moderately impaired cognitive skills for daily decision making. Item C1310, Signs and Symptoms of Delirium, revealed disorganized thinking that fluctuates and changes in severity.
Record review of the Body Audit Roster for Resident #16 revealed on 3/30/21 performed with no new skin issues noted, on 4/6/21 performed and with no new skin issues, on 4/13/21 performed and no new skin issues noted, on 4/20/21 performed and no new skin issues noted, and on 4/29/21 performed and with no new skin issues.
Record review of care plan revealed no care plan for refusal of care, bathing, or ADL care.
Record review of care plan revealed a care plan for potential for skin breakdown related to frail skin, age, decreased mobility, episodes of incontinence. Interventions included: encourage/assist to turn and reposition while in bed and use pillows and wedges as needed; incontinence care every 2 hours and as needed (PRN), use moisture barrier after each incontinent episode - he is able to toilet self but has frequent episodes of bowel incontinence and occasional episodes of bladder incontinence; notify MD/NP if condition warrants; weekly body audits; pressure relief devices to bed and wheelchair; provide treatments as ordered; keep skin clean and dry; inspect skin daily during bathing and report any redness or areas of concern to treatment or charge nurse; float heels while in bed.
Record review revealed a care plan for requiring assistance with ADLs related to weakness, lack of coordination, unsteadiness on feet, history of shoulder repair. His ADL function varies from day to day. Interventions include: bed mobility with staff assist per needs or request; dress in neat clothing daily with assist per needs or request; hygiene with staff assist per needs or request; incontinent care/assist with toileting every 2 hours and PRN. He is able to toilet self but is occasionally incontinent of bladder and frequently incontinent of bowel; nail care weekly and prn; locomotion on/off unit via wheelchair with assist per daily needs or request; shower 3 x a week with assist per daily needs or request; notify MD/NP if condition warrants; independent with transfers, assist per daily needs or request.
Record review of behavior log revealed the resident had no negative behaviors from January 2021 - 4/7/21. Record review of resident's departmental notes from January 2021 to 4/7/21 revealed no incidents of resident's refusal of incontinent care, ADL care, bathing, or clothing changes were documented.
Record review of the Face Sheet revealed Resident #16 was admitted to facility on 6/3/2019 with diagnoses of Major Depressive Disorder, Vitamin Deficiency, Mild Cognitive Impairment.
Record review of Quarterly Minimum Data Set (MDS) dated [DATE], Section C, revealed resident with a Brief Interview of Mental Status (BIMS) score of 11, indicating moderate cognitive impairment. Review of section E - Behavior - revealed for E0800 - Rejection of care: presence and frequency revealed behavior not exhibited. Section H - Bowel and Bladder - revealed resident was occasionally incontinent of urine and was continent of bowel.
Record review of a sign-in sheet signed by CNA #1 revealed she attended the in-service titled, Incontinent Care Monitoring, dated 11/12/20.
Record review of a CNA New Employee Orientation Itinerary, Day 2, revealed CNA #2 was oriented to Activity of Daily Living check-offs on 3/22/2016. CNA#2's name was not identified on the 2/16/2020 or 6/25/2020 CNA training provided by the facility.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Quality of Care
(Tag F0684)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, resident interview, staff interview and facility policy review the facility failed to administer a treatme...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, resident interview, staff interview and facility policy review the facility failed to administer a treatment cream as ordered for a rash for one (1) of six (6) treatments observed. Resident #12.
Findings include:
Review of facility policy titled Medication Administration dated 6/27/2019, revealed, medications shall be administered only upon the order of physicians, dentists or podiatrists, who are members of the medical staff or have been granted clinical privileges. Up to date medication information shall be available to the individual administering the medication. Available information shall include, but not be limited to: information on drug therapy, side effects, toxicology, dosage, indications for use, route of administration, potential drug to drug interactions, potential allergies or cross sensitivities, proper dose ranges, proper instructions for administration. Medication Administration Record shall be compared with physician orders prior to preparation of any medication. The individual administering the medication shall verify the medication and be aware of the following information concerning each medication before administration: route and frequency of administration, appropriate timing of medication administration.
On 04/05/2021 at 11:10 AM, an interview with Resident #12 revealed he had a rash on his lower back, right side of back, and upper right hip and it was uncomfortable for him. Resident stated the staff had put cream on the rash some mornings and nights, but the rash is still bothering him.
On 04/05/2021 at 4:40 PM, an observation of rash to Resident #12's side under his back. Rash appears moist and red. Unable to see rash to lower back due to resident not feeling like turning.
An interview on 4/5/2021 at 4:40 PM, with Resident #12 revealed the rash feels very irritating and uncomfortable and he does not believe he is getting his medication to his rash as ordered.
Interview with Licensed Practical Nurse (LPN) #7, Treatment Nurse, on 4/7/2021 at 2:00 PM, revealed the 2:00 PM uncharted medication doses were not given due to oversight. Stated the treatment nurses (herself and LPN #8) were to administer these medications as ordered. Stated for the night doses and other scheduled times when the treatment nurses are not in facility, the nurse on the medication cart would administer these treatments. Confirmed the resident did not receive some of the scheduled doses of cream ordered to improve his skin irritation.
Interview with LPN #8, Treatment Nurse, on 4/7/2021 at 2:00 PM revealed the 2:00 PM uncharted medication doses were not given due to oversight. Stated she and LPN #7 administer these treatments on the shifts they work. Stated the treatment nurses were responsible for administering this medication and it was not given as ordered. Stated the resident missed several scheduled doses of this cream medication, ordered to help with resident's skin condition. Confirmed the resident did not received this medication as scheduled and ordered.
Interview with LPN #2, Quality Assurance Nurse, on 4/7/2021 at 2:30 PM, revealed the resident was scheduled for doses of Triamcinolone Cream 1% three times a day (TID) as ordered at 6:00 AM, 2:00 PM, and 10:00 PM. Stated the nurses failed to administer medication as ordered, therefore, a medication error occurred. The QA Nurse confirmed the facility failed to administer resident's treatment to improve a skin condition as ordered.
Interview with the Director of Nursing (DON) on 4/7/2021 at 2:30 PM, revealed doses of ordered cream medication were not documented. She stated the treatment nurses are responsible for administering the medication as ordered when they are working. SA informed DON that both treatment nurses confirmed they overlooked the order for this treatment and missed administering this on several occasions, and, also, the resident had stated he only received this medication some mornings and nights. The DON confirmed the facility failed to administer the treatments as ordered to improve Resident #12's skin condition.
Interview with Resident #12, on 4/8/2021 at 2:30 PM revealed his skin irritation has improved. Stated he was getting cream in the morning and at night, but they also put it on a few minutes earlier.
On 4/9/2021 at 5:30 PM, an interview with Resident #12 revealed he is receiving his cream medication and his rash has improved and no longer irritating.
On 4/9/2021 at 5:30 PM, an observation of Resident #12's rash on lower back, upper hips and right side, revealed area dry and not red at this time.
Record review of orders revealed an order on 4/1/2021 for Triamcinolone cream 1% apply topically to right buttocks and right hip three times a day (TID) for 10 days.
Record review of Medication Administration Record (MAR) revealed Resident #12 was scheduled to receive the medication daily at 6:00 AM, 2:00 PM, and 10:00 PM. Record review of MAR revealed Resident #12 received the ordered cream medication on 4/2/2021, 4/3/2021, 4/4/2021, and 4/5/2021 at 6:00 AM. No documentation of medication being given as ordered on 4/6/2021 and 4/7/2021 at 6:00 AM. Record review of MAR revealed Resident #12 received ordered cream medication on 4/2/2021, 4/4/2021, 4/5/2021, and 4/6/2021 at 10:00 PM. No documentation for ordered medication being given on 4/3/2021 at 10:00 PM. Record review of MAR revealed Resident #12 was scheduled for 2:00 PM medication administration of cream. No documentation for medication being given at this time for 4/2/2021, 4/3/2021, 4/4/2021, 4/5/2021, and 4/6/2021.
Care plan related to potential for skin breakdown related to decreased mobility, incontinence, DM (Diabetes Melliltus) history of yeast, vitamin deficiency. Interventions included: encourage/assist to turn and reposition while in bed, use pillows and wedges as needed; incontinence care every 2 hours and PRN and use moisture barrier after each incontinent episode; notify MD/NP if condition warrants; weekly body audits; pressure relief devices to bed and wheelchair; provide treatments as ordered; keep skin clean and dry; inspect skin daily during bathing and report any redness or areas of concern to treatment or charge nurse.
Record review of the Face Sheet revealed Resident #12 was admitted to the facility on [DATE] with diagnoses of Acute on Chronic Diastolic (Congestive) Heart Failure, Morbid (Severe) Obesity with Alveolar Hypoventilation, Chronic Diastolic (Congestive Heart Failure), Type 2 Diabetes Mellitus, Alcohol Abuse.
Record review of Minimum Data Set (MDS) dated [DATE], Section C, revealed a Brief Interview for Mental Status (BIMS) score of 14, indicating resident is cognitively intact.
Record review of MDS dated [DATE], Section G - Functional Status, revealed bed mobility as resident's need for extensive assistance with one person physical assist. Revealed resident with need for total dependence with one person physical assist with bathing. Record review revealed need for extensive assistance with one person physical assist for personal hygiene. Record of Section E - Behavior - revealed for rejection of care - behavior not exhibited.
Record review of signed Treatments and Medication Administration Observation check offs noted for LPN #7 and LPN #8 dated 11/18/20.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0760
(Tag F0760)
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, Pharmacy Consultant, Physician, Nurse Practitioner, and Nurse Consultant i...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, record review, Pharmacy Consultant, Physician, Nurse Practitioner, and Nurse Consultant interview and facility policy review, the facility failed to ensure residents were free from significant medication errors identified during the preparation and administration of medications for one (1) of nine (9) residents observed during medication administration observation. Resident #9
Findings Include:
Record review of the facility policy, Medication Administration with a revised date of 6/27/19 revealed, Up-to- date information shall be available to the individual administering the medication. Available information shall include, but not limited to: Proper instruction for administration .Errors in administration of medication shall be reported immediately to the attending physician and a Notification Form shall be sent to the Nursing Administration ant the Pharmacy by the end of the shift in which the error was committed. The medication administered shall be documented on the medical record. The resident's reaction, if any or if observable, shall be documented in the medical record. Any orders received from the resident's physician and/or any necessary actions taken to protect the resident from the potential effects of the medication error shall be documented in the medical record.
Record review of the facility policy titled Pharmacy Consultant Services, with a revised date 11/28/17, included .assess the performance of the nursing staff in medication administration through the process of medication pass observation, as requested by the Nursing and Administration and as necessary .
Record review of the facility policy Prescribing and Ordering Medications: General Practices with a revised date of 11/28/2017 did not address crushing of medications.
Record review of Davis's Drug Guide/Do not Crush list dated 10/25/16 obtained from B-Hall Upper Cart indicated Klor-Con Tablet, Klor-Con M Tablet (SR) was listed on the Do Not Crush list.
In an interview, on 4/8/21, with LPN #11 reports the facility keeps the Do Not Crush list in a notebook on the medication carts.
Observation on 4/6/21, at 7:55 AM, with LPN #9 during medication observation, revealed LPN#9 crushed Potassium Chloride (KCL) 20 meq (milliequivalents) to administer to Resident #9.
During an interview with LPN #9 on 4/6/21 at 8:00 AM, confirmed she crushed the potassium chloride tablet and she reported that she had crushed it and given it at least five (5) other times within the last month.
Record review of the Electronic Medication Administration Record (eMAR) for March 2021 revealed LPN#9's initials were noted 13 times on March 8, 9, 12, 14, 17, 18, 22, 23, 26, 27, 28, and 31 on Potassium CL, indicating it had been administered.
In an interview with the Pharmacy Consultant on 4/6/21, at 11:35 AM revealed he recommended to not crush Potassium tablets. He stated it ideally is best to use the liquid form of Potassium. He stated he vaguely remembers a recommendation about this resident and her potassium, but he would have to check his record to see.
Record review of the Face Sheet for Resident #9 revealed Resident #9 was admitted to the facility on [DATE] with diagnoses which included Hypokalemia and Essential (primary) Hypertension.
Record review of LPN #9's Medication Administration Observation dated 3/10/21, indicated all areas on the medication pass competency was checked as met.
In an interview with the Director on Nurses (DON) on 4/8/21 at 4:55 PM, confirmed LPN #9 had crushed the potassium 4/6/21. She reported the procedure for medication errors would be to immediately notify the physician, monitor the resident, notify the responsible party (RP),notify the DON, carry out any new physician orders, disciplinary actions for the nurse that made the error and re-education. She stated that the physician would give the order for how long to monitor the resident. She further reported that an incident report would be completed. She stated she thinks the root cause of LPN #9's error with crushing the potassium was because she was nervous.
Record review of the nurse's notes dated 3/2/21 through 4/1/21 revealed no documentation of monitoring or any reactions Resident #9 had related to the crushed potassium.
Record review of the Note to the Attending Physician/Prescriber dated 12/30/20 revealed consider adding a coded diagnosis to the following medications: KCL (potassium). The Physician/Prescriber response was agree-add dx (diagnosis) CHF (Congestive Heart Failure).
Record review of Physician Orders dated April 2021 revealed an order date of 12/8/20 for Potassium CL ER(Extended Release) 20 MEQ. Give 1 tab (tablet) PO daily (hypokalemia). LPN #9's initials were noted on 4/6/21 at 8 AM, as administered.
Record review of Physician orders dated April 2021 revealed a new order for potassium CL 10% (20 MEQ/15ML) (milliters). Give 15ML= ( 20 MEQ) PO DLY.
Record review of Resident #9's Care Plan with a review date of 6/30/21 for Hypokalemia revealed an intervention Administer medication as ordered.
Record review of untitled notes that were filed under the Physician Progress notes section in the clinical record, dated 1/28/21 through 3/23/21, signed by the attending Physician and Nurse Practitioner, revealed no documentation in the clinical record from the Physician or Nurse Practitioner that crushing medication would not adversely affect the resident.
During an interview on 4/9/21, at 8:45 AM, with the Geriatric Nurse Practitioner (GNP), reported when asked what negative side effects from crushing potassium could be, stated, It could cause GI (gastrointestinal) upset.
During an interview with the DON on 4/9/21 at 11:00 AM, when asked if crushing a medication that is recommended to not be crushed would be a medication error, she stated, Yes this would be a medication error.
During an interview with the Facility Administrator on 4/9/21, at 11:50 AM, stated when asked is crushing an extended-release potassium tablet acceptable, she stated, You should look to the drug book for guidance about crushing medication.
During an interview with the Pharmacy Consultant (PC), on 4/9/21 at 1:00 PM, confirmed he does watch medication pass. He stated, I have done it in the past. He reported he has not recently completed a medication pass. When asked what the potential side effects of crushing extended-release potassium could be the PC stated, It's just not going to be as effective. It could cause some GI upset or ulceration. I would recommend not crushing it. I would prefer it be done differently. The PC further stated that the process is that he makes recommendations but lets the DON know before he leaves the facility so she can be working on the recommendations.
During an interview on 4/9/21, at 3:45 PM, with Resident #9's primary Physician revealed when asked about the possible side effects of crushing potassium, the Physician stated, It could cause GI side effects. It doesn't make sense to crush, just use liquid.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0773
(Tag F0773)
Could have caused harm · This affected 1 resident
Resident #118
On 04/06/2021 at 8:17AM, an observation of Resident #118 revealed License Practical Nurse (LPN) #4 performed a finger stick blood glucose.
On 04/08/2021 at 2:00PM, record review of the ...
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Resident #118
On 04/06/2021 at 8:17AM, an observation of Resident #118 revealed License Practical Nurse (LPN) #4 performed a finger stick blood glucose.
On 04/08/2021 at 2:00PM, record review of the April 2021 Physicians Orders revealed there was not a physician order for Finger Stick Blood Glucose.
Record review of Medication Administration Record (MAR) for April 2021 revealed a finger stick blood glucose result is recorded four times a day along with each insulin administration recording for a total of 30 (thirty) times.
On 04/08/2021 at 2:30PM, an interview revealed LPN #5 stated the Resident always receives a finger stick blood glucose prior to scheduled insulin administration and it is recorded on the MAR as a special needs that pops up when we chart the insulin.
On 04/08/2021 at 3:05PM, revealed LPN #6 Medical Records Nurse stated she had searched the medical records and could not find a written order for the finger sticks as of now.
Based on observation, record review, staff interview and facility policy review, the facility failed to obtain a physician's order for blood glucose finger sticks for one (1) of five (5) finger sticks observed. Residents #118
Findings include:
Record Review of the Facility policy titled Diagnostic Services: Lab Tests and X-Ray with a revised date of 11/28/17 revealed Procedure: Quality lab tests and radiology services only are performed upon medical order from the resident's physician . When an order is received from a physician requesting blood work to be drawn or an x-ray be taken, the order shall be written on the Physician's Order Sheet.The licensed nurse on duty shall be responsible for inputting the order into the computer.
Understanding Severity Codes (click to expand)
Life-Threatening (Immediate Jeopardy)
J - Isolated
K - Pattern
L - Widespread
Actual Harm
G - Isolated
H - Pattern
I - Widespread
Potential for Harm
D - Isolated
E - Pattern
F - Widespread
No Harm (Minor)
A - Isolated
B - Pattern
C - Widespread
Questions to Ask on Your Visit
- "What changes have you made since the serious inspection findings?"
- "Can I speak with families of current residents?"
- "What's your RN coverage like on weekends and overnight?"
Our Honest Assessment
Strengths
- • No fines on record. Clean compliance history, better than most Mississippi facilities.
- • 40% turnover. Below Mississippi's 48% average. Good staff retention means consistent care.
Concerns
- • Multiple safety concerns identified: 1 life-threatening violation(s), 1 harm violation(s). Review inspection reports carefully.
- • 23 deficiencies on record, including 1 critical (life-threatening) violation. These warrant careful review before choosing this facility.
- • Grade D (43/100). Below average facility with significant concerns.
Bottom line: Trust Score of 43/100 indicates significant concerns. Thoroughly evaluate alternatives.
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About This Facility
What is Oxford Health & Rehab Center's CMS Rating?
CMS assigns OXFORD HEALTH & REHAB CENTER an overall rating of 3 out of 5 stars, which is considered average nationally. Within Mississippi, this rating places the facility higher than 99% of the state's 100 nursing homes. This mid-range rating indicates the facility meets federal standards but may have areas for improvement.
How is Oxford Health & Rehab Center Staffed?
CMS rates OXFORD HEALTH & REHAB CENTER's staffing level at 4 out of 5 stars, which is above average compared to other nursing homes. Staff turnover is 40%, compared to the Mississippi average of 46%. This relatively stable workforce can support continuity of care.
What Have Inspectors Found at Oxford Health & Rehab Center?
State health inspectors documented 23 deficiencies at OXFORD HEALTH & REHAB CENTER during 2021 to 2025. These included: 1 Immediate Jeopardy (the most serious level, indicating potential for serious harm or death), 1 that caused actual resident harm, and 21 with potential for harm. Immediate Jeopardy findings are rare and represent the most serious regulatory concerns. They require immediate corrective action.
Who Owns and Operates Oxford Health & Rehab Center?
OXFORD HEALTH & REHAB CENTER is owned by a for-profit company. For-profit facilities operate as businesses with obligations to shareholders or private owners. The facility is operated by ADVANCED HEALTH CARE MANAGEMENT, a chain that manages multiple nursing homes. With 120 certified beds and approximately 102 residents (about 85% occupancy), it is a mid-sized facility located in OXFORD, Mississippi.
How Does Oxford Health & Rehab Center Compare to Other Mississippi Nursing Homes?
Compared to the 100 nursing homes in Mississippi, OXFORD HEALTH & REHAB CENTER's overall rating (3 stars) is above the state average of 2.6, staff turnover (40%) is near the state average of 46%, and health inspection rating (2 stars) is below the national benchmark.
What Should Families Ask When Visiting Oxford Health & Rehab Center?
Based on this facility's data, families visiting should ask: "What changes have been made since the serious inspection findings, and how are you preventing similar issues?" "Can I visit during a mealtime to observe dining assistance and food quality?" "How do you handle medical emergencies, and what is your hospital transfer rate?" "Can I speak with family members of current residents about their experience?" These questions are particularly relevant given the facility's Immediate Jeopardy citations.
Is Oxford Health & Rehab Center Safe?
Based on CMS inspection data, OXFORD HEALTH & REHAB CENTER has documented safety concerns. Inspectors have issued 1 Immediate Jeopardy citation (the most serious violation level indicating risk of serious injury or death). The facility has a 3-star overall rating and ranks #1 of 100 nursing homes in Mississippi. Families considering this facility should ask detailed questions about what corrective actions have been taken since these incidents.
Do Nurses at Oxford Health & Rehab Center Stick Around?
OXFORD HEALTH & REHAB CENTER has a staff turnover rate of 40%, which is about average for Mississippi nursing homes (state average: 46%). Moderate turnover is common in nursing homes, but families should still ask about staff tenure and how the facility maintains care continuity when employees leave.
Was Oxford Health & Rehab Center Ever Fined?
OXFORD HEALTH & REHAB CENTER has no federal fines on record. CMS issues fines when nursing homes fail to meet care standards or don't correct problems found during inspections. The absence of fines suggests the facility has either maintained compliance or corrected any issues before penalties were assessed. This is a positive indicator, though families should still review recent inspection reports for the full picture.
Is Oxford Health & Rehab Center on Any Federal Watch List?
OXFORD HEALTH & REHAB CENTER is not on any federal watch list. The most significant is the Special Focus Facility (SFF) program, which identifies the bottom 1% of nursing homes nationally based on persistent, serious quality problems. Not being on this list means the facility has avoided the pattern of deficiencies that triggers enhanced federal oversight. This is a positive indicator, though families should still review the facility's inspection history directly.