DIVERSICARE OF SOUTHAVEN
For profit - Limited Liability company
140 Beds
DIVERSICARE HEALTHCARE
Data: November 2025
2 Immediate Jeopardy citations
Trust Grade
0/100
#158 of 200 in MS
Photo by Diversicare of Southaven
Photo by Diversicare of Southaven
Photo by Google Street View
1 / 5 photos
Last Inspection: March 2025
Within standard 12-15 month inspection cycle. Federal law requires annual inspections.
Overview
Families considering Diversicare of Southaven should note that it has received a Trust Grade of F, indicating significant concerns about the facility’s care and operations. Ranked #158 out of 200 nursing homes in Mississippi, it is in the bottom half of facilities statewide and the lowest option in De Soto County. Unfortunately, the facility's issues are worsening, increasing from 9 problems in 2024 to 14 in 2025. While staffing is a relative strength with a 3/5 rating and a turnover rate of 35%-better than the state average-serious incidents have occurred, including a resident escaping the facility unnoticed and another being transferred improperly, leading to a fall. Additionally, the facility has incurred $59,175 in fines, raising concerns about compliance with regulations.
- Trust Score
- F
- In Mississippi
- #158/200
- Safety Record
- High Risk
- Inspections
- Getting Worse
- Staff Stability ○ Average
- 35% turnover. Near Mississippi's 48% average. Typical for the industry.
- Penalties ✓ Good
- $59,175 in fines. Lower than most Mississippi facilities. Relatively clean record.
- Skilled Nurses ○ Average
- Each resident gets 36 minutes of Registered Nurse (RN) attention daily — about average for Mississippi. RNs are the most trained staff who monitor for health changes.
- Violations ⚠ Watch
- 40 deficiencies on record. Higher than average. Multiple issues found across inspections.
0/100
Bottom 21%
Review needed
9 → 14 violations
★☆☆☆☆
1.0
Overall Rating
★★★☆☆
3.0
Staff Levels
★★★☆☆
3.0
Care Quality
★☆☆☆☆
1.0
Inspection Score
↔
Stable
2024: 9 issues
2025: 14 issues
The Good
-
Full Sprinkler Coverage · Fire safety systems throughout facility
-
No fines on record
-
Staff turnover below average (35%)
13 points below Mississippi average of 48%
Facility shows strength in fire safety.
The Bad
1-Star Overall Rating
Below Mississippi average (2.6)
Significant quality concerns identified by CMS
Staff Turnover: 35%
11pts below Mississippi avg (46%)
Typical for the industry
Federal Fines: $59,175
Above median ($33,413)
Moderate penalties - review what triggered them
Chain: DIVERSICARE HEALTHCARE
Part of a multi-facility chain
Ask about local staffing decisions and management
The Ugly 40 deficiencies on record
2 life-threatening 5 actual harm
Mar 2025
2 deficiencies
2 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
Comprehensive Care Plan
(Tag F0656)
A resident was harmed · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview, record review, and facility policy review the facility failed to implement a resident's care plan when...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview, record review, and facility policy review the facility failed to implement a resident's care plan when Resident #1 was transferred without the required number of staff members and the use of the proper assistive devices for one (1) of three (3) residents care plans reviewed. Resident #1
Findings Include:
Record review of the facility policy titled, Comprehensive Care Plans revealed Policy: It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident .
A record review of the facility investigation revealed that on 3/14/25, while Resident #1 was being transferred to bed by Certified Nursing Assistant (CNA) #1, the resident stated, ow, and CNA #1 eased the resident to the floor. CNA #1 immediately notified the nurse. Upon evaluation, no injury or complaint of pain was noted. After assessing the resident, the Registered Nurse (RN) assisted her back to bed, identifying no apparent injury, bruising, or swelling. However, within 48 hours, swelling was observed above the right knee. An intervention was provided for comfort, and the physician was notified of the change in conditions. An X-ray revealed a fracture above the previous joint replacement device. The Nurse Practitioner (NP) and the Responsible Party were notified, and Resident #1 was transferred to the local emergency room for further evaluation and treatment.
Record review of the Comprehensive Care plan for Resident #1 revealed, under Focus I have a physical functioning deficit with transfers and require assistance from team members and an (proper lift name) total lift. Under Interventions : (proper lift name) total lift with medium yellow sling .Two (2) members will assist with transfers with each episode
On 3/26/25 at 9:15 AM, during an interview with the Administrator she verified that on the evening of 3/14/25, CNA #1 transferred Resident #1 to bed using a stand-pivot transfer method instead of a lift and had to lower the resident to the ground. During the transfer, the resident said, ow, but upon assessment by the RN, no injury was noted. She stated that within 48 hours, Resident #1 was moaning during care and an x-ray was ordered that showed the resident had a right femoral shaft fracture.
A record review of a printout of the Kiosk [NAME] for Resident #1 revealed the following: Safety .Two members will assist with transfers with each episode .Lift 4 Care: type of lift, sling size, etc. total lift with medium yellow sling.
During an interview with CNA #2, CNA #3, and CNA #4 on 3/26/25 at 10:00 AM confirmed that the residents [NAME] informed them of what the residents' care plans were and should be checked at the beginning of each shift. CNA #2, CNA #3, and CNA #4 all agreed that the [NAME] would show how many staff were needed for a resident transfer and what type of lift to use based on the resident's care plan.
On 3/26/25 at 11:32 AM, during a telephone interview with CNA #1 she confirmed that on the evening of 3/14/25 she transferred Resident #1 from the chair to the bed using the wrong type of lift method. She admitted that she did not look at or follow the residents' [NAME] or care plan but used the stand pivot method of transfer instead of a total lift. She confirmed that when she stood the resident up and pivoted her to the bed, the resident's knees buckled, and she lowered her to the floor.
During a follow-up interview with the Administrator on 3/26/25 at 12:00 PM, she stated that the care plan interventions for the total lift automatically pull to the [NAME] kiosk for the CNAs to follow. She confirmed that it was her expectation that CNAs check the [NAME] at the beginning of each shift and follow the care plan interventions.
Record review of the admission Record revealed the facility admitted Resident #1 on 4/10/18 with diagnoses that included dementia.
Record review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 2/9/25 revealed that Resident #1 has impaired range of motion (ROM) of lower extremities on both sides and maximal assistance for transfers.
SERIOUS
(G)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Actual Harm - a resident was hurt due to facility failures
Accident Prevention
(Tag F0689)
A resident was harmed · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Revised 6/4/25
After quality review by the Centers for Medicare and Medicaid Services Regional Office, the deficiency originally...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Revised 6/4/25
After quality review by the Centers for Medicare and Medicaid Services Regional Office, the deficiency originally cited at F 600 has been moved to F 689.
Based on staff interview, record review, and facility policy review, the facility failed to ensure a resident's environment was free from accident hazards when the facility staff failed to refer to the kiosk [NAME] to ensure staff transferred the resident with the required number of staff members and failed to use the proper assistive device for one (1) of three (3) residents reviewed. Resident #1
Findings Include:
Record review of the facility policy titled, Lift 4 Care-Safe 4 All revealed Purpose: To provide team members guidance with assisting patients and residents to safely reposition or transfer . 7. In order to maintain patients' and residents' safety , patients and residents should be lifted or transferred by the lift and sling, which is deemed appropriate after the lift evaluation is completed.
Record review of the facility [NAME] Guidelines revealed Purpose: to ensure optimal communication and connection between our caregivers and residents resulting in enhanced quality of care and life . The [NAME] will be reviewed daily in clinical startups and updated with any changes in a resident condition. Team members providing care will view the [NAME] through the POC (Plan of Care) portal.
A record review of the facility investigation revealed that on 3/14/25, while Resident #1 was being transferred to bed by Certified Nursing Assistant (CNA) #1, the resident stated, ow, and CNA #1 eased the resident to the floor. CNA #1 immediately notified the nurse. Upon evaluation, no injury or complaint of pain was noted. After assessing the resident, the Registered Nurse (RN) assisted her back to bed, identifying no apparent injury, bruising, or swelling. However, within 48 hours, swelling was observed above the right knee. An intervention was provided for comfort, and the physician was notified of the change in conditions. An X-ray revealed a fracture above the previous joint replacement device. The Nurse Practitioner (NP) and the Responsible Party were notified, and Resident #1 was transferred to the local emergency room for further evaluation and treatment.
A record review of the Computed Tomography (CT) scan of Resident #1's right knee from the local hospital, dated 3/20/25, revealed an acute comminuted periprosthetic fracture of the distal femoral metaphysis.
A record review of the Lift Transfer Evaluation, dated 4/7/24, revealed that Resident #1 required a total lift with a medium yellow sling for transfers.
A record review of a printout of the Kiosk [NAME] for Resident #1 revealed the following: Safety .Two members will assist with transfers with each episode .Lift 4 Care: type of lift, sling size, etc. total lift with medium yellow sling.
During an interview with the Administrator on 3/26/25 at 9:15 AM, she verified that the facility investigation confirmed that on the evening of 3/14/25, CNA #1 transferred Resident #1 to bed using a stand-pivot transfer method instead of a lift and had to lower the resident to the ground. During the transfer, the resident said, ow, but upon assessment by the RN, no injury was noted. She stated that within 48 hours, Resident #1 was moaning during care. Upon assessment by the nurse, the resident's right knee was swollen and tender to touch. The resident was assessed by the NP, who noted swelling but no other signs of trauma. A right knee X-ray was ordered on 3/19/25, and results received on 3/20/25 revealed a fracture of the femoral shaft. The NP was notified, and orders were given to transfer the resident to the hospital.
A record review of the Progress Notes from 3/14/25 through 3/20/25 confirmed that on 3/16/25, the resident was moaning during care, prompting the nurse to be notified. The resident was observed to have swelling in the right knee with tenderness to touch. The leg was elevated for comfort, and the NP was notified. On 3/17/25, the resident was assessed by the NP, who noted swelling in the right knee without redness, tenderness, warmth, or pain. The resident was diagnosed with right knee effusion, and the current treatment with diuretics was continued. On 3/19/25, the NP saw the resident again, observing no change in the knee's condition. An X-ray of the right knee was ordered. On 3/20/25, the NP noted that the resident continued to have knee swelling without pain. The X-ray results showed a femur fracture, and the NP ordered the resident's transfer to the emergency room for further evaluation and treatment.
During a telephone interview with CNA #1 on 3/26/25 at 11:32 AM, she confirmed that on the evening of 3/14/25, she transferred Resident #1 from the chair to the bed by standing the resident up and pivoting her to bed. She explained that while the resident was standing in front of the bed, the resident's knees buckled, and she lowered her to the floor. She called the nurse, and they assisted the resident back into bed. CNA #1 stated that the resident moaned at some point during the transfer. She added that she had always transferred the resident in this manner because that was how she had been taught when hired. She acknowledged being aware that the [NAME] on the kiosk provided information on the resident's care needs and transfer status. She also confirmed that, during her orientation, she was instructed to check the [NAME] at the beginning of each shift for any changes in the resident's needs or transfer requirements. CNA #1 admitted that she did not realize Resident #1 required a total lift for transfers because she had not checked the [NAME]. She agreed that failing to follow the [NAME] instructions could result in resident injury.
Record review of the admission Record revealed the facility admitted Resident #1 on 4/10/18 with diagnosis that include dementia.
Record review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 2/9/25 revealed that Resident #1 has impaired range of motion (ROM) of lower extremities on both sides and maximal assistance for transfers.
Mar 2025
12 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0583
(Tag F0583)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, record review, and facility policy review, the facility failed to secure electronic healt...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, record review, and facility policy review, the facility failed to secure electronic health records as evidenced by an Electronic Medication Administration Record (EMAR) visible while the medication cart was unattended on the [NAME] unit for two (2) of 58 residents residing on the [NAME] Hall. Residents #86 and Resident #104
Findings include:
A review of the facility policy with a date of May 1, 2012, titled Residents' Rights Summary, revealed Privacy and Confidentiality: The resident has the right to personal privacy and confidentiality of his/her personal and clinical records .
Resident #86
An observation on 3/18/25 at 9:10 AM revealed that a computer located on a medication cart on the [NAME] unit was opened with Resident #86's EMAR information visible on the screen. Licensed Practical Nurse (LPN) #1 was away from her medication cart, and the screen was visible to anyone passing the medication cart in the hallway. The visible information included Resident #86's name, medications, and room number.
An interview on 3/18/25 at 9:12 AM, LPN #1 confirmed that the EMAR for Resident #86 was visible on the screen to anyone walking by and should be closed when she was away from the medication cart to secure private health information. She stated, I had to step away from the cart to assist a resident but should have made sure the screen was closed.
A record review of Resident #86's admission Record revealed the resident was admitted to the facility on [DATE].
Resident #104
An observation on 3/18/25 at 11:44 AM revealed a medication cart on the [NAME] Hall was left unattended, and a computer sitting on the cart was opened with Resident #104's EMAR information visible on the screen and was visible to anyone passing by the medication cart in the hallway. The visible information included Resident #104's name, medications, and room number.
In an interview on 3/18/25 at 11:50 AM, LPN #1 confirmed that Resident #104's EMAR was visible on the screen to anyone walking by. She stated, I know I shouldn't have left the cart unattended with the resident's information left up; I know I did it earlier this morning, but I usually make sure the screen is closed when I leave the cart. LPN #1 confirmed that this violates the privacy of the residents' medical records.
An interview on 3/18/25 at 3:09 PM, the Director of Nursing (DON) confirmed that a resident's information should never be left up on the computer screen while the cart is unattended. He revealed Resident #86 and Resident #104's EMAR should not have been visible while the cart was unattended. He confirmed this is a privacy issue.
A record review of Resident #104's admission Record revealed the resident was admitted to the facility on [DATE].
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 F0692
(Tag F0692)
Could have caused harm · This affected 1 resident
Based on record reviews, staff interviews, and facility policy reviews, the facility failed to accurately monitor and document fluid intake for one (1) of six (6) residents receiving dialysis. Residen...
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Based on record reviews, staff interviews, and facility policy reviews, the facility failed to accurately monitor and document fluid intake for one (1) of six (6) residents receiving dialysis. Resident #32.
Findings Include:
Review of a statement, on company letter head, dated 3/19/25 and signed by the Administrator (ADM) revealed Standards of Practice, the expectation set forth by (Proper name of facility) management is that the nurses comply with current standards of practice in terms of following physician's orders and fluid restriction documentation.
A record review of the Order Summary Report for Resident #32 revealed an order for a one liter (1L) fluid restriction. Nursing was to provide 150 cubic centimeters (cc) on the 7:00 AM-3:00 PM shift, 150 cc on the 3:00 PM-11:00 PM shift, and 100 cc on the 11:00 PM-7:00 AM shift. Dietary was to provide 12 ounces (oz) of fluids on the breakfast tray, four (4) oz on the lunch tray, and four (4) oz on the dinner tray.
A record review of Resident #32's Electronic Medication Administration Record (eMAR) documentation of fluid intake from the last two weeks revealed the resident exceeded 1 liter fluid intake daily on the following days; 3/3/25, 3/5/25, 3/8/25, 3/9/25, 3/10/25, 3/12/25, 3/13/25, 3/14/25, and 3/17/25.
On 3/18/25 at 8:47 AM, during a review of the eMAR documentation of Resident #32's fluid intake with Licensed Practical Nurse (LPN) #1, she verified that the resident was on a one (1) liter per 24-hour fluid restriction. She confirmed that she only documented the 150 cc she administered during her shift and was unaware of how other nurses documented the resident's intake. She admitted that she did not know if the resident was adhering to the fluid restriction. Upon further review of the eMAR, she was unable to determine the resident's total 24-hour fluid intake. She acknowledged that it appeared the resident may have exceeded the one (1) liter fluid restriction on multiple days but was unsure of the accuracy due to inconsistent documentation. She agreed that accurately monitoring fluid intake is essential for a resident on dialysis to prevent fluid overload.
On 3/18/25 at 8:50 AM, during an interview and record review of the eMAR documentation of Resident #32's fluid intake with the Director of Nursing (DON), he confirmed that he was unable to determine if the resident was adhering to his fluid restriction. He agreed that it appeared the resident may have exceeded one (1) liter on multiple days but was unsure how staff were documenting fluid intake. The DON stated that he was uncertain whether the 7:00 AM-3:00 PM and 3:00 PM-11:00 PM shifts included the fluid the resident received with his meals.
During an interview and record review of Resident #32's eMAR fluid intake documentation with the Nurse Practitioner (NP) on 3/18/25 at 10:00 AM, she stated that based on the documentation, it appeared the resident was not adhering to his fluid restriction. However, she could not be certain due to the inconsistent and unclear documentation. She agreed that failure to accurately monitor fluid intake could exacerbate the residents' medical conditions.
A record review of the admission Record revealed that the facility admitted Resident #32 on 01/31/2020 with a diagnosis of End-Stage Renal Disease.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0761
(Tag F0761)
Could have caused harm · This affected 1 resident
Based on observation, staff interviews, and facility policy review the facility failed to ensure a medication cart was locked and medications were secured for one (1) of four (4) survey days.
Finding...
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Based on observation, staff interviews, and facility policy review the facility failed to ensure a medication cart was locked and medications were secured for one (1) of four (4) survey days.
Findings include:
Record review of the facility policy titled, Medication Storage with a revision date of 04/23 revealed .It is the responsibility of the facility to keep the medication cart locked and secure at all times when not in use . Medications or sharps cannot be stored on top of the medication cart. All safety measures must be taken to protect the residents from accessing medications and other objects that could potentially harm the resident or others .
An observation on 3/18/25 at 11:44 AM revealed the [NAME] Wing medication cart sitting by the door of room W-18. The medication cart was unattended and unlocked, and sitting on the cart was a medication cup with six (6) pills in it. Two visitors walked by the unattended medication cart.
An observation and interview on 3/18/25 at 11:50 AM Licensed Practical Nurse (LPN) #1 returned to the medication cart and confirmed she left the cart unlocked and medications sitting on top of the cart. She revealed she was getting ready to give a resident their medication but stepped away from the medication cart to help move a bed and should never have done that. She revealed she should have secured the medications or completed her task and never left the cart unlocked or the medications exposed. She revealed it could have put others in danger. LPN #1 confirmed the pills in the medication cup were Lasix, Amiodarone, Protonix, Eliquis, Tamsulosin, and Midodrine.
In an interview on 3/18/25 at 3:09 PM, the Director of Nurses (DON) revealed that our expectation and policy is that all medication carts are locked and that medications are kept secure when a medication cart is unattended. He revealed this is a nursing standard of practice.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Medical Records
(Tag F0842)
Could have caused harm · This affected 1 resident
Based on observation, staff interview, record review and facility policy review the facility failed to ensure accurate documentation of the care and services provided for a resident with a Peripherall...
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Based on observation, staff interview, record review and facility policy review the facility failed to ensure accurate documentation of the care and services provided for a resident with a Peripherally Inserted Central Catheter (PICC) for one (1) of three (3) residents receiving IV (Intravenous) therapy. Resident #430
Findings Include:
Record review of the facility policy titled Purpose of the Patient Record revealed Process; clinical records are maintained to provide complete and accurate patient information for continuity of care .
On 3/19/25 at 9:18 AM, an observation of Registered Nurse (RN) #4 revealed she flushed Resident #430's PICC located on the right upper arm with 10 ML (milliliters) normal saline and started Vancomycin (antibiotic) infusing via dial a flow. There was a transparent dressing over the residents' PICC line dated 3/14/25.
Record review of Resident #430's Electronic Medication Administration Record (EMAR) revealed the resident did not have an order to flush the PICC or to change the dressing.
An interview with RN #5 on 3/19/25 at 9:45 AM, confirmed Resident #430 did not have a physician's order to flush the PICC or to change the dressing. She confirmed the resident should have an order to keep the line patent and prevent it from becoming occluded. She stated, We just do it.
An interview with the Director of Nursing on 3/19/25 at 9:56 AM confirmed Resident #430 should have PICC care orders to ensure the line remained patent and free from complications.
Review of the admission Record revealed the facility admitted Resident #430 on 2/27/25 with medical diagnosis that included Aftercare following Explantation of the Knee Joint Prosthesis.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0925
(Tag F0925)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, resident and staff interview, and record review, the facility failed to maintain an effective pest control...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, resident and staff interview, and record review, the facility failed to maintain an effective pest control program to address and eliminate the presence of mice droppings in the resident's dresser drawers, posing a potential risk of contamination and health hazards for one (1) of 134 resident's rooms observed (Resident #70).
Findings include:
Review of the facility's policy titled Pest Control, with an effective date of September 1, 2014, revealed the policy stated: Purpose: It is the policy of this center to maintain an effective pest control program .
During an interview with Resident #70 on 3/17/25 at 3:08 PM, the resident stated that her husband noticed mice droppings inside her dresser drawers while assisting her with retrieving clothing. Resident #70 further stated she reported the presence of the mouse droppings to staff.
An observation of Resident #70's dresser drawers, conducted with Certified Nurse Assistant (CNA) #10 on 3/17/25 at 3:10 PM, revealed numerous amounts of what black substances the size of pieces of rice in the second, third, and fourth drawers. CNA #10 confirmed the presence of the black substance and stated it appeared to be mice droppings and stated that mice carry diseases, expressing concern regarding the findings.
During an interview with Registered Nurse (RN) #1 on 3/18/25 at 10:45 AM, RN #1 confirmed the presence of mice droppings in Resident #70's dresser drawers. RN #1 stated the resident's clothing would be contaminated with feces and bacteria as a result.
During an interview with the Administrator on 3/18/25 at 10:50 AM she confirmed that the droppings could cause potential health concerns.
During an interview with the Maintenance Supervisor on 3/18/25 at 11:10 AM, he stated the mice droppings in Resident #70's dresser drawers had been reported to him through a work order dated 3/15/25.
Review of the work order, provided by the Maintenance Supervisor, revealed staff reported mice and mice dropping in (Resident #70's room number removed), entered on 3/15/25 at 12:07 PM.
Record review of Resident #70's admission Record revealed the resident was admitted on [DATE] with a diagnosis of Occlusion and Stenosis of an Unspecified Vertebral Artery.
Record review of Resident #70's Minimum Data Set (MDS), Section C with an Assessment Reference Date (ARD) of 2/22/25, revealed a Brief Interview for Mental Status (BIMS) score of 15, indicating the resident was cognitively intact.
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0558
(Tag F0558)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Resident #42
An observation on 3/17/25 at 10:25 AM revealed Resident #42 lying in bed asleep; the resident's call light was posi...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Resident #42
An observation on 3/17/25 at 10:25 AM revealed Resident #42 lying in bed asleep; the resident's call light was positioned inside the closed drawer of his nightstand, making it inaccessible.
An observation on 3/17/25 at 1:20 PM and again at 3:45 PM revealed the call light hanging down on the left side of the nightstand and was not within reach of the resident.
An observation on 3/18/25 at 8:30 AM revealed that Resident #42 was lying in bed; his call light was hanging down from the wall and positioned to the right of the nightstand on the floor, and out of reach of the resident.
During an interview and observation on 3/18/25 at 11:16 AM of Resident #42's call light position, CNA #4 confirmed the call light was hanging down from the wall and positioned to the right of the nightstand on the floor and was inaccessible to the resident and had not been accessible all morning. She revealed his call light should always be within reach so we can be notified if he needs anything.
An interview on 03/18/25 at 2:15 PM, the Director of Nurses (DON) confirmed that staff are expected to ensure call lights are always within residents' reach. The DON stated, Residents should always have access to their call lights to request assistance. This is a critical aspect of resident safety and care.
A record review of Resident #42's admission Record revealed he was admitted to the facility on [DATE] with diagnoses that included Hemiplegia and Hemiparesis following Cerebral Infarction affecting Right Dominant Side.
Based on observation, staff and resident interview, record review, and facility policy review, the facility failed to ensure that resident call lights were within reach, which limited a resident's ability to request assistance as needed for two (2) of 134 residents observed on survey. Resident #32 and Resident #42
Findings include:
Review of the facility policy with a revision date of October 2022 titled Call Lights: Accessibility and Timely Response revealed, The purpose of this policy is to assure the facility is adequately equipped with a call light at each residents' bedside, toilet, and bathing facility to allow residents to call for assistance . 5. Staff will ensure the call light is within reach of residents and secured, as needed .6. The call system will be accessible to residents while in their bed or other sleeping accommodations within the resident's room .
Resident # 32
An observation and interview on 3/17/25 at 10:30 AM revealed Resident #32 in bed with the call light wrapped around the side rail on the right side of the bed and hanging out of the resident's reach. When asked how he called the staff for assistance, he stated I use the call light if I can find it, you can't push what you can't find.
An observation of Resident #32's room and interview with Registered Nurse (RN) #2 and Certified Nursing Assistant (CNA) #2 on 3/17/25 at 10:32 AM, they verified that the call light was wrapped around the side rail on the right side of the bed and hanging out of the resident's reach. CNA #2 stated that is on me, I just left to throw something away and forgot to put it where he could reach it, I was coming back. RN #2 confirmed that the call light should be kept in the resident's reach because if there was a problem or emergency the resident would not be able to call for assistance.
Record review of the admission Record revealed that the facility admitted Resident #32 on 01/31/2020 with diagnoses that included Blindness Right Eye and End Stage Renal Disease.
Record review of the Minimum Data Set (MDS) with an Assessment Reference Date of 12/22/24 for Resident #32 revealed a Brief Interview for Mental Status (BIMS) score of 15, indicating that the resident is cognitively intact.
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Safe Environment
(Tag F0584)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Resident #17
An observation and interview on 3/17/25 at 11:30 AM revealed three white bath towels lying on the floor in front of...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Resident #17
An observation and interview on 3/17/25 at 11:30 AM revealed three white bath towels lying on the floor in front of the air conditioner unit in Resident #17's room. Resident #17 revealed that staff change those towels out but was not sure why they were there. Resident #17 stated that the towels may be for the air conditioner but admitted they looked messy. During this observation a thick black substance was noted covering the entire bottom base of the resident's overbed table.
On 3/18/25 at 8:44 AM, an observation revealed no changes in Resident #17's overbed table and the three white bath towels remained lying on the floor in front of the air conditioner unit.
During an interview on 3/18/25 at 2:37 PM, Housekeeper #2 revealed that the air conditioner in Resident #17's room leaks, and they change out the towels every day and sometimes two times a day. She revealed it had been reported to the previous administrator.
During an observation and interview on 3/18/25 at 2:50 PM, the Director of Nurses (DON) confirmed towels were lying on the floor in front of the air conditioner unit, and the overbed table had a thick black substance over the metal base. During this observation, it was noted that the resident's window had a white towel stuck in the side, and there was a gap of approximately three (3) inches to the remaining top of the window, which exposed the outside elements. There was no screen in the window. Resident #17 revealed they put that towel in there but didn't stop the whole gap. He revealed the window didn't close. The DON confirmed that the window had a gap of approximately 3 inches with a towel positioned in it and was open to the outside elements. He revealed Resident #17 should have a clean, functional room that is free of outside elements. He revealed this is just not acceptable.
During an interview on 3/18/25 at 3:00 PM, the Maintenance Supervisor revealed he wasn't aware of the air conditioner unit leaking and didn't have a work order for it and, therefore, wasn't aware of the towels on the floor under the unit. He revealed he was aware of the gap in the window and that he used to have a helper, and he thought that the helper had repaired the window.
A record review of Resident #17's admission Record revealed the resident was admitted on [DATE] with diagnoses that included Unspecified Dementia and Anxiety Disorder.
A record review of Resident #17's MDS, Section C, with an ARD of 2/7/25, revealed a BIMS score of 5, indicating severe cognitive impairment.
Based on observations, resident and staff interviews, record review, and facility policy review, the facility failed to provide a safe, clean, and homelike environment for nine (9) of 134 residents residing in the facility. (Residents #14, # 17, #32, # 70,, #71, #79, #87, #93, and #95).
Findings include:
Review of the facility policy titled, Room Audit, with an effective date of September 1, 2014, revealed, Purpose: To assess resident rooms to identify items that should be repaired, replaced, or addressed to ensure a home-like standard that meets acceptable standards .General Room Appearance - Housekeeping issues should be noted and reported to housekeeping. Damaged drywall, furniture, or non-functioning equipment should be noted, a work order created and addressed accordingly to priority .
Resident #14
During an observation of Resident #14's room and interview with the resident on 3/17/25 at 11:10 AM revealed the headboard of the resident's bed was broken on both sides, exposing jagged wood edges. Pieces of the broken headboard were observed lying on the floor behind the bed. He stated the headboard had been broken for a while and confirmed he reported it to staff.
A follow-up observation of Resident #14's room on 3/18/25 at 8:58 AM revealed the headboard remained broken with jagged edges exposed.
An observation conducted with Registered Nurse (RN) #1 on 3/18/25 at 10:45 AM confirmed the headboard was broken in half on both sides, with jagged edges of wood exposed. She stated that the jagged edges could potentially injure the resident.
During an interview with the Administrator on 3/18/25 at 10:55 AM confirmed the broken headboard should have already been identified and repaired. She acknowledged the condition could cause concerns for the resident's safety.
During an interview on 3/18/25 at 11:10 AM the Maintenance Supervisor revealed he was unaware of the broken headboard in Resident #14's room. He confirmed staff should have reported the issue and entered a work order. He acknowledged the jagged edges of the headboard could be dangerous.
Record review of Resident #14's admission Record revealed the resident was admitted on [DATE] with diagnoses that included Type II Diabetes Mellitus.
Record review of Resident #14's Minimum Data Set (MDS), Section C with an Assessment Reference Date (ARD) of 1/24/25, revealed a Brief Interview for Mental Status (BIMS) score of 12, indicating moderate cognitive impairment.
Resident #70
During an interview with Resident #70 on 3/17/25 at 3:08 PM, the resident stated her husband noticed mice droppings inside her dresser drawers while helping her retrieve clothing. Resident #70 stated she reported the mouse droppings to staff.
An observation of Resident #70's dresser drawers conducted with Certified Nurse Assistant (CNA) #10 on 3/17/25 at 3:10 PM revealed numerous amounts of black substances approximately the size of rice in the second, third, and fourth drawers. CNA #10 confirmed the presence of the black substances and revealed it appeared to be mice droppings and expressed concern that mice carry diseases.
During an interview with RN #1 on 3/18/25 at 10:45 AM confirmed the presence of what appeared to be mice droppings in Resident #70's dresser drawers. RN #1 stated the resident's clothing would be contaminated with feces and bacteria.
During an interview with the Administrator on 3/18/25 at 10:50 AM confirmed the substance that appeared to be mice droppings should have been cleaned immediately upon discovery to prevent health concerns.
During an interview with the Maintenance Supervisor on 3/18/25 at 11:10 AM it was revealed that mice droppings in Resident #70's dresser drawers were reported to him on 3/15/25. He confirmed staff should have cleaned the droppings at the time they were discovered to avoid potential health concerns.
Record review of Resident #70's admission Record revealed the resident was admitted on [DATE] with diagnoses that included Occlusion and Stenosis of an Unspecified Vertebral Artery.
Record review of Resident #70's MDS, Section C with an ARD of 2/22/25, revealed a BIMS score of 15, indicating the resident was cognitively intact.
Resident #79
An observation of Resident #79's room on 3/17/25 at 11:00 AM revealed a hole in the wall beside the resident's bed, with a metal vent cover hanging out of the hole.
An observation of Resident #79's room conducted with RN #1 on 3/18/25 at 10:41 AM confirmed there was a hole in the wall and the vent cover was hanging out. She stated the condition posed a potential hazard because the resident could injure himself on the vent cover or stick his arm into the hole.
During an interview on 3/18/25 at 10:54 AM the Administrator confirmed the hole in Resident #79's wall was a hazard and should have been identified and addressed.
During an interview on 3/18/25 at 11:04 AM the Maintenance Supervisor revealed he was unaware of the hole in Resident #79's wall until today. He measured the hole as approximately four by six inches in diameter and confirmed staff should have identified the damage and submitted a work order. He stated he makes weekly rounds to check for maintenance concerns but did not have documentation of the rounds conducted.
Record review of Resident #79's admission Record revealed the resident was admitted on [DATE] with diagnoses that included Obstructive Hydrocephalus.
Resident # 32
An observation of Resident #32's bed on 3/17/25 at 10:34 AM, revealed Resident #32 in bed with the bed remote control wrapped around the side rail on the right side of the bed with two (2) inches of wire exposed on the cord.
An observation of Resident #32's bed and interview with RN #2 on 3/17/25 at 10:34 AM ,she verified that the wires on the bed remote control were exposed and that they could be a safety hazard because the exposed wires could cause a shock.
During an interview on 3/18/25 at 2:00 PM the Maintenance Director stated that he was not notified prior to 3/17/25 that the resident's remote had exposed wires. He confirmed that the wires were exposed and agreed that it could have caused a risk of shock. He revealed that staff were supposed to notify him of maintenance issues by putting in a work order.
Record review of the admission Record revealed that the facility admitted Resident #32 on 01/31/2020 with diagnoses that included End Stage Renal Disease.
Record review of the MDS with an ARD of 12/22/24 for Resident #32 revealed a BIMS score of 15, indicating that the resident is cognitively intact.
Resident # 71
An observation of Resident #71's room on 3/17/25 at 11:31 AM with CNA #2 revealed the mattress was noted to have a 12 by 12 inch area of sagging to the middle portion of the mattress, as well as a 36 by 12 inch, irregular shaped area in which the top layer of the mattress was peeling off exposing the under layer. The bed was electric, but staff could not raise or lower the head, foot or height of the bed. CNA #2 verified that the mattress was in disrepair and the bed was not working. She stated they had gotten the resident out of bed because of this. She stated she was unsure of how long the mattress had been in disrepair or how long the bed wasn't working stating We report these things all the time and we can never get anyone to fix them. She stated that they put in a work order to notify maintenance. She agreed that the bed being in disrepair could negatively affect the resident's comfort and positioning.
An interview on 3/18/25 at 2:02 PM the Maintenance Director confirmed that staff were to notify him via work order if something needs to be fixed. He stated that he was not notified prior to 3/17/25 that the resident's mattress and bed was in disrepair. He verified that the mattress and the remote control on the bed had to be replaced. He agreed that the bed being in disrepair could negatively affect the resident's comfort and positioning.
Record review of the admission Record revealed that the facility admitted Resident #71 on 3/27/23 with diagnoses that included Systolic Congestive Heart Failure.
Resident #93
An observation and interview on 3/17/2025 at 10:20 AM and again on 3/18/2025 at 11:00 AM revealed Resident #93 lying in bed with his overbed light on. He revealed that his overbed light had been broken for some time and that he had informed the staff about it. This observation revealed that the overhead light lacked a pull string, preventing him from turning it off.
An observation and interview with RN #1 on 3/18/2025 at 11:12 AM confirmed that Resident #93's light was broken. She explained that staff members were responsible for reporting broken items to maintenance for repairs.
During an interview with the Administrator on 3/18/2025 at 11:50 AM, she confirmed that staff members were responsible for reporting necessary repairs to maintenance, while maintenance was responsible for fixing them. She also acknowledged that Resident #93 should have had functioning equipment in his room.
Record review of the admission Record revealed Resident #93 had been admitted to the facility on [DATE] with a medical diagnosis that included Aphasia following Cerebral Infarction.
Record review of the MDS with an ARD of 12/24/2024, indicated that under section C, the BIMS score was 6, which indicated that Resident #93 was severely cognitively impaired.
Resident #95
An observation of Resident #95's room on 3/18/2025 at 10:37 AM revealed that the curtains over the windows were stained with large, dark brown marks. Additionally, 10 brown boxes containing various enteral feeding supplies were stacked on the floor.
During an interview with RN #1 on 3/18/2025 at 11:12 AM, she confirmed that Resident #95's curtains were dirty and needed to be washed. She also acknowledged that the boxes on the floor had created clutter and posed a fall risk. RN #1 confirmed that the resident should have a clean and clutter-free environment.
An interview with the Administrator on 3/18/2025 at 11:50 AM, she confirmed that Resident #95 should have a clean and safe living environment.
Record review of the admission Record revealed Resident #95 was admitted to the facility on [DATE] with a medical diagnosis that included Dysphagia following Cerebral Infarction.
Resident #87
On 3/17/25, at 10:30 AM, and again on 3/18/25, at 11:10 AM, an observation of Resident #87's room revealed multiple large brown spots on the window curtains and four boxes stacked on the floor containing tube feeding supplies. Further observation revealed a broken left bed rail, and an oxygen concentrator covered in a gray and white powdery substance. The wall behind the oxygen concentrator had a dried yellow substance.
During an interview with RN #1 on 3/18/25 at 11:12 AM, she confirmed the presence of the boxes on Resident #87's floor and revealed that she was informed by central supply that the boxes were to be stored in the resident's room. She mentioned that the boxes were previously kept in central supply but was unsure why they were no longer stored there. RN #1 acknowledged that the boxes on the floor posed a potential hazard for staff and visitors. She also revealed that she reported any broken equipment to maintenance but was unaware of Resident #87's broken bed rail.
An interview with the Maintenance Director on 3/18/25 at 2:26 PM revealed that he did not conduct routine room rounds, as department heads completed Embrace rounds. He explained that any necessary repairs were documented in the computer work-order system or reported directly by staff. He revealed he was unaware of Resident #87's broken bed rail.
Record review of the admission Record revealed the facility admitted Resident # 87 on 01/04/2025 with a medical diagnosis that included Hemiplegia and Hemiparesis following Cerebral Infarction affecting Right Dominant Side.
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Comprehensive Care Plan
(Tag F0656)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, resident and staff interview, record review, and facility policy review, the facility failed to implement ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, resident and staff interview, record review, and facility policy review, the facility failed to implement an activities of daily living (ADL) care plan for resident's dependent on staff assistance (Residents #12, #111, and #118) and failed to implement a care plan related to fluid restriction for (Resident #32) for four (4) of 45 resident care plans reviewed.
Findings include:
Review of the facility policy titled, MDS (Minimum Data Set) and Care Plans, with an effective date of August 2019, revealed, Policy: Care plans will be developed per the RAI (Resident Assessment Instrument) guidelines.
Resident #12
A record review of Resident #12's Care Plan revealed that he had a self-care deficit related to (Cerebral Vascular Accident) with left hemiplegia, impaired cognition, and immobility with interventions that included Nail, hair, shave and oral care daily and as needed.
An observation on 3/17/25 at 12:05 PM and again on 3/18/25 at 9:20 AM of Resident #12's mouth and gums revealed a thick white substance that was adhered to the upper and lower gum lines.
During an interview and observation on 3/18/25 at 11:00 AM, Certified Nurse Aide (CNA) # 6 confirmed that Resident #12's teeth were bed and had a lot of gunk on them. She admitted that it looked like it had been a long time since his teeth had been taken care of.
During an interview on 3/18/25 at 3:26 PM, the Director of Nurses (DON) revealed that all residents are to be adequately groomed, including oral care. He revealed that his care plan was not followed if the resident was not provided with oral care as he should have been.
A review of the admission Record for Resident #12 revealed he was admitted to the facility on [DATE] with diagnoses that included Alzheimer's Disease, and Hemiplegia and Hemiparesis following Cerebral Infarction affecting the Left Dominant Side.
Resident #111
Record review of Resident #111's Care Plan revealed that she had an ADL self-care performance deficit related to Dementia, Parkinson's, abnormal gait and mobility with interventions that included Bathing/Showering: Check nail length and trim and clean .daily as needed on bath day and as necessary. Report any changes to the nurse.
An observation and interview on 3/17/25 at 10:54 AM revealed Resident #111's fingernails were long, jagged and had a brown substance under each nail. Resident #111 stated that his nails were sharp and needed cut and cleaned.
An observation and interview on 3/18/25 at 9:05 AM Resident #11 revealed no change in the appearance of her fingernails. She stated that she got cleaned up last night, but they did not do anything with her nails.
During an interview on 03/18/25 at 2:00 PM, the DON confirmed that residents should receive assistance with their ADLs, including proper nail care. He revealed that if the resident's fingernails were not adequately groomed, their care plan was not being followed, and it should have been.
A review of the admission Record for Resident #111 revealed she was admitted to the facility on [DATE] for diagnoses which included Type 2 Diabetes Mellitus and Parkinson's Disease.
A review of the MDS with an ARD of 3/13/25 revealed Resident #111 had a BIMS of 15, indicating the resident was cognitively intact.
Resident #118
Review of the care plan for Resident #118 titled, I have ADL self-care performance deficit r/t (related to) weakness, impaired cognition, with a revision date of 2/24/2025 revealed interventions: Personal Hygiene: The resident requires limited assistance x (1) one staff with personal hygiene and oral care.
An observation and interview with Resident #118 on 3/17/2025 at 10:15 AM revealed the residents' fingernails were long, jagged with a dark brown substance present underneath the nail beds. Resident #118 stated that he did not like his fingernails to be long and could not recall the last time they had been trimmed.
An observation on 3/18/2025 at 10:48 AM was conducted with RN #1 who confirmed that Resident #118's fingernails needed cut and cleaned and looked like it had been a while since they were taken care of.
During an interview with the DON on 3/18/2025 at 11:10 AM, he confirmed after review of the ADL care plan for Resident #118 that staff did not implement the care plan related to personal hygiene. He stated the purpose of the care plan is to direct staff on how to care for the residents. He also stated that concerns from staff not implementing care plans are that the residents may not receive the care they need.
A review of the admission Record for Resident #118 revealed he was admitted on [DATE], with diagnoses including a Need for Assistance with Personal Care and Urinary Tract Infection.
Resident #32
A record review of the Care Plan for Resident #32 revealed Focus: [Resident Proper Name] has alteration in Kidney Function Due to End Stage Renal Disease (ESRD), evidenced by hemodialysis, left nephrostomy tube. Goal: I will reduce short term complications associated with impaired renal function through review date. Interventions: one liter (1L) fluid restriction. Nursing to provide: 150 cc on 7-3 shift, 150 cc fluids on 3-11 shift, 100 cc fluids on 11-7 shift. Dietary to provide: 12 oz fluids on breakfast tray, 4 oz fluids on lunch tray, 4 oz fluids on dinner tray.
A record review of Resident #32's Electronic Medication Administration Record (eMAR) documentation of fluid intake revealed the resident was on a 1-liter fluid restriction daily and there were 9 days out of the last two weeks that indicated fluid intake exceeded 1 liter within a 24-hour period. Those days were 3/3/25, 3/5/25, 3/8/25, 3/9/25, 3/10/25, 3/12/25, 3/13/25, 3/14/25, and 3/17/25.
During an interview and record review of Resident #32's documented fluid intake with Licensed Practical Nurse (LPN) #1 on 3/18/25 at 8:47 AM, she stated that Resident #32 was on a 150-cc fluid restriction for the 7:00 AM-3:00 PM shift. She clarified that this did not include his fluid intake from breakfast or lunch, only the fluids administered by the nursing staff during her shift. She admitted that she did not check his meal trays to verify that dietary provided the ordered amount of fluid for breakfast and lunch, nor did she monitor or document his fluid intake from those meals. After record review, LPN #1 verified that it was hard to tell from the documentation how much the resident was actually getting but appeared that the resident may have went over the one liter limit a few day.
On 3/18/25 at 8:50 AM, during an interview and record review with the DON, he admitted that Resident #32 may have exceeded the one liter daily limit for multiple days.
During an interview on 3/20/25 at 9:30 AM, with the MDS Nurse stated that the care plan is formulated as a guideline for resident care based on their needs. She agreed that the interventions are to be followed by staff in order for the residents to reach their goals. She stated that the staff's failure to accurately monitor and document Resident 32's fluid restriction was a failure to implement his current care plan.
A record review of the admission Record revealed that the facility admitted Resident #32 on 01/31/2020 with a diagnosis of End-Stage Renal Disease.
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
ADL Care
(Tag F0677)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, resident and staff interview, record review, and facility policy review, the facility failed to provide ac...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, resident and staff interview, record review, and facility policy review, the facility failed to provide activities of daily living (ADL) care for resident's dependent on staff assistance for three (3) of five (5) residents reviewed for ADL's. (Residents #12, #111, and #118).
Findings include:
Review of the facility policy titled ADLs, effective August 2021, revealed the following: Policy: Ensure ADLs are provided in accordance with accepted standards of practice, the care plan, and reasonable accommodation of the resident's choice and preferences.
Resident #12
An observation on 3/17/25 at 12:05 PM and again on 3/18/25 at 9:20 AM revealed that Resident #12's upper and lower teeth were covered in a thick white substance that adhered to the upper and lower gum lines.
During an interview and observation on 3/18/25 at 11:00 AM, Certified Nurse Aide (CNA) #6 confirmed Resident #12's teeth were bad and had a bunch of gunk on them. She revealed she honestly thought they looked like it had been quite some time since his mouth had been tended to.
During an interview on 03/18/25 at 2:10 PM, Registered Nurse (RN) #3 revealed that Resident #12 has a hospice aide that comes twice a week and provides personal hygiene but admits that it is all of their responsibility to make sure the residents oral care is taken care of. She stated that there is no excuse for a residents' daily oral care to not be completed.
During an interview on 3/18/25 at 3:26 PM, the Director of Nurses (DON) revealed that all residents are to be adequately groomed, including oral care.
A record review of Resident #12's admission Record revealed he was admitted to the facility on [DATE] with diagnoses that included Alzheimer's Disease, and Hemiplegia and Hemiparesis following Cerebral Infarction affecting Left Dominant Side.
Resident #111
An observation and interview on 3/17/25 at 10:54 AM revealed Resident #111's fingernails to be one and one-half (1.5) inches long past the tip of the fingers, jagged in appearance with a brown substance under the nail beds. Resident #111 stated, I am a diabetic, and the nurse has to cut them. They are sharp, and I don't like them this long. I'm not sure when the last time they were cut and cleaned.
An observation and interview on 3/18/25 at 9:05 AM with Resident #111 revealed she got cleaned up last night by the bath girl but admitted that she didn't get her fingernails cut. Her fingernails remain long and jagged. She revealed the girl who gave her a bath couldn't cut her fingernails because she is diabetic, and the nurse had to cut them. She stated, I don't know when I will get my fingernails trimmed, but they need them.
An interview and observation on 3/18/25 at 11:10 AM CNA #5 revealed she was assigned to the resident today and confirmed that the resident's nails were long and jagged. She revealed that she couldn't cut them since the resident is diabetic, but we are supposed to notify the nurses when we notice the fingernails are long and need to be cut. She revealed she had not reported it to the nurse.
During an interview and observation on 3/18/25 at 11:15 AM, Licensed Practical Nurse (LPN) #3 confirmed that the resident is diabetic, and the nurses are responsible for trimming the resident's fingernails. She confirmed Resident #111's nails were long and jagged and needed to be trimmed. Resident #111 stated, I would like my fingernails cut.
During an interview on 03/18/25 at 2:00 PM, the DON confirmed that Resident #111 should receive assistance with their ADLs, including proper nail care.
A record review of the admission Record for Resident #111 revealed she was admitted to the facility on [DATE] with diagnoses which included Type 2 Diabetes Mellitus and Parkinson's Disease.
A record review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 3/13/25 revealed Resident #111 had a Brief Interview of Mental Status (BIMS) score of 15 indicating the resident was cognitively intact.
Resident #118
An observation of Resident #118 on 3/17/2025 at 10:15 AM revealed the resident had jagged fingernails approximately one-half (½) inch in length with a dark brown substance present underneath the nail beds. During an interview conducted at the time of the observation, Resident #118 verbalized he did not like his fingernails to be long and could not recall the last time they had been trimmed.
A subsequent observation and interview on 3/18/2025 at 10:48 AM was conducted with RN #1, she confirmed that Resident #118's fingernails were long, jagged, and visibly soiled with a dark brown substance under the nail beds. RN #1 further acknowledged the nails appeared untrimmed for a prolonged period and required attention. RN #1 expressed concern that the resident could potentially scratch himself, increasing the risk of skin breakdown or infection due to the dirty nails.
During an interview with the DON on 3/18/2025 at 11:10 AM he confirmed that Resident #118 was dependent on staff assistance for personal care and should have already received nail care.
A record review of the admission Record for Resident #118 revealed he was admitted on [DATE], with diagnoses including A Need for Assistance with Personal Care.
Record review of the MDS with an ARD of 1/28/25 revealed Resident #118 had a BIMS score of 09, indicating the resident had moderate cognitive impairment.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Accident Prevention
(Tag F0689)
Could have caused harm · This affected multiple residents
Based on observation, staff interview, Safety Data Sheet review, and facility policy review, the facility failed to safely store and lock hazardous cleaning chemicals on two (2) of three (3) housekeep...
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Based on observation, staff interview, Safety Data Sheet review, and facility policy review, the facility failed to safely store and lock hazardous cleaning chemicals on two (2) of three (3) housekeeping carts observed during survey.
Findings include:
Review of facility policy titled Environmental Services Chemical Use/Dilution and Hazards revealed Overview of proper chemical use .6. Each housekeeping cart has a lockbox. All chemicals are to be stored in the lock box. Do not leave your cart unattended .
An observation and interview on 3/17/25 at 10:50 AM revealed an unattended housekeeping cart on the west hall that was unlocked. An interview at this time with Housekeeper #5 confirmed that the housekeeping cart was not locked. She then stated that the door on the side of the cart and the roll cabinet on the top of the cart did not lock. Further observation of the cart with Housekeeper #5 revealed that the following chemicals were stored on the cart: Crew Bathroom Disinfectant Cleaner, Virex Plus One-step disinfectant cleaner & deodorant, and Crew clinging Toilet bowl cleaner. Housekeeper #5 stated that she was not sure how long the lock had not worked and at one point someone had used tape to keep the door shut, but they really needed new ones. She stated that the cart is supposed to be locked to keep the chemicals away from the residents because they are dangerous and could hurt them if they drank it or got it on them.
An observation and interview on 3/17/25 at 11:00 AM with Housekeeper #4 revealed that the rehabilitation hall housekeeping cart was locked but the following chemicals were stored outside the cart, within resident reach: Crew Bathroom Disinfectant Cleaner, Virex Plus One step disinfectant cleaner & deodorant, and Crew clinging Toilet bowl cleaner. Housekeeper #4 stated that he stored the chemicals there because he did not have a key to unlock the cart. He stated that he has worked at the facility for about a month. He stated that the cart is supposed to be locked to keep the chemicals away from the residents because they are dangerous and could hurt them if they drank it or got it on them.
An interview with the Housekeeping Supervisor on 3/18/25 at 9:07 AM, he stated that he was not aware that the west housekeeping cart was not locking. He stated he knew that there had been a previous issue with it not locking but stated that he had used it about a month ago and it was locking with no issue. He further stated that Housekeeper #4 had just recently started using the rehabilitation housekeeping cart and he had forgotten to tell him to come and get his key. He confirmed that it was important to keep the cleaning chemicals secure because they were caustic and could cause injury if the residents got them on them or drank them.
An interview with the Administrator on 3/18/25 at 2:45 PM, she stated she was not aware of the issues with the housekeeping cart and that it was her expectation that she would have been notified if the housekeeping cart was not locking or if an extra key was needed.
Record review of the Safety Data Sheets (SDS) review for Crew Bathroom Disinfectant Cleaner, Virex Plus One step disinfectant cleaner & deodorant, and Crew clinging Toilet bowl cleaner revealed: Crew Bathroom Disinfectant Cleaner, Hazard Statement: None .4. First Aid Measures, Eyes: Rinse with plenty of water, if irritation occurs or persists, get medical attention . Virex Plus One step disinfectant cleaner & deodorant: Hazard Statement: combustible liquid. Causes severe skin burns and serious eye damage. Harmful if swallowed. May cause damage to organs through prolonged or repeated exposure First Aid Measures, Eyes: If in eyes rinse cautiously with water for several minutes .Continue rinsing for at least 15 minutes. Crew clinging Toilet bowl cleaner: Hazard Statement: Causes severe skin burns and serious eye damage First Aid Measures, Eyes: If in eyes rinse cautiously with water for several minutes .Continue rinsing for at least 15 minutes .
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Resident #118
An observation and interview on 3/19/25 at 9:35 AM with CNA #1 performing Foley catheter care for Resident #118 re...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Resident #118
An observation and interview on 3/19/25 at 9:35 AM with CNA #1 performing Foley catheter care for Resident #118 revealed there was no observation of CNA #1 applying a gown as part of EBP. In a continued interview with CNA #1 she confirmed after seeing the EBP sign on the resident's door that she failed to wear a gown as part of EBP and confirmed that she should have worn the gown to reduce the risk of transmission of bacteria between the staff and resident.
During an interview with the Infection Preventionist on 3/19/25 at 10:36 AM she revealed the purpose of EBP is to place a layer of protection between staff and residents to reduce the risk of spread of infection. She revealed that all residents who have devices like indwelling catheters, wounds, and other devices should be on enhanced barrier precautions.
During an interview with the Director of Nursing (DON) on 03/19/25 11:30 AM he revealed if staff failed to use EBP for a resident during catheter care they increased the risk of the spread of infection between the staff and the residents.
Record review of the Order Summary Report for Resident #118 revealed an order with an onset date of 1/22/25 to clean Foley catheter with warm soapy water, rinse with clean water and pat dry every shift.
A review of Resident # 118's admission Record revealed that he was admitted on [DATE], with a diagnosis of Need Assistance with Personal Care and Urinary Tract Infection.
Based on observation, staff interview, record review, and facility policy review, the facility failed to implement infection prevention and control practices when the facility failed to properly dispose of and contain contaminated garbage and resident belongings for one (1) of two (2) resident's on contact isolation (Resident #125) and utilize Enhanced Barrier Precautions (EBP) for two (2) of 32 resident's requiring EBP (Resident #4 and Resident #118)
Findings include:
Review of the facility's Infection Control Guide revealed under, Environmental Cleaning: Cleaning, disinfection and sterilization are important measures used to prevent and reduce the spread of infections in the healthcare setting. The oversight and monitoring of cleaning, sterilization and disinfection practices are the responsibility of the infection control care team which should include the Administrator, Director of Nursing Services, Clinical Educator, Infection Control Preventionist, Housekeeping Supervisor and Dietary Manager. Additionally, revealed under, Transmission Based Precautions: Transmission Based Precautions (TBP) are used to help stop the spread of germs from one person to another. The goal is to protect residents, their families, visitors, and healthcare workers - and stop germs from spreading across a Healthcare setting .
Record review of the facility policy Implementing the Use of Enhanced Barrier Precautions (EBP) in Skilled Long-Term Care (LTC) Nursing Facilities revealed, Enhanced Barrier Precautions .EBP should be used for residents with any of the following: Colonization or infection with targeted Multi Drug Resistant Organisms (MDROs). Chronic wounds (e.g. pressure ulcers, diabetic foot ulcers) or indwelling devices (e.g. central venous catheters, indwelling urinary catheters, tracheostomy, feeding tube) that increases their risk of acquiring MDROs.
Resident #4
On 3/19/25 at 9:04 AM, the Treatment Nurse (TN) and Certified Nursing Assistant (CNA) # 4 were observed entering Resident #4's room to provide wound care. Resident #4 had EBP signage located on the resident room door that instructed staff to wear a gown and gloves during high contact resident care activities such as changing briefs or assisting with toileting and wound care for chronic wounds. CNA #4 and the TN were observed performing hand hygiene then CNA #4 uncovered Resident #4, unfastened her brief, and positioned her on her right side. She did not wear a gown. The TN provided Resident #4's wound care but did not wear a gown.
An interview with the TN and CNA #4 on 3/19/25 at 9:10 AM, they stated that they did see the EBP sign on the door and knew that they should have worn a gown to provide care. The TN stated that she forgot because there was no Personal Protective Equipment (PPE) on the door. The TN stated that EBP was used for residents with wounds to prevent the spread of infection.
On 3/20/25 at 9:35 AM, during an interview, the Infection Control Nurse stated that PPE for EBP was kept in a central location on each unit and they are readily available for all staff. She verified that EBP should be followed during wound care to prevent the spread of infection, and the TN and CNA should have worn a gown.
Record review of the admission Record revealed that the facility admitted Resident #4 on 8/23/19 with a diagnosis of Diabetes Mellitus.
Resident #125
On 3/17/25 at 3:25 PM, an observation outside Resident #125's room door revealed a sign announcing contact isolation precautions and a 3-compartment drawer containing PPE. Further observation inside the room revealed a regular trash receptacle with disposed of yellow gowns and gloves inside. There were no biohazard containers for the linen or trash.
An interview with Licensed Practical Nurse (LPN) #5 on 3/17/25 at 3:30 PM revealed Resident #125 was on contact precautions due to Clostridium Difficile infection (C. diff). She revealed staff should be dressing out in gloves and gowns and dispose of the PPE in a biohazard container before leaving the room. She confirmed the resident did not have biohazard barrels in the room and should have.
An interview with the Administrator on 3/18/25 at 11:50 AM, confirmed biohazard containers should have been in Resident #125's room to prevent the spread of the pathogen to other residents and staff.
An interview with Housekeeping #2 on 3/19/25 at 11:25 AM revealed she used Virex disinfectant to wipe down the bedside tables, bed rails, mattress, overhead lights, dressers, knobs, and she wiped down everything in the bathroom. She revealed she mopped the floor with Stride cleaner. She confirmed they (housekeeping services) used these products for all resident rooms in the facility, including Resident #125.
Review of the Environmental Protection Agency (EPA) Registered list of antimicrobial products effective against C. diff spores revealed Virex and Stride were not listed as effective.
An interview with the Housekeeping Supervisor on 3/19/25 at 12:07 PM confirmed he was aware housekeepers were using Virex and Stride to clean Resident #125's room. He confirmed these solutions were not effective against C. diff spores and revealed they should be using Clorox. He stated, I knew we had an isolation but did not know what kind. The Housekeeping Supervisor confirmed not using the appropriate chemicals could cause a nasty spread of infection in the building.
An interview with the Infection Preventionist (IP) on 3/19/25 at 12:12 PM revealed when the facility had a resident on transmission-based precautions (TBP), it was her responsibility to notify the other departments so the necessary equipment such as the biohazard barrels could be placed in the rooms. She confirmed she did not let anyone know about placing the biohazard barrels in Resident #125's room. She revealed she did not directly speak to the housekeeping supervisor to notify him that the resident had C. diff, but they all attended the stand-up meeting where it was discussed. The IP confirmed failing to handle the resident's clothing and trash in the proper manner and using ineffective cleaning products could spread the infection to staff and residents.
Record review of the Order Summary Report for Resident #125 revealed an order dated 3/14/25, Vancomycin oral capsule 125 MG (milligrams) by mouth four times a day related to Enterocolitis due to Clostridium Difficile.
Review of the admission Record revealed the facility re-admitted Resident #125 on 3/14/25 with a medical diagnosis that included Enterocolitis due to Clostridium Difficile.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Staffing Data
(Tag F0851)
Could have caused harm · This affected most or all residents
Based on staff interview, record review, Payroll-Based Journal (PBJ) staffing data report review, and facility policy review, the facility failed to accurately submit staffing data into the PBJ system...
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Based on staff interview, record review, Payroll-Based Journal (PBJ) staffing data report review, and facility policy review, the facility failed to accurately submit staffing data into the PBJ system for one (1) of four (4) quarters reviewed. First Quarter 2025 (October-December 2024)
Findings Include:
Review of the facility policy titled Payroll Based Journal Entry Submission unrevised, revealed under, Policy: CMS (Centers for Medicare and Medicaid Services) regulations for Payroll Based Journal (PBJ) entries submission are adhered too.
Record review of the PBJ Staffing Data Report revealed the facility submitted excessively low weekend staffing data for the 1st quarter 2025 (October 1-December 31).
An interview with the Regional Human Resource on 3/18/25 at 11:30 AM revealed the facility's payroll system handled late clock-ins and shifts that crossed midnight as counting toward the next shift. He revealed if a staff member clocked in late, it would automatically transfer over to the next shift because of the federal overtime laws in place. He revealed he was unsure if the department heads that worked the weekend were captured on the payroll-based journal (PBJ).
An interview with Human Resources on 3/19/25 at 9:00 AM, she revealed the facility's corporate office submitted the payroll-based journal (PBJ). She confirmed that with the payroll system that they use, if someone clocks in late, the hours will automatically transfer over to the next shift. She confirmed that she did not manually correct the employee hours in the system.
An interview with the Administrator (ADM) on 3/19/25 at 10:37 AM revealed every morning she went over the PPD (Patient Per Day) and looked at call ins from the day before to ensure the PPD was accurate. She revealed they had not had any low staffing. She revealed that on the weekends, they have an on-call person, and they come in and work as a CNA or nurse or whatever was needed to ensure that they met that PPD. Furthermore, she explained that they had the current payroll system for about a year and had not worked out all the kinks yet. She confirmed that no one manually corrected payroll. She revealed that she had compared the workforce manager's schedule with the human resources report and saw for herself that the hours were not captured correctly. The ADM revealed that if someone came in 2 hours late, their hours would not be captured that shift. She confirmed this could cause a discrepancy with the hours submitted in the payroll-based journal.
May 2024
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
Quality of Care
(Tag F0684)
A resident was harmed · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff and Resident Representative (RR) interview, record review and Administrator statement review the facility failed ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff and Resident Representative (RR) interview, record review and Administrator statement review the facility failed to ensure a resident received treatment and services in accordance with professional standards of practices as evidenced by failure to change the negative pressure wound therapy system dressing as ordered by the provider for one (1) of three (3) residents with wound care reviewed. Resident # 1
Findings include:
Record review of a typed document, undated, on facility letterhead and signed by the Administrator revealed (Proper Name of Facility) utilizes Negative Pressure Wound Therapy System manufactures guidelines.
Record review of the NEGATIVE PRESSURE WOUND THERAPY SYSTEM (NPWT) Instructions for Use revealed .The NPWT system should remain on and in use for the duration of the prescribed treatment .
During a telephone interview on 5/8/24 at 10:00 AM, with Resident # 1's RR, she stated she notified the facility staff that Resident #1's wound vac dressing to the left abdominal wound needed to be changed. She stated she was told that the dressing is only changed if the suction broke. She stated that the facility did not remove Resident #1's abdominal dressing the week of 04/01/24 until 4/10/24 and at that time the foam from the dressing was adhered to the wound.
Record review of the Order Summary Report with active orders as of 3/26/24 revealed an order dated 3/26/24 Treatment; Surgical wound to left lateral abdomen (#4) Clean with NS (normal saline), apply wound vac at 125 mmHg (millimeters of mercury) every Monday and Thursday PRN (as needed) for drainage/dislodgement .
Record review of the April 2024 electronic treatment administration record (eTAR) for Resident #1 revealed there was no documentation that the wound vac dressing was changed on 4/1/2024, 4/4/2024 or 4/8/2024.
Record review of General Notes for Resident #1, dated and timed 4/10/24 at 1:33 PM, revealed Wound vac dressing removed from left lat (lateral) abdomen .Lower wound remains open. Foam dressing adhered to wound bed .
Record review of Progress Note Details for Resident #1 dated 4/11/2024, completed by Wound Care Nurse Practitioner (NP) revealed, .The wound vac was last changed on 3/25/24 and removed by the facility NP and DON (Director of Nursing) on 4/10/24 with sponge fragments remaining in the wound .The site was debrided today removing .fragments .Not all fragments were able to be removed .Recommend dressing changes .until evaluated by surgeon .
In an interview with Registered Nurse #1 (RN) on 5/8/24 at 12:30 PM, she stated that the resident's RR notified her that the wound vac dressing needed to be changed, but she was unsure of the date she was notified. She stated that she observed the abdominal wound vac dressing at that time and it looked like it needed to be changed. She stated she did not recall the date on the dressing. RN #1 stated that the previous DON was responsible for wound care at that time, and she notified her that the dressing needed to be changed. RN #1 verified that the eTAR for April 2024 had no documentation that the wound vac dressing had been changed and that if there was no documentation, then it was not performed.
Interview with NP #1 on 5/8/24 at 12:45 PM, she verified that she was informed by the previous DON on 4/10/24 that the foam from the wound vac dressing was adhered to the residents wound bed. She stated upon her assessment of the abdominal wound on 4/10/24 that the foam from the dressing was adhered to the wound bed and they were unable to remove it. She verified that failure to change the wound vac dressing as ordered could cause the foam to be adhered to the wound and prevent healing.
In an interview with the Administrator on 5/8/24 at 2:00 PM, he agreed Resident #1's wound vac dressing should have been changed as ordered.
Record review of the admission Record revealed Resident #1 was admitted to the facility on [DATE] with a diagnoses that included Unspecified open wound of the abdominal wall.
Apr 2024
2 deficiencies
2 IJ
CRITICAL
(J)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Immediate Jeopardy (IJ) - the most serious Medicare violation
Comprehensive Care Plan
(Tag F0656)
Someone could have died · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview, facility policy review, facility statement review and record review, the facility failed to implement ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview, facility policy review, facility statement review and record review, the facility failed to implement an elopement/wandering risk plan of care for Resident #1 who had worn a wander guard since his admission on [DATE]. Resident #1 had a documented history of wandering and elopement attempts prior to his admission to the facility. Resident #1 was one (1) of four (4) residents identified by the facility, who were at risk for elopement and that wore a wander guard.
On 3/31/24 Resident #1 exited the facility unsupervised and undetected by facility staff. It was determined that Resident #1 was missing from the facility for approximately ten to twenty minutes prior to discovery. No facility staff saw resident leave the facility and no facility staff were aware that Resident #1 was missing until approximately 10:40 PM when they received a verbal report from a friend of a staff member that Resident #1 was at an apartment complex parking lot, off the facility grounds, talking to the police. Resident #1 was returned to the facility via personal vehicle by a facility staff at approximately 10:50 PM on 03/31/24.
The facility's failure to provide supervision resulted in Resident #1's elopement and has the likelihood to result in serious harm, serious injury, serious impairment, or death for Resident #1 and all other cognitively impaired residents who leave the facility unsupervised.
The State Agency (SA) identified an Immediate Jeopardy (IJ) which began on 3/31/24 and provided the Administrator with the IJ template.
Based on the facility's implementation of corrective actions on 03/31/24 through 04/01/24, the SA determined the IJ to be Past Non-Compliance (PNC) and the IJ was removed on 04/02/24, prior to the SA's entrance on 04/05/24.
Findings Include:
Record review of a statement on facility letterhead revealed Policy: Care Plans and MDS (Minimum Data Set) will be developed and maintained per RAI (Resident Assessment Instrument) Guidelines. The most recent effective date was August 2019.
Record review of the facility's undated policy titled Missing Resident/Elopement revealed Purpose To establish a process that identifies risk and establishes interventions to mitigate the occurrence of elopements. Process . If an elopement risk is determined an individual plan is established and intervention is initiated to mitigate that risk. When the nurse identifies the intervention it is documented on the care plan and on the caregiver guide .
Record review of the Care Plan for Resident #1 with an initiation date of 2/12/24 revealed Focus: At risk for elopement related to Wandering .Interventions: .Check Placement and function of Wander Guard to Left Ankle every shift .Redirect patient from doors .
Record review of the March 2024 Medication Administration Record (MAR) revealed Check Placement of Wander Guard to Left Ankle every shift for Elopement Risk. The MAR documentation revealed there were 11 times on day shift, 10 times on evening shift and seven (7) times on night shift that N was documented, indicating No, that the wander guard for Resident #1 had not been checked.
Interview on 04/05/24 at 9:10 AM, with the facility Administrator (ADM) confirmed that Resident #1 had been identified upon his admission as a wanderer and a wander guard alarm was placed on his ankle for security.
Interview on 04/05/24 at 9:30 AM with the Assistant Director of Nursing (ADON) who was the interim Director of Nurses (DON), revealed that she understood that the kitchen door was not properly shut which allowed Resident #1 to leave undetected out the back kitchen door on 03/31/24 after 10:30 P.M. The ADON confirmed that Resident #1 was identified and care planned as a wanderer and he wore a wander guard alarm on his ankle.
Interview and record review of Resident #1's care plan on 04/09/24 at 8:45 AM with the MDS/ Care Plan nurse (RN #2), revealed that she had completed the MDS and the Care Plan for Resident #1 upon his admission on [DATE] and had made care plan revisions on 04/01/24. RN #2 confirmed that she made elopement revisions to the care plan of Resident #1 on 04/01/24 after he had eloped on 03/31/24.
Record review of the admission Record for Resident #1 revealed that he was admitted to the facility on [DATE] with diagnoses that included Senile Degeneration of the brain, Dementia, Muscle Weakness, Unsteadiness on Feet, Abnormalities of Gait or Mobility, Lack of Coordination, and Cognitive Communication Deficit.
The facility implemented that following Corrective Action Plan prior to the State Agency (SA) entering the facility on 04/05/24:
On 03/31/24 at approximately 10:50 PM Resident #1 was assisted back to the facility via facility staff personal vehicle. Resident #1 was thoroughly assessed head to toe by RN #1 and no adverse injuries/incidents were found. RN #1 contacted the RR; the Medical Director (MD); the facility Administrator; the facility ADON; and placed Res #1 on one to one (1:1) close observation by facility staff. The elopement risk assessment was updated for Resident #1 and the care plan was revised. The elopement book kept at the nursing station was reviewed and updated. Facility staff conducted room to room audits of all residents in the building to ensure safety. The facility conducted a Quality Assurance (QA) meeting with the Medical Director (MD) in attendance via telephone on 04/01/24 at 8:00 A.M. An elopement drills were conducted on 3/31/24 and 4/01/24 and every day since the incident of 03/31/24 on all three (3) shifts. All residents with wander guard bracelets were checked for functionality and positioning on each shift. The ADM and the ADON began in-services on 04/01/24 of all staff on elopement protocol; wander guard monitoring; and Abuse and Neglect. All doors and windows were checked for for proper functioning and operation. ADM began an investigation to determine how Res #1 eloped. ADM called the incident in to the Mississippi State Department of Health (MSDH) office 04/01/2024 at 6:00 P.M. Resident #1 was placed on 1:1 close observation on 03/31/24 immediately upon his return to the facility at 10:50 PM on 03/31/24 and remained on 1:1 by staff until his transfer on 04/02/24 at 12:00 noon. There was a staff member placed at the front door to monitor the entrance and exits of the building and the staff would remain at the front door 24/7 until the new wander guard alarm system was installed on 04/01/24. No staff were allowed to work until they were in-serviced on elopements; Abuse/Neglect; and monitoring of wander guard systems.
Immediate Actions:
At 10:50 PM on 03/31/24 the RN#1 notified the ADM; the ADON; the Maintenance Director; the RR and the MD; and the Nurse Practitioner; via telephone of the elopement of Res #1.
At 10:50 PM on 03/031/24 the facility staff conducted a 100% head count of all residents to ensure they were all accounted for. All residents were found to be in the facility.
Upon return to the facility RN #1 assessed Res #1 from head to toe and found no injuries or incidents.
Beginning at 10:50 PM on 03/31/24 all doors were monitored by staff 24/7 until the wander guard system was found fully functioning and new punch pad systems were installed on the kitchen doors.
On 03/31/24 at 10:50 PM four (4) residents with risks of elopement were reevaluated and updated to ensure all residents at risk for elopement had appropriate interventions in place. No negative findings were identified on 3/31/24.
On 03/31/24 at 10:50 PM RN #1 and the ADM began officially investigating and obtaining statements for the Elopement of Res #1.
On 03/31/24 at 10:30 PM staff In-services were begun by RN#1 and the ADM; and the ADON, to include all staff on Elopement Protocols, Wander Guard checks; and Abuse/Neglect with no staff allowed to work until in-services were completed.
On 04/01/24 at 8:00 AM a QA meeting was held via telephone with the MD. The DON; the Maintenance Director; the Dietary Director; ADM; MDS/Care Plan Nurses x 3 were present; along with the Social Worker; and QA/Infection Control Nurse. All members of the QA committee were in attendance via telephone.
On 03/31/24 the Maintenance Director checked the functioning of the wander guard alarm/security system and found that the alarm was functioning properly and the alarm was sounding. It was discovered that Resident #1 exited the facility through the kitchen doors, which had not been properly shut and did not contain an alarm, causing Resident #1 to leave the facility unsupervised and undetected. The vendor came to the facility on [DATE] and installed new punch pads and alarms and locks to the kitchen doors x 3. The doors were also monitored by a staff member 24/7 until the wander guard system was installed on the kitchen doors.
On 04/01/24 at 6:00 PM the ADM contacted the SA and the MS Attorney General's Office (AGO) to report the elopement of Resident #1.
All corrective actions were completed on 04/01/24 and the facility alleged removal of the immediate Jeopardy (IJ) on 04/02/24.
Validation:
The State Agency (SA) completed the validation for the facility's Past Non Compliance (PNC) Corrective Action Plan on 04/09/24.
The SA validated through interviews and record reviews that at 10:50 PM on 03/31/24 RN #1 notified the ADM, the ADON, Maintenance Director, the RR and the MD via telephone of the elopement of Resident #1.
The SA validated through interviews and record reviews that at 10:50 PM on 03/31/24 the facility staff conducted a 100% head count of all residents to ensure they were all accounted for. All residents were found to be in the facility.
The SA validated through interviews and record reviews that upon return to the facility RN #1 assessed Resident #1 from head to toe and found no injuries or incidents.
The SA validated through observations, record reviews, and interviews that beginning at 10:50 PM on 03/31/24 all doors were monitored by staff 24/7 until the wander guard system was found fully functioning on all doors including the kitchen doors.
The SA validated through observations, record reviews and interviews that on 03/31/24 at 10:50 PM four (4) residents with risks of elopement were re-evaluated and updated to ensure all residents for risk for elopement had appropriate interventions in place. No negative findings were identified on 03/31/24.
The SA validated through record reviews and interviews that on 03/31/24 at 10:50 PM RN #1 and the ADM began officially investigating and obtaining statements of the Elopement of Resident #1.
The SA validated through interviews and record reviews that on 03/31/24 at 11:30 PM staff in-services were initiated by RN #1, the ADON and the ADM to include all staff on Elopement Protocols, Wander Guard checks and Abuse/Neglect with no staff allowed to work until in-services were completed.
The SA validated through interviews and record reviews that on 04/01/24 at 8:00 AM a Quality Assurance (QA) meeting was held via telephone with the MD. The ADON, ADM, MDS/Care Plan Nurses x 3, Maintenance Director, Dietary Manager; Social Worker, and the QA/Infection Control Nurse were present. All members of the QA committee were in attendance via telephone.
The SA validated through interviews, and record reviews, and review of vendor receipts that on 04/01/24 the Maintenance Director staff checked the functioning of the wander guard alarm system and found that there were three doors in the kitchen area that had not been properly shut and locked. It was discovered that the kitchen doors were not shut properly and the alarm did not sound when Resident #1 exited the facility through the kitchen unsupervised and undetected. The vendor came to the facility on [DATE] and installed new punch pad locks to the kitchen doors. The doors were monitored by a staff 24/7 until the wander guard system was installed on the kitchen doors.
The SA validated through interviews and record reviews that on 04/01/24 at 6:00 P.M. the ADM contacted the SA and the MS Attorney General's Office (AGO) to report the elopement of Resident #1.
The SA validated through observations, record reviews, and interviews that all corrective actions were completed on 04/01/24 and the facility alleged removal of the Immediate Jeopardy (IJ) on 04/02/24.
CRITICAL
(J)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Immediate Jeopardy (IJ) - the most serious Medicare violation
Accident Prevention
(Tag F0689)
Someone could have died · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff and family interviews, record review and facility policy review the facility failed to provide adequ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff and family interviews, record review and facility policy review the facility failed to provide adequate supervision to prevent Resident #1, who was identified as an elopement and wandering risk, from exiting the facility unnoticed and unsupervised for one (1) of four (4) residents reviewed. Resident #1
On 3/31/24 Resident #1 exited the facility unsupervised and undetected by facility staff. It was determined that Resident #1 was missing from the facility for approximately ten to twenty minutes prior to discovery. No facility staff saw resident leave the facility and no facility staff were aware that Resident #1 was missing until approximately 10:40 PM when they received a verbal report from a friend of a staff member that Resident #1 was at an apartment complex parking lot, off the facility grounds, talking to the police. Resident #1 was returned to the facility via personal vehicle by a facility staff at approximately 10:50 PM on 03/31/24.
The facility's failure to provide supervision resulted in Resident #1's elopement and has the likelihood to result in serious harm, serious injury, serious impairment, or death for Resident #1 and all other cognitively impaired residents who leave the facility unsupervised.
The State Agency (SA) identified an Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC) which began on 3/31/24 and provided the Administrator with the IJ templates.
Based on the facility's implementation of corrective actions on 03/31/24 through 04/01/24, the SA determined the IJ and SQC to be Past Non-Compliance (PNC) and the IJ was removed on 04/02/24, prior to the SA's entrance on 04/05/24.
Findings Include:
Record review of a statement on facility letterhead, dated 4/5/2024 and signed by the Administrator revealed Supervision (Name of facility) provides supervision based on care plans, individual needs, and Resident Rights. The statement was signed by the facility administrator.
Record review of the facility's undated policy titled Missing Resident/Elopement revealed Purpose To establish a process that identifies risk and establishes interventions to mitigate the occurrence of elopements. Process . If an elopement risk is determined an individual plan is established and intervention is initiated to mitigate that risk. When the nurse identifies the intervention it is documented on the care plan and on the caregiver guide .
An interview on 04/05/24 at 9:10 AM with the facility Administrator (ADM) revealed that Resident #1 was currently transferred to a Behavioral Health hospital for evaluation of his emotional and mental status as well as for his behaviors and medications. The ADM confirmed that on 03/31/24 after 10:30 PM Resident #1 left the facility without the knowledge of the staff. A visitor to the facility verbally reported that a male that appeared to be a facility Resident was seen at an apartment complex talking to the police. The facility staff immediately began searching for Resident #1 and ran to the apartment complex where the police were talking to a man. Upon arriving at the apartment complex it was determined that Resident #1 had walked to the parking lot of the apartment complex located below a hillside from the facility. The staff placed Resident #1 in a staff member's vehicle and brought Resident #1 back to the facility for evaluation. The staff began assessing Resident #1 at approximately 10:50 PM upon arrival back to the facility. Resident #1 was found not to be injured and in no distress. The Resident Representative (RR) and the Nurse Practitioner for Resident #1 were contacted and told of the elopement of Resident #1. The ADM confirmed that Resident #1 had been identified upon his admission as a wanderer and a wander guard alarm was placed on his ankle for security. The ADM stated that she observed on the facility security camera that Resident #1 had left out of the kitchen's back door that had not been properly closed shut and locked. Therefore, the wander guard alarm had not sounded and no staff saw Resident #1 leave the building because the kitchen had no wander guard alarm system and there was no staff assigned to that area that late at night.
An observation and interview on 04/05/24 at 9:20 A.M. with Dietary Worker #1 revealed that a push pad lock and/or keypad lock was not on the kitchen doors on 3/31/24 when Resident #1 exited the facility. The Dietary Worker #1 confirmed that a keypad lock had been placed on the three (3) doors in the kitchen on 04/01/24.
During an interview on 04/05/24 at 9:30 AM, with the Assistant Director of Nursing (ADON) who was the interim Director of Nurses (DON), revealed that she understood that the kitchen door was not properly shut which allowed Resident #1 to leave undetected out the back kitchen door on 03/31/24 after 10:30 P.M. The ADON confirmed that Resident #1 was identified and care planned as a wanderer and he wore a wander guard alarm on his ankle.
During an interview on 04/08/24 at 3:15 PM with Certified Nursing Assistant (CNA) #3 revealed that she worked 3:00 PM - 11:00 PM on 03/31/24. She stated that as soon as she was told that Resident #1 was missing from the facility, she began to look inside and outside of the facility for Resident #1. She stated that a visitor reported that they thought they saw a Resident talking to the police in the parking lot of the apartment complex that was located down a hill from the facility. She immediately went outside and saw a man in a white T-shirt standing in the parking lot of the apartment complex talking to police. CNA #3 and two (2) other staff ran down the hill and found Resident #1. They told the police that he was a resident of the facility and the police released Resident #1. CNA #3 and CNA #4 along with the Registered Nurse (RN) Supervisor (RN #1) placed Resident #1 in their personal vehicle and returned him to the facility. Resident #1 remained calm and did not reveal any distress. Resident #1 told the facility staff that he would go where he wanted to and do what he wanted to because he was a grown man. CNA #3 stated that Resident #1 was a known wanderer and that he would often wander in and out of other Residents rooms and all about the facility hallways. CNA #3 stated that Resident #1 wore a wander guard alarm on his ankle since his admission to the facility.
An interview on 04/08/24 at 3:30 PM with RN #1 Supervisor, revealed that she was told at approximately 10:40 PM that Resident #1 was missing from the facility and the staff had not seen Resident #1 since 10:30 PM. RN #1 stated that a friend of a staff member reported that he had seen a Resident in the parking lot of a nearby apartment complex talking to police. RN #1 and 2 other staff members took off running down the hill to the apartment complex to look for Resident #1. He was in the parking lot of the apartment complex talking to the police, and RN #1 told the police that he was a resident of the facility and that she would take him back to the facility for evaluation where she was the Nurse Supervisor. Resident #1 got into RN #1's vehicle and came back with her for evaluation without any incidents. RN #1 stated that Resident #1 was thoroughly assessed, and no injuries or distress were found. RN #1 stated that the Director of Maintenance found that the kitchen doors were not properly closed and had not been locked and Resident #1 had left the facility out the kitchen door.
During an interview on 04/08/24 at 3:50 PM, with the Maintenance Director revealed he had been called to the facility at approximately 11:00 PM and immediately went to the facility and began assessing how Resident #1 left the facility without staff knowledge. The Maintenance Director stated he found that the door to the kitchen had not been properly shut and was not locked. He immediately reported his findings to the facility Administrator and to the RN Supervisor. He made sure the facility was secure, the wander guard alarm system was properly working and safe before he left the facility the night of 03/31/24.
During an interview on 04/08/24 at 4:10 PM, CNA #4 revealed that he worked 3:00 PM - 11:00 PM on 3/31/24. He was assigned to the care of Resident #1. CNA #4 stated that he saw Resident #1 walking in the hallway at approximately 10:30 PM and had redirected him to his room. CNA #4 stated that walking and wandering about the facility was a regular occurrence for Resident #1. Resident #1 usually wandered about the facility, and he wore a wander guard alarm around his ankle because he had a tendency to wander. At approximately 10:40 PM, CNA #4 received word that Resident #1 was missing from the facility and the entire staff began looking for Resident #1. CNA #4 stated that he, CNA #3 and the RN Supervisor found Resident #1 approximately 200 yards off the facility grounds, down a hillside from the facility at an apartment complex. CNA #4 stated that Resident #1 told the staff that he would go where he pleased because he was a grown man and could take care of himself.
Interview on 04/08/24 at 5:15 PM, with the Resident Representative (RR) of Resident #1 revealed Resident #1 had been living with family prior to his admission to the facility and he had made numerous attempts to elope and to wander away without supervision. The RR stated that the reason for Resident #1's admission to the facility was due to his wandering and resistance to care. He reported that the family was up-front with the facility about Resident #1's tendency to wander. He stated the family was unable to provide the level of supervision in their home that Resident #1 required. The RR stated that on 03/31/24 very late at night, a message had been left on his voicemail that Resident #1 had eloped. The RR stated that on 04/01/24 he came to the facility first thing in the morning to inquire as to what had happened and he agreed to have Resident #1 evaluated by the Behavioral Hospital unit.
An interview on 04/09/24 at 10:00 AM with the ADM, revealed Resident #1 was admitted to a Behavioral Health facility for evaluation and that he would return to the facility. The ADM stated that on the night that Resident #1 eloped he was wearing a white T-shirt, tennis shoes, and gray sweatpants. The weather was clear and mild, and the temperature was in the low 60's. The elopement occurred on 3/31/24 at approximately 10:40 PM
Observation on 04/09/24 at approximately 10:30 AM, by the SA revealed that the distance off the facility grounds to the apartment complex parking lot was approximately 200 yards from the facility and down a steep hillside.
Record review of the admission Record for Resident #1 revealed that he was admitted to the facility on [DATE] with diagnoses that included Senile Degeneration of the brain, Dementia, Muscle Weakness, Unsteadiness on Feet, Abnormalities of Gait or Mobility, Lack of Coordination, and Cognitive Communication Deficit.
Record review of the Elopement Risk Evaluation dated 02/14/2024 revealed that Resident #1 was an elopement risk and had a history of wandering or elopement prior to his admission to the facility. The Narrative revealed Patient is a new admission. Patient states he need to get out of here to go home.
Record review of the Elopement Risk Evaluation dated 04/03/2024 revealed Narrative: Resident continues to walk from East to [NAME] in the center. He continues to talk about his vehicle and he needs to find it. Wander Guard in place.
Record review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 2/19/24 revealed Resident #1 had a Brief Interview of Mental Status (BIMS) score of 8, which implicated that Resident #1 had moderate cognitive impairment.
Record review of the Progress Note for Resident #1 written by the facility Nurse Practitioner (NP) dated 04/01/2024 at 22:59 (10:59 PM) revealed Patient is seen today for f/u (follow-up) on nurse report of elopement. He is laying in bed calm and cooperative with examination. No injuries noted. He denies having any pain. No grimacing noted during exam. He continue to be confused. Respond inappropriately to all orientation question except name. He is a/o x 1(alert and oriented times one). Staff is concurrently working to find appropriate facility for Resident. Family has been notified of current poc (plan of care).
The facility implemented that following Corrective Action Plan prior to the State Agency (SA) entering the building on 04/05/24:
On 03/31/24 at approximately 10:50 PM Resident #1 was assisted back to the facility via facility staff personal vehicle. Resident #1 was thoroughly assessed head to toe by RN #1 and no adverse injuries/incidents were found. RN #1 contacted the RR; the Medical Director (MD); the facility Administrator; the facility ADON; and placed Res #1 on one to one (1:1) close observation by facility staff. The elopement risk assessment was updated for Resident #1 and the care plan was revised. The elopement book kept at the nursing station was reviewed and updated. Facility staff conducted room to room audits of all residents in the building to ensure safety. The facility conducted a Quality Assurance (QA) meeting with the Medical Director (MD) in attendance via telephone on 04/01/24 at 8:00 A.M. An elopement drills were conducted on 3/31/24 and 4/01/24 and every day since the incident of 03/31/24 on all three (3) shifts. All residents with wander guard bracelets were checked for functionality and positioning on each shift. The ADM and the ADON began in-services on 04/01/24 of all staff on elopement protocol; wander guard monitoring; and Abuse and Neglect. All doors and windows were checked for for proper functioning and operation. ADM began an investigation to determine how Res #1 eloped. ADM called the incident in to the Mississippi State Department of Health (MSDH) office 04/01/2024 at 6:00 P.M. Resident #1 was placed on 1:1 close observation on 03/31/24 immediately upon his return to the facility at 10:50 PM on 03/31/24 and remained on 1:1 by staff until his transfer on 04/02/24 at 12:00 noon. There was a staff member placed at the front door to monitor the entrance and exits of the building and the staff would remain at the front door 24/7 until the new wander guard alarm system was installed on 04/01/24. No staff were allowed to work until they were in-serviced on elopements; Abuse/Neglect; and monitoring of wander guard systems.
Immediate Actions:
At 10:50 PM on 03/31/24 the RN#1 notified the ADM; the ADON; the Maintenance Director; the RR and the MD; and the Nurse Practitioner; via telephone of the elopement of Res #1.
At 10:50 PM on 03/031/24 the facility staff conducted a 100% head count of all residents to ensure they were all accounted for. All residents were found to be in the facility.
Upon return to the facility RN #1 assessed Res #1 from head to toe and found no injuries or incidents.
Beginning at 10:50 PM on 03/31/24 all doors were monitored by staff 24/7 until the wander guard system was found fully functioning and new punch pad systems were installed on the kitchen doors.
On 03/31/24 at 10:50 PM four (4) residents with risks of elopement were reevaluated and updated to ensure all residents at risk for elopement had appropriate interventions in place. No negative findings were identified on 3/31/24.
On 03/31/24 at 10:50 P.M. RN #1 and the ADM began officially investigating and obtaining statements for the Elopement of Res #1.
On 03/31/24 at 10:30 PM staff In-services were begun by RN#1 and the ADM; and the ADON, to include all staff on Elopement Protocols, Wander Guard checks; and Abuse/Neglect with no staff allowed to work until in-services were completed.
On 04/01/24 at 8:00 A.M. a QA meeting was held via telephone with the MD. The DON; the Maintenance Director; the Dietary Director; ADM; MDS/Care Plan Nurses x 3 were present; along with the Social Worker; and QA/Infection Control Nurse. All members of the QA committee were in attendance via telephone.
On 03/31/24 the Maintenance Director checked the functioning of the wander guard alarm/security system and found that the alarm was functioning properly and the alarm was sounding. It was discovered that Resident #1 exited the facility through the kitchen doors, which had not been properly shut and did not contain an alarm, causing Resident #1 to leave the facility unsupervised and undetected. The vendor came to the facility on [DATE] and installed new punch pads and alarms and locks to the kitchen doors x 3. The doors were also monitored by a staff member 24/7 until the wander guard system was installed on the kitchen doors.
On 04/01/24 at 6:00 P.M. the ADM contacted the SA and the MS Attorney General's Office (AGO) to report the elopement of Resident #1.
All corrective actions were completed on 04/01/24 and the facility alleged removal of the immediate Jeopardy (IJ) on 4/02/24.
Validation:
The State Agency (SA) completed the validation for the facility's Past Non Compliance (PNC) Corrective Action Plan on 04/09/24.
The SA validated through interviews and record reviews that at 10:50 PM on 03/31/24 RN #1 notified the ADM, the ADON, Maintenance Director, the RR and the MD via telephone of the elopement of Resident #1.
The SA validated through interviews and record reviews that at 10:50 PM on 03/31/24 the facility staff conducted a 100% head count of all residents to ensure they were all accounted for. All residents were found to be in the facility.
The SA validated through interviews and record reviews that upon return to the facility RN #1 assessed Resident #1 from head to toe and found no injuries or incidents.
The SA validated through observations, record reviews, and interviews that beginning at 10:50 PM on 03/31/24 all doors were monitored by staff 24/7 until the wander guard system was found fully functioning on all doors including the kitchen doors.
The SA validated through observations, record reviews and interviews that on 03/31/24 at 10:50 PM four (4) residents with risks of elopement were re-evaluated and updated to ensure all residents for risk for elopement had appropriate interventions in place. No negative findings were identified on 03/31/24.
The SA validated through record reviews and interviews that on 03/31/24 at 10:50 PM RN #1 and the ADM began officially investigating and obtaining statements of the Elopement of Resident #1.
The SA validated through interviews and record reviews that on 03/31/24 at 11:30 PM staff in-services were initiated by RN #1, the ADON and the ADM to include all staff on Elopement Protocols, Wander Guard checks and Abuse/Neglect with no staff allowed to work until in-services were completed.
The SA validated through interviews and record reviews that on 04/01/24 at 8:00 AM a Quality Assurance (QA) meeting was held via telephone with the MD. The ADON, ADM, MDS/Care Plan Nurses x 3, Maintenance Director, Dietary Manager; Social Worker, and the QA/Infection Control Nurse were present. All members of the QA committee were in attendance via telephone.
The SA validated through interviews, and record reviews, and review of vendor receipts that on 04/01/24 the Maintenance Director staff checked the functioning of the wander guard alarm system and found that there were three doors in the kitchen area that had not been properly shut and locked. It was discovered that the kitchen doors were not shut properly and the alarm did not sound when Resident #1 exited the facility through the kitchen unsupervised and undetected. The vendor came to the facility on [DATE] and installed new punch pad locks to the kitchen doors. The doors were monitored by a staff 24/7 until the wander guard system was installed on the kitchen doors.
The SA validated through interviews and record reviews that on 04/01/24 at 6:00 P.M. the ADM contacted the SA and the MS Attorney General's Office (AGO) to report the elopement of Resident #1.
The SA validated through observations, record reviews, and interviews that all corrective actions were completed on 04/01/24 and the facility alleged removal of the Immediate Jeopardy (IJ) on 04/02/24.
Mar 2024
6 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
Resident Rights
(Tag F0550)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, record review and facility policy review, the facility failed to provide a resident with ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, record review and facility policy review, the facility failed to provide a resident with sheets and a blanket while their bedroom window was open and 38 degrees outside for one (1) of 11 residents on sample. Resident # 2
Findings include:
Review of the facility policy titled, Resident Rights Summary with a revision date of 5/1/12 revealed #1. Exercise of Rights: The resident has the right to exercise his/her rights as a resident of the facility and as a citizen of the United States .
An observation on 3/18/24 at 6:25 AM, revealed Resident #2 lying in bed with no sheets or a bedspread observed, resident was lying on the bare mattress. The resident's knees were pulled up to his chest and he was covered in an approximate 30 inch by 30-inch velour throw and had one folded in a square under his buttocks. This observation revealed the resident's curtains were blowing in and out and when the curtains were pulled open it revealed the window was cracked open and the current temperature outside was 38 degrees.
An interview on 3/18/24 at 6:30 AM, with Licensed Practical Nurse (LPN) #3 confirmed she was Resident #2's nurse and was not sure why the resident did not have sheets or proper blankets on him or why the window was open. She stated that the window did not need to be opened and he needed some linens and a blanket on his bed because it was cold outside.
An interview and observation on 3/18/24 at 6:40 AM, with Certified Nurse Assistant (CNA) #3 confirmed she was Resident #2's CNA and she confirmed the resident did not have sheets or a blanket because they did not have any clean linens in the building and that it happens a lot. She stated she is not sure why the window was open, but she realized it was cold in there and turned the air off in his room a little bit ago.
An interview and observation on 3/18/24 at 7:00 AM, with the Administrator confirmed that Resident #2 should have sheets and a blanket to cover him, and his window should not have been opened with it that cold outside. The Administrator confirmed with a laundry staff member that there were no clean blankets or linens at this time.
An interview on 3/20/24 at 10:00 AM, with the Director of Nurses (DON) confirmed that Resident #2 should have had sheets on his bed and a blanket big enough to cover him, because that is his right. She stated she is not sure why the window was open, but the staff should have seen that and closed it. She stated that Resident #2 not having sheets on his bed and not having a blanket to fully cover him is a basic human right and he should have had better.
Record review of Resident #2's admission Record revealed the resident was admitted to the facility on [DATE] with medical diagnoses that included Hypokalemia.
Record review of Resident #2's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 3/7/24 revealed in Section C a Brief Interview for Mental Status (BIMS) score of 10, which indicated the resident is moderately cognitively impaired.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Comprehensive Care Plan
(Tag F0656)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Resident #1
Record review of Resident #1's Care Plans revealed the resident has an ADL and physical functioning deficit related ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Resident #1
Record review of Resident #1's Care Plans revealed the resident has an ADL and physical functioning deficit related to weakness and debility and contractures to bilateral fingers. Resident #1 requires the need for extensive assistance with toileting.
An interview on 3/18/24 at 9:40 AM with Resident #1 revealed she has to wait for a female Certified Nursing Aide (CNA) or nurse to come provide her care, because they have other residents assigned to them. She stated she has complained about not wanting to have a male CNA and there is always a male assigned to her, so she has to wait for the female CNA to provide incontinent care. She stated she had talked with both the head nurse and the administrator. She stated she has waited 2 hours several times and one time she waited eight (8) hours while she was wet, just to get a female to change her and clean her up.
Record review of the admission Record for Resident #1 revealed the resident was admitted to the facility on [DATE] with medical diagnoses that included Other Specified Arthritis, multiple sites.
Record review of Resident #1's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/23/23 revealed in Section GG that the resident needed assistance with Activities of Daily Living (ADL).
Resident #3
Record review of Resident #3's care plans revealed the resident has an ADL self-care deficit related to chronic debilitation, generalized weakness and history of CVA with right side weakness. Interventions include extensive assistance of 2 staff for toileting.
An interview on 3/19/24 at 9:00 AM with Resident #3 revealed he gets mainly bed baths. He stated that it has been so long since he has had a shower that he can't remember when it was. He stated he preferred to get a shower because it's always warm. He revealed he has to have help going to the bathroom, but they are slow to get to him sometimes and they never ask to take him to the bathroom during the day when he is up in his wheelchair. He laughed and said oh no they are not going to ask that would mean they would have to take me.
An interview on 3/20/24 at 10:00 AM with the Director of Nurses (DON) confirmed that residents not getting their incontinent care timely and getting bed baths instead of showers has been a problem. She confirmed that residents do get mainly bed baths because some of the aides think it is easier. She stated that not all of her nursing staff are meeting her expectations of basic human needs and care and therefore not always following residents care plans.
Record review of Resident #3's admission Record revealed the resident was admitted to the facility on [DATE] with medical diagnoses that included Type 2 Diabetes Mellitus.
Record review of Resident #3's MDS with and ARD of 2/3/24 revealed in Section C a BIMS score of 13, which indicates the resident is cognitively intact.
Based on observation, resident and staff interview, record review and facility policy review the facility failed to implement a comprehensive care plan for a resident requiring assistance with Activities of Daily Living (ADLs) for three (3) of 11 residents sampled. Resident #1, Resident #3, and Resident #6.
Findings include.
A review of the facility policy titled MDS and Care Plans, Effective August 2019 revealed, Policy: Care plans and MDS will be developed and maintained per RAI (Resident Assessment Instrument) Guidelines.
Resident #6
A record review of Resident #6's care plan revealed he has an ADL self-care performance deficit related to cognition with interventions which included assist with facial hair daily and as needed, he is dependent on one person's assistance for bathing, and requires extensive assistance of one staff with personal hygiene.
An observation and interview of Resident #6 with the Treatment Nurse present on 03/18/24 at 10:30 AM, revealed the resident lying in bed awake and alert times. The resident was disheveled wearing only a shirt and a brief. The resident's hair was oily, and he had facial hair covering his cheeks and chin that was approximately one-half inch long. The resident stated, They haven't shaved me in a long time, and I want them to shave the hair off of my face. The resident could not remember the last day he received a shave. The resident confirmed that he had not had a shower in about two (2) weeks and that he would like to go to the shower. Resident #6 stated, They have been washing me up in bed'. The Treatment Nurse confirmed that the resident's hair was oily and that he needed a shave and a shower.
An interview on 03/20/24 at 10:05 AM with the Minimum Data Set (MDS) Nurse confirmed that Resident #6 has a care plan for assistance with ADL care. The MDS Nurse confirmed that the resident requires extensive assistance of one with bathing on Tuesday, Thursday, and Saturday. The MDS Nurse stated I don't see where he has had but one bath since the beginning of March 2024 and if they have not given him a bath, they are not following the care plan. The MDS nurse confirmed that the purpose of the care plan is to guide the residents care in a safe manner. The MDS nurse confirmed that not following the care plan could result in the resident not getting the care he is supposed to get.
An interview on 03/20/24 at 10:30 AM with the Director of Nursing (DON) confirmed that the purpose of the care plan is to guide the resident's care. The DON confirmed the resident not receiving his bath and a shave means the staff was not following the care plan, which could result in the resident not getting the care that he is supposed to get.
A record review of Resident #6's MDS section GG revealed that the resident requires substantial/maximal assistance with showering, bathing, and personal hygiene.
A review of the facility admission Record for Resident #6 revealed that he was admitted to the facility on [DATE] with medical diagnoses that included muscle weakness, unsteadiness on feet and need for assistance with personal care.
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
ADL Care
(Tag F0677)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Resident #1
On 3/18/24 at 9:40 AM, an interview with Resident #1 revealed she has to wait for a female Certified Nursing Assista...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Resident #1
On 3/18/24 at 9:40 AM, an interview with Resident #1 revealed she has to wait for a female Certified Nursing Assistant (CNA) or nurse to come provide her care, because they have other residents assigned to them. She stated she has complained about not wanting to have a male CNA and there is always a male assigned to her, so she has to wait for the female CNA to provide incontinent care. She stated she had talked with both the head nurse and the Administrator. She stated she has waited 2 hours several times and one time she waited eight (8) hours while she was wet, in order to get a female to change her and clean her up.
On 3/19/24 at 3:05 PM, interview with the Ombudsman confirmed that Resident #1 complained that she has to wait a long time for the female aids to provide incontinent care because they have other residents, and she has made the Administrator aware. She stated the resident informed her that staff told her, You are just going to have to deal with it.
Review of Resident #1's admission Record revealed the resident was admitted to the facility on [DATE] with medical diagnoses that included Other Specified Arthritis, other sites.
Record review of Resident #1's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/23/23 revealed in Section C a Brief Interview for Mental Status (BIMS) score of 15, which indicates the resident is cognitively intact and in Section GG that the resident needed assistance with ADLs.
Resident #3
On 3/19/24 at 9:00 AM, an interview with Resident #3 revealed he gets mainly bed baths. He stated that it has been so long since he has had a shower that he can't remember when it was. He stated he preferred to get a shower because it's always warm. He revealed he has to have help going to the bathroom, but they are slow to get to him sometimes and they never ask to take him to the bathroom during the day when he is up in his wheelchair. He laughed and said, Oh no they are not going to ask that would mean they would have to take me.
Record review of Resident #3's admission Record revealed the resident was admitted to the facility on [DATE] with medical diagnoses that included Type 2 Diabetes Mellitus.
Record review of Resident #3's MDS with and ARD of 2/3/24 revealed in Section C a BIMS score of 13, which indicates the resident is cognitively intact and in Section GG indicated the resident needed supervision and/or touching assistance with toileting.
On 3/19/24 at 3:30 PM, an interview with LPN #5 confirmed that the residents do not get showers like they should, and she has told the Administrator about that. She said my residents have had showers for the past two days, but it is because you all have been here.
On 3/20/24 at 10:00 AM, in an interview with the Director of Nurses (DON) confirmed that residents not getting their incontinent care timely and getting bed baths instead of showers has been a problem. She confirmed that residents do get mainly bed baths because some of the aides think it is easier. She revealed that is something she has been working on since she got here. She confirmed that not all of her nursing staff are meeting her expectations of basic human needs and care. She revealed she feels like they have plenty of staff, they just have some lazy staff.
Based on observation, resident and staff interview, record review and facility policy review the facility failed to provide assistance with Activities of Daily Living (ADL) for residents that required assistance for three (3) of seven (7) sampled residents. Resident # 6, #1, and #3.
Cross Reference F725
Findings Include.
A review of the facility policy titled ADL's Effective August 2021, revealed, Policy: Ensure ADLs are provided in accordance with accepted standards of practice, the care plan, and reasonable accommodation of the resident's choices and preferences.
Resident #6
On 03/18/24 at 10:30 AM, observation/interview of Resident #6 with the Treatment Nurse present revealed the resident lying in bed and appeared disheveled wearing only a shirt and a brief. The resident's hair was oily, and he had facial hair that was covering his cheeks and chin and was approximately one-half inch long. The resident stated, They haven't shaved me in a long time, and I want them to shave the hair off of my face. The resident could not remember the last day he received a shave. The resident confirmed that he had not had a shower in about two (2) weeks and that he would like to go to the shower. Resident #6 stated, They have been washing me up in bed'. The Treatment Nurse confirmed that the resident's hair was oily, had a large amount of facial hair that needed to be shaved and needed to have a shower.
On 03/18/24 at 12:47 PM, interview with Licensed Practical Nurse (LPN) #3 confirmed that Resident #6 had not been shaved recently and was unsure of the date of the last shave because she could not find the bath sheet. LPN# 3 confirmed that the resident is supposed to receive a bath on Tuesday, Thursday, and Saturday. LPN #3 confirmed that the residents having a bath and being clean helps prevent skin breakdown.
On 03/18/24 at 1:15 PM, an interview with LPN #2 confirmed that there was only one bath sheet on 03/12/24 for Resident #6. LPN #2 confirmed that the resident is supposed to receive a bath on Tuesday, Thursday, and Saturday and that he should be shaved when he receives a bath. LPN #2 confirmed that the purpose of the bath is to keep the resident's skin clean to prevent breakdown and infections.
A review of the facility admission Record for Resident #6 revealed that he was admitted to the facility on [DATE] with medical diagnoses that included Muscle Weakness, Unsteadiness on feet and Need for assistance with personal care.
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 F0725
(Tag F0725)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, resident and staff interview, record review and facility policy review, the facility failed to provide su...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, resident and staff interview, record review and facility policy review, the facility failed to provide sufficient staff as evidenced by staff not providing assistance with bathing, grooming and personal hygiene for three (3) of seven (7) sampled residents residing in the facility. Resident #1, Resident #3,and Resident #6.
Cross Reference F677
Findings include:
A review of the facility policy titled ADL's Effective August 2021, revealed, Policy: Ensure ADLs are provided in accordance with accepted standards of practice, the care plan, and reasonable accommodation of the resident's choices and preferences .
An interview on 03/18/24 at 6:30 AM, with Certified Nurse Aide (CNA) #1 confirmed that the nurse aides on the night shift have approximately 20 residents each to care for and that it is too many to take care of them properly. CNA # 1 stated that they used to have four (4) nurse aides on the night shift for one (1) wing, but they cut the number of nurse aides back to three (3). CNA #1 stated. They said they had to cut us back because of the budget or something.
An interview on 03/18/24 at 6:45 AM, with CNA #2 confirmed that having only 3 nurse aides on the night shift that they have a hard time getting everyone's care done timely.
Resident #1
During an interview on 3/18/24 at 9:40 AM, with Resident #1 revealed she has to wait for a female CNA or nurse to come provide her care, because they have other residents assigned to them. She stated she has complained about not wanting to have a male CNA and there is always a male assigned to her, so she has to wait for the female CNA to provide incontinent care. She stated she had talked with both the head nurse and the Administrator, but she has waited two (2) hours several times and one time she waited eight (8) hours while she was wet just to have a female CNA change her.
During an interview on 3/19/24 at 3:05 PM, with the Ombudsman confirmed that Resident #1 complained that she has to wait a long time for the female aids to provide incontinent care because they have other residents, and she has made the Administrator aware. She stated the resident informed her that staff told her, You are just going to have to deal with it.
Review of Resident #1's admission Record revealed the resident was admitted to the facility on [DATE].
Record review of Resident #1's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/23/23 revealed in Section C a Brief Interview for Mental Status (BIMS) score of 15, which indicates the resident is cognitively intact and in Section GG that the resident needed assistance with Activities of Daily Living (ADL).
Resident #6
During an observation/interview on 03/18/24 at 10:30 AM, of Resident #6 and the Treatment Nurse present revealed the resident lying in bed awake and appearing disheveled wearing only a shirt and a brief. The resident's hair was oily, and he had facial hair covering his cheeks and chin that was approximately one-half inch long. The resident stated, They haven't shaved me in a long time, and I want them to shave the hair off of my face. The resident could not remember the last day he received a shave. The resident confirmed that he had not had a shower in about two (2) weeks and that he would like to go to the shower. Resident #6 stated, They have been washing me up in bed'.
During an interview on 03/18/24 at 1:15 PM, with Licensed Practical Nurse (LPN) #2 confirmed that there was only one bath sheet indicating the days he received a bath on 03/12/24 for Resident #6. LPN #2 confirmed that the resident is supposed to receive a bath on Tuesday, Thursday, and Saturday and that he should be shaved when he received a bath.
Record review of Resident #6's admission Record revealed the resident was admitted to the facility on [DATE].
Record review of Resident #6's MDS with an ARD of 1/24/24 revealed in Section C a BIMS score of 13, which indicates the resident is cognitively intact.
Resident #3
During an interview on 3/19/24 at 9:00 AM, with Resident #3 revealed he gets mainly bed baths. He stated that it has been so long since he has had a shower that he can't remember when it was. He stated he preferred to get a shower because it's always warm. He revealed he has to have help going to the bathroom, but they are slow to get to him and they never ask to take him to the bathroom during the day when he is up in his wheelchair. He laughed and said Oh no they are not going to ask, that would mean they would have to take me.
Record review of Resident #3's admission Record revealed the resident was admitted to the facility on [DATE].
Record review of Resident #3's MDS with an ARD of 2/3/24 revealed in Section C a BIMS score of 13, which indicates the resident is cognitively intact and in Section GG indicated the resident needed supervision and/or touching assistance with toileting.
An interview on 3/19/24 at 3:30 PM, with Licensed Practical Nurse (LPN) #5 confirmed that staffing is an issue. She stated she has 30 residents with 15 blood sugars and vital signs and 15-20 meds per resident normally. She stated it is too overwhelming and I've been a nurse in Long Term Care (LTC) for 30 years and this is the worst place that I have seen. She revealed she has voiced these concerns to the Administrator but did not get a response. She stated that the LPN on 11-7 shift has 60 residents she is responsible for and that it is just too much. She confirmed that the residents do not get showers like they should, and she has told the Administrator about that. She said my residents have had showers for the past two days, but it is because you all have been here.
During an interview on 3/20/24 at 10:00 AM, with the Director of Nurses (DON) confirmed that not all of her nursing staff are meeting her expectations of basic human needs and care. She revealed she has had to start with the basic bottom line of incontinent care, nutrition, and wounds since she has been here. She stated that not all staff are attentive as they need to be with their care. She confirmed that residents not getting their incontinent care timely and getting bed baths instead of showers has been a problem and is reflected in the amount of moisture associated skin disorders we have had in the past. She confirmed that residents do get mainly bed baths because some of the aides think it is easier. She revealed that is something she has been working on since she got here. She revealed she feels like they have plenty of staff, they just have some lazy staff.
An interview on 03/20/24 at 12:51 PM, with the Workforce Manger confirmed that she was aware that she ran low on staffing scheduling on 03/16/24 and 03/17/24. The Workforce Manager stated, I only received training on completing the schedule for one (1) day before I started doing it. The Workforce Manager confirmed that there were not enough staff providing resident care if she had someone requiring one-on-one or had an orientee working. She stated I just copy my monthly schedule onto the staffing grid, and I never make changes to my schedule to reflect if someone calls in or not, so I don't ever know what the numbers equal out to. I thought the Administrator was looking at that, because I'm not.
An interview on 03/20/24 at 1:00 PM, with the Administrator revealed that she was unaware that the Workforce Manager had not been trained in staffing and that it could cause staffing concerns and the staff scheduled to be wrong.
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 F0919
(Tag F0919)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff and resident interview and facility policy review, the facility failed to ensure that call lights we...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff and resident interview and facility policy review, the facility failed to ensure that call lights were functioning in all resident rooms as evidenced by Resident #3 and Resident #6's call lights not functioning for two (2) of seven (7) residents sampled.
Findings Include:
Record review of the facility policy titled, Nurse Call System with a revision date of 9/1/14 revealed, Policy .To maintain center nurse call systems in an ideal mechanical condition to ensure optimum performance when residents request assistance from staff .
An observation on 3/18/24 at 6:15 AM, of Resident #3's room revealed the call light outside the room door was on, but no noise was alerting staff.
An interview on 3/18/24 at 6:16 AM with Licensed Practical Nurse (LPN) #3 confirmed that Resident #3's call light is not working and stays on all of the time, so they have bells.
An observation and interview on 3/18/24 at 6:17 AM, with Resident #3 revealed there were no call light cords in the resident's room, no bell was noted and he has no idea if he has a call light and has never had a bell. He stated he has seen a call light cord before, but it's been a while. He picked his cell phone up and stated he used this if he had to.
An interview on 3/18/24 at 6:18 AM with Licensed Practical Nurse (LPN) #3 confirmed that she needed to put a work order in for Resident #3's call light and stated that she thought they had bells to ring, but confirmed that they didn't.
An interview and observation on 3/18/24 at 9:13 AM, with LPN #4 revealed that as far as she knew, all the call lights worked, and no one has had a bell in a long time. On this observation it was revealed that Resident #3 had call light cords and when they were pulled the light came on but did not make a noise. She stated a work order needs to be put in for this, I had no idea. She stated she was going to notify maintenance.
An observation and interview on 03/18/24 at 10:30 AM, with Resident #6 stated that the staff comes when he calls for them. The resident pressed his call light, and the call light did not work. The treatment nurse LPN #1 was present in the residents' room and confirmed that the call light was not working.
An interview and observation on 3/19/24 at 11:00 AM with the Administrator and the Director of Nurses (DON) of Resident #3's room confirmed that the residents' call light would come on when it was pushed but there was no sound at the nurse's station to alert staff that the resident needed help. They confirmed that a work order should have been put in by the staff that were aware it was broken. The Administrator revealed if staff are aware that there are problems with a call light then a work order needed to be put in and they need to let me know. She stated that she would investigate to find out why Resident #3's room did not have call light cords on observation at 3/18/24 at 6:17 AM. She revealed that the call light would come on and stay on when the cord is pulled out of the wall.
An observation and interview on 3/19/24 at 10:00 AM with Maintenance Staff #2 confirmed that the call light in Resident #3's room came on with no noise and needed to be fixed, but he had not been made aware that it was broken.
An interview on 3/20/24 at 10:00 AM with the Director of Nurses (DON) confirmed that residents not having functioning call lights is an issue that could lead to a problem for the resident if they are not able to call for help.
Record review of Resident #3's admission Record revealed the resident was admitted to the facility on [DATE].
Record review of Resident #3's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 2/3/24 revealed in Section C a BIMS score of 13, which indicated the resident is cognitively intact.
Record review of Resident #6's admission Record revealed the resident was admitted to the facility on [DATE].
Record review of Resident #6's MDS with and ARD of 1/24/24 revealed in Section C a BIMS score of 13, which indicated the resident is cognitively intact.
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Safe Environment
(Tag F0584)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, staff and resident interview, record review and facility policy review, the facility failed to provide a ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, staff and resident interview, record review and facility policy review, the facility failed to provide a safe, clean, homelike environment as evidenced by damaged floors on the East Wing, trash build up, unclean floors and no clean linens for two (2) of three (3) wings.
Findings Include:
Review of the facility policy titled, 5-Step Daily Room Cleaning with no revision date revealed, Purpose .proper cleaning method to sanitize a patient room or any area in a healthcare facility .1. Empty Trash, 2. Horizontal Surfaces-disinfect, 3. Spot Clean Walls, 4. Dust Mop, 5. Damp Mop; The most important area of a patient's room to disinfect is the floor .When damp mopping floors pay close attention to any possible build up .
Review of the facility policy titled, Structuring the Laundry System with a revision date of 10/25/18 revealed, .Stage 1: Establishing Linen PARS .A linen par is the amount of linen needed to satisfy the daily needs of each and every resident .The rule of thumb is that linen inventory should be a minimum of 3 times your par (the amount of linen needed to satisfy the daily needs of each and every resident), 8 times par for wash cloths .
Review of the facility policy titled, Work Orders and Paging with a revision date of 9/1/14 revealed, Purpose .To establish a productive procedure for communicating and coordinating the needs of residents and employees from the Maintenance Department .
An observation on 3/18/24 at 6:05 AM, of the East wing hall leading to the nurse's station from the front entrance revealed three areas of buckled, unsecured vinyl flooring that was torn and raised up from the concrete floor. There were two indentions in the floor that was approximately 3 inches wide and 1 inch deep, multiple uneven areas and multiple peeling laminate that was sticking up. One area was approximately 5 feet long by 7 feet wide and was closest to the ice machine on that hall, and the other two areas closest to the nurse's station were approximately 20 feet long by 7 feet wide and one was 10 feet long by 7 feet wide. This hall is a high traffic area and is the path traveled for residents, staff, and visitors from their rooms on the East halls to the dining room. This observation revealed there were no cones or precaution signs to alert staff, residents or visitors of the damaged, uneven floor.
An observation on 03/18/24 at 6:20 AM, of the [NAME] wing hall revealed the floors were dirty and had discarded pieces of paper, dried liquid stains and food crumbs throughout the hall.
An observation on 3/18/24 at 6:28 AM, revealed Resident #2 lying in bed with no sheets or a full blanket. The resident's knees were pulled up to his chest and he was covered in an approximate 30 inch by 30-inch velour throw and had one folded under his buttocks. This observation revealed the resident's curtains were blowing in and out and when the curtains were pulled open it revealed the window was cracked open and the current temperature outside was 38 degrees.
An interview on 3/18/24 at 6:30 AM, with Licensed Practical Nurse (LPN) #3 confirmed she was Resident #2's nurse and was not sure why the resident did not have sheets or proper blankets on him or why the window was open, but it did not need to be, and he needed some linens on his mattress. She revealed that the floor on the East Hall had been messed up for a while now, but she is not sure what they have done to fix it and stated she thinks they had a water leak.
An interview and observation on 3/18/24 at 6:42 AM, with Certified Nurse Assistant (CNA) #3 confirmed she is Resident #2's CNA and she confirmed the resident did not have sheets or a blanket because they did not have any linen and that happens a lot lately. She confirmed the resident deserves to have a full blanket and sheets, but she is doing the best she can because that was all she could find to put on him.
An observation/interview, on 03/18/24 at 6:45 AM, revealed that the [NAME] Wing shower room door was propped open with a maintenance cart. Certified Nurse Assistant (CNA) #2 revealed that shower room has been broken for about two (2) months because there was some problem with the water, but they are having to change the shower head. CNA #2 confirmed that the residents have been receiving bed baths. CNA #2 stated, We don't have enough linen to take care of the residents because we only have one washer working.
Observation on 03/18/24 at 6:48 AM, of the linen closet on the [NAME] Wing revealed one fitted sheet and one flat sheet. There were no towels, wash cloths or blankets.
An observation on 03/18/24 at 06:50 AM, of room [NAME] 16 B revealed there was an area approximately three (3) foot by two (2) foot of dried brown sticky substance running underneath the resident's bed.
An observation/interview on 03/18/24 at 6:55 AM, of resident room [NAME] 22 A revealed there were small brown and white crumbs of food scattered on the floor from the top of the resident's bed to the foot of the bed and a brown sticky substance splattered on the floor in an area approximately two (2) feet by 2 feet on the right side of the bed .
An observation with CNA #3 on 03/18/24 at 7:00 AM, of the linen closet on the East Wing confirmed there were no linens of any type, the closet was empty. She stated she went to the laundry room when she came on duty at 11 PM and there were no clean linens in the laundry room at that time. Laundry staff #1 walked past as we were viewing the empty linen closet and confirmed there was no clean linens, because they were down to one washer and stated she has some sheets washing now but that it will be awhile.
An interview and observation on 3/18/24 at 7:00 AM, with the Administrator revealed when she attempted to enter the laundry room from the dirty side that there were so many bags of dirty laundry, she could not open the door all of the way. She stated the reason they were behind on laundry was because they only work one shift and do not work at night. She stated, I'll be honest I was not aware that we were down to one washing machine. The Administrator confirmed that Resident #2 needed sheets and a blanket covering him and asked the laundry staff to take one to him immediately. Laundry Staff #1 informed her she did not have any clean blankets at this time. The Administrator ask Laundry Staff #1 to get some in the washer and she stated as soon as this load is finished I will. The Administrator then stated she was aware that the washing machine had broken down and that they were trying to get it fixed but did not know any details.
An observation and interview on 3/18/24 at 7:30 AM, with LPN #4 revealed there were three yellow poles on the East Hall with the damaged floors covering the approximate 3 inch wide by 1-inch-deep holes. LPN #4 stated that they put yellow poles up in three places for an area that is approximately 10 feet long and 7 feet wide to alert residents to avoid the floor hazards in that area. She confirmed the facility had multiple water leaks in the floors and the floors had to be repaired multiple times. She revealed that the three yellow poles did not cover all of the areas of the floor that was damaged, and it could be a hazard for residents trying to walk over the damaged floor areas.
An observation and interview on 3/18/24 at 7:40 AM, with the Administrator confirmed the floor is damaged on the East Hall due to more than one water leak. She stated that they were supposed to come fix it two weeks ago but the work crew didn't show up. She confirmed that the floor could be hazardous for residents due to its condition.
An interview and review of invoices regarding water leak repairs and replacement flooring with the Administrator on 3/18/24 at 8:30 AM, revealed there had been two water leaks in the concrete slab floor on the East Hall that had to be repaired with the first one being 5/27/23 and the second one occurred 11/7/23-11/14/23. Review of the invoice for replacement flooring revealed it was ordered on 3/13/24 and is scheduled to be replaced on 3/20/24. A confirmation interview with the Administrator confirmed that she had said they were supposed to have been at the facility two weeks ago to replace the floors, but that the floors were not ordered until last week. She confirmed that it had been almost nine (9) months since the first water leak that damaged the floors.
An interview on 3/18/24 at 9:00 AM, with CNA #4 revealed that she has had complaints from family and residents about the cleanliness of the facility. She revealed that housekeeping does not work at night, and she has noticed that some of the floors in the rooms are not clean; they could do better.
An observation on 03/18/24 at 10:00 AM, revealed Housekeeper #4 entered resident room [NAME] 16, The housekeeper was noted coming out of the room and going back into the room with a mop.
An interview on 03/18/24 at 10:12 AM, with Registered Nurse (RN) #1 confirmed that the floor in room [NAME] 16 still had a dried brown substance on the floor and needed to be cleaned. RN #1 stated, The floor needs to be cleaned.
An observation/interview on 03/18/24 at 10:15 AM, of Housekeeper #4 coming out of resident room [NAME] 16, she confirmed that she was finished cleaning the resident's room. An observation of the residents' floor revealed the dried splattered brown substance was still on the floor and underneath the resident's bed. RN #1 was standing outside of the residents' door. RN #1 entered the room and confirmed that the feeding was still on the floor and underneath the bed and that it did not provide a clean environment for the resident. RN#1 confirmed that the housekeeper had just exited the resident's room but did not clean the brown substance off the floor and that it did not appear that she had mopped the resident's floor at all.
An interview on 03/18/24 at 10:20 AM, with Housekeeper #4 confirmed that she did not get the dried brown substance off the floor. Housekeeper #4 stated It's not our job to get the milk up. This is my first day back anyway from maternity leave, so that's not on me.
An observation and interview on 03/18/24 at 10:30 AM, of Resident #6 lying in bed with a urinal underneath a chair that sat against the wall in the center of the room. Resident #6 confirmed that the urinal underneath the chair belonged to the resident who was in the room before him and was not his.
An interview and observation on 03/18/24 at 12:47 PM, with LPN #4 confirmed that the urinal underneath the chair in Resident #6's room belonged to the resident that was in the room previously and had not been removed. She revealed that Resident #6 was admitted to that room on 3/8/24 and it appeared that the room had not been cleaned.
An interview on 3/19/24 at 9:00 AM, with Resident #3 revealed that he can self-propel his wheelchair and the floor on his hall (East) has a place that is hard for him to roll his wheelchair over. They sometimes have to push me over that area. He stated the floor is rough in that area and it's been like that for a long time.
An observation and interview on 3/19/24 at 10:00 AM, with Maintenance Staff #2 confirmed the floors on the East Hall was unlevel because of several water leaks and that they had to tear up the floor back last year. He stated that after the last water leak, they Had us fix it with self-leveling concrete and lay new vinyl flooring. He revealed that maintenance laid the self-leveling concrete but it did not work and the floors were not level, with dips and holes in the floor and also peeling and pulled up vinyl planks for an area approximately 10 feet long by 7 feet wide near the nurse station, an area approximately 20 feet long and 7 feet wide toward the middle of the East Hall in front of rooms E 8-E 12 and an area 5 feet long and 7 feet wide at the end of the East Hall in front of the ice machine. He admitted that the floor was unlevel and could be dangerous to residents and visitors. He stated he was made aware on Friday morning 3/15/24 that one of the washers was out, and he found that the water hose had busted. He revealed that he replaced the water hose but forgot to turn the hot water back on. He stated that he repaired that first thing Friday morning and left the facility around 4:30 PM with no one making him aware that the washer still wasn't working before he left. He admitted that he never told the Administrator anything about that but should have.
Record review of the invoices for water leak repairs revealed the East Hall had two water leaks. The review of the invoice dated 6/28/23 from (Proper name) Companies, Inc revealed multiple leaks and repairs were made over the days from 5/27/23 to 6/1/23. The notation dated 6/1/23 revealed that the repair company left the slab a little low for whoever replaced the floor to use leveling compound to make sure the flooring grade matched the existing; cleaned up the site and left. Review of the invoice dated 11/27/23 revealed (Proper Name) Companies Inc repaired a floor leak between 11/7/23 and 11/14/23.
Record review of the invoice dated 3/13/24 from (Proper Name of flooring company) revealed that 470.86 square feet of flooring had been ordered.
An observation and interview with CNA #5, DON and Administrator on 3/19/24 at 11:00 AM, revealed multiple bags of foul-smelling garbage piled up to the counter height and to the door in the biohazard room on the East Wing. An interview with CNA #5 confirmed she could barely open the door and she cannot get to the replacement battery for her total lift that is charging in that room. An interview and observation with the DON and Administrator confirmed that was a lot of bagged garbage that appeared to be resident's dirty briefs and staff should have already taken that out.
An interview on 3/19/24 at 11:15 AM, with the Environmental Manager revealed he took over this facility a short time ago and it still needs work. He stated that he was not aware that the washer broke on Friday, and he honestly does not know for sure if it is housekeeping's responsibility to take the garbage out every morning from the biohazard room, but he will get to the bottom of it. He revealed that there should have been clean linen available for the residents.
An observation and interview on 3/19/24 at 11:30 AM, revealed Housekeep Staff #5 rolling a large barrel of foul-smelling garbage down the hall. On interview she confirmed it came from the biohazard room on the East Hall and it was her or the floor techs responsibility to take it out every morning. She stated I've been talking to the Administrator and the one before her about taking this responsibility off of me. She stated that the current Administrator told her they have to baby the CNA's. She stated she was supposed to have taken it out this morning but got busy doing paperwork. She stated that this is 3 PM-11 PM AND 11 PM-7 AM' s' garbage because they don't want to take it out there in the dark.
An interview on 3/19/24 at 3:15 PM, with Laundry Staff #3, assistant supervisor, stated she walked up to the Administrator where she was sitting at the conference table for the stand-up meeting on Friday and told her the washer was out and they had staffing issues. She stated that Maintenance came and looked at the washer on Friday but did not fix anything and told us he would have to call someone to come look at it.
An interview on 3/20/24 at 10:00 AM, with the Director of Nurses (DON) stated that Resident #2 not having sheets on his bed and not having a blanket to fully cover him is a basic human right and he should have had better, but I realize they were doing the best they could do since they did not have any clean linen. She confirmed that the garbage in the biohazard room that was resident's dirty briefs and such should have been taken out first thing yesterday morning and the staff that were responsible for that knew to do it.
Record review of Resident #2's admission Record revealed the resident was admitted to the facility on [DATE].
Record review of Resident #2's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 3/7/24 revealed in Section C a Brief Interview for Mental Status (BIMS) score of 10, which indicated the resident is moderately cognitively impaired.
Record review of Resident #3's admission Record revealed the resident was admitted to the facility on [DATE].
Record review of Resident #3's MDS with and ARD of 2/3/24 revealed in Section C a BIMS score of 13, which indicates the resident is cognitively intact.
Record review of Resident #6's admission Record revealed the resident was admitted to the facility on [DATE].
Record review of Resident #6's MDS with an ARD of 1/24/24 revealed in Section C a BIMS score of 13, which indicates the resident is cognitively intact.
Nov 2023
9 deficiencies
2 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
Comprehensive Care Plan
(Tag F0656)
A resident was harmed · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Resident #15
A record review of Resident #15's care plan, with an onset date of 6/20/23, revealed, Focus: Resident's proper name...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Resident #15
A record review of Resident #15's care plan, with an onset date of 6/20/23, revealed, Focus: Resident's proper name has Diabetes Mellitus with potential for complications .Interventions .If infection is present, consult doctor regarding any changes in diabetic medications .
A record review of Resident #15's Blood Sugar Summary and Medication Administration Record (MAR) for October revealed that on 10/26/23 at 5:27 AM the resident's blood sugar was 466.
A record review of October Physician orders revealed an order, with a start date of 10/25/23, for Macrobid Oral Capsule 100 milligrams (MG) give one (1) capsule by mouth two times a day for Urinary Tract Infection (UTI) for seven (7) days.
During an interview on 11/1/23 at 3:00 PM, the Minimum Data Set Nurse (MDS) verified that Resident #15's care plan was not followed when the nurse failed to notify the Nurse Practitioner (NP) of Resident #15's blood sugar of 466. The MDS nurse stated failure to follow the care plan could lead to a delay in treatment.
A record review of Resident #15's admission Record revealed that the resident was readmitted to the facility on [DATE]. Resident #15's active diagnoses included Type 2 Diabetes Mellitus and Urinary Tract Infection.
Resident #108
An observation/interview on 10/30/23 at 10:30 AM with Resident #108 confirmed that she was unable to open her left hand and that she could not move her left arm. The resident's left hand was contracted with her thumb pressed between the second and ring finger. There was no splint in Resident #108 left hand.
Record review of Care Plans for Resident #108 revealed a care plan initiated on 10/22/23 for a Restorative Splint/Brace program - Place Carrot (hand roll) in hand as often as able to tolerate.
An interview, with Director of Nursing (DON) on 11/01/23 at 4:11 PM confirmed that the purpose of the care plan was to provide a structured means of providing care and communicating with other staff. The DON confirmed that failure to follow a care plan could result in providing the wrong care to a patient or not providing the care that the resident needs.
A review of the facility face sheet for Resident #108 revealed the facility admitted the resident on 3/08/23 with a diagnosis of Hemiplegia to left side, Contracture of left hand, Hyperlipidemia and Hypertension
A review of the Minimal Data Set (MDS) with an Assessment Reference Date (ARD) of 8/23/23 revealed a Brief Interview for Mental Status (BIMS) score of nine (9) which indicated Resident #108 was cognitively impaired.
Resident #102
An observation on 10/30/23 at 10:29 AM, revealed Resident #102's call light laying on the floor underneath the bed.
A review of the care plan titled, I am at risk for falls related to New environment, CVA (cerebral vascular accident) needing assist with transfer and bed mobility, impaired cardiovascular, dementia and psychotropic medication use, revised 10/31/23 revealed Call light or personal items available and in east reach.
An interview with the Minimum Data Set Nurse (MDS) on 10/31/23 at 3:19 PM confirmed after review of Resident #102's care plans, staff did not follow the care plan for keeping call light in reach and revealed the purpose of the care plan is direct resident specific care. The MDS nurse stated not following the care plan could lead to resident specific care needs not being met.
Record review of the admission Record revealed that the facility admitted Resident #102 to the facility on [DATE] with diagnoses Adult Failure to Thrive and Cerebral Infarction.
Record review of the Minimum Data Set (MDS) Section C with an Assessment Reference Date (ARD) of 9/28/23, revealed that Resident #102 had a Brief Interview of Mental Status (BIMS) score of 06 which indicated that she was severely cognitively intact.
Based on resident and staff interview, record review, and facility policy review, the facility failed to develop/implement care plans for (2) two residents related to shaving Resident #90 and Resident #173; failed to ensure a call light was in reach of (1) one resident, Resident #102; failed to consult a physician for medication changes for (1) resident, Resident #15; and failed to apply a splint for (1) one of (4) four residents reviewed with assistive devices, Resident #108; for a total of five (5) residents out of 26 sampled residents.
Findings include:
A review of the policy titled, Comprehensive Care Plans, 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 timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment.
Resident #90
An observation on 10/30/23 at 11:25 AM revealed Resident #90 in wheelchair with long facial hair. Resident #90 stated he wanted to be shaved.
An observation and interview on 10/31/23 at 4:38 PM with Resident #90 and Licensed Practical Nurse (LPN) #4, LPN #4 confirmed the resident stated he wanted to be shaved. Resident #90 stated he tried his best about a week ago to do it himself but just couldn't.
An interview, on 11/1/23 at 11:30 AM with CNA #4 revealed that she was assigned to Resident #90 this morning. She stated that residents should be shaved on their shower days or as needed unless they refuse. She stated that when she saw Resident #90 this morning the hair on his face was ridiculous and that she shaved him first thing this morning.
Review of the admission Record resident information form revealed Resident #90 was admitted to the facility on [DATE] with diagnoses that included Hemiplegia and Hemiparesis following Cerebral Infarction affecting left dominate side, Anxiety disorder, Restlessness and Agitation, and Anemia.
Review of the quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 8/29/23 revealed a Brief Review for Mental Status (BIMS) score of 12 which indicated Resident #90 had moderate cognitive impairment.
Resident #173
An observation, on 10/30/23 at 1:20 PM revealed Resident #173 in bed, verbally unresponsive. Resident #173's spouse was at the bedside. She stated he has not been shaved since he was admitted . She stated the staff has not offered to shave him. Resident #173's spouse stated in the past Resident #173 always shaved his face except for a mustache.
An interview, on 10/31/23 at 8:15 AM with the Director of Nursing (DON) revealed the staff should offer to shave residents, this was part of the resident's daily care.
An interview, on 11/01/23 at 11:29 AM with Certified Nursing Assistant (CNA) #1 revealed when they give the residents a bath or shower, they should shave them if they have hair on their face.
An interview, with the Licensed Practical Nurse (LPN) Minimum Data Set (MDS) nurse confirmed Resident #90 nor Resident #173 had an Activities of Daily Living (ADL) care plan for shaving. She stated that she thought everyone should know that shaving should be a part of bathing or showering. She confirmed it should be part of the care plan. The purpose of the care plan was to let staff know what care the resident should get.
An interview on 11/02/23 at 8:57 AM with the DON revealed that care plans should be in place for resident's ADL care and stated the care plan should be in place to make sure appropriate care is provided to the residents and the care plan is the staffs' communication tool for resident care.
Review of the admission Record resident information form revealed the facility admitted Resident #173 on 10/17/23 with diagnoses that included Essential Hypertension, Acute Embolism and Thrombosis of Unspecified Deep Veins of left lower extremity, Cognitive Communication Deficit, and Diabetes Mellitus Type 2.
SERIOUS
(G)
Actual Harm - a resident was hurt due to facility failures
Deficiency F0688
(Tag F0688)
A resident was harmed · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, resident/staff interview, record review, and facility policy review the facility failed to apply a hand sp...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, resident/staff interview, record review, and facility policy review the facility failed to apply a hand splint that was recommended by Occupational Therapy to prevent worsening of a contracture for one (1) of three (3) residents with splints resulting in loss of Range of Motion (ROM) for the resident. Resident #108
Findings Include:
A review of the facility policy titled, Splinting and orthotics, revealed: It is the policy of (Proper Name) Rehabilitation that therapists recommend, within their scope of practice, appropriate splinting and orthotics for patients currently receiving therapy services, as the need arises.
An observation and interview, on 10/30/23 at 10:30 AM with Resident #108 confirmed that she was unable to open her left hand and that she could not move her left arm. The resident's left hand was contracted with her thumb pressed between the second finger and the ring finger. There is nothing splinting the left hand.
An observation, on 10/30/23 at 1:45 PM, confirmed that the resident's left hand is contracted and had a bath cloth rolled up and placed in her hand, however the resident's thumb was not on top or around the cloth and was pressed against the palm of her hand. The resident confirmed she was unable to open her hand or move her left arm.
An observation/interview, on 10/31/23 at 9:48 AM revealed Occupational Therapist (OT) was sitting at a table in the day room with Resident #108 and was performing exercises to the residents left hand. There was a Carrot Splint (circular hand splint) inside of Resident #108 left hand. OT confirmed that he was evaluating Resident #108 to possibly be admitted back to therapy for contracture management. OT confirmed that they treated the resident previously and that when they discharged her from therapy to restorative care, therapy could open the resident's left hand halfway, and left thumb was extended out. OT stated that the facility's restorative staff were supposed to place the Carrot Splint inside her left hand daily. OT confirmed that the Carrot Splint had not been being placed into Resident #108 left hand due to being misplaced. OT confirmed that the hand now has an odor and that there is a reddening between the digits where the thumb is contracted and pressing. OT confirmed that Resident #108 has a decreased range of motion (ROM) to the left hand since being discharged from Occupational therapy.
An interview, on 11/01/23 at 10:45 AM with Certified Nurse Aide (CNA) #2 confirmed she was the CNA assigned to Resident #108 for the day and that she did not put a splint on the resident. CNA #2 confirmed that she was unaware of needing to put a splint on Resident #108.
An interview, on 10/31/23 at 02:00 PM with Director of Nursing (DON) confirmed that Resident #108 has a contracted left hand that OT recommended a splint for the left hand and that it had not been in her hand on 10/30/23. The DON confirmed that not having a splint in the contracted hand could result in a skin integrity issue and worsening of the contracture.
A record review of the OT evaluation revealed Resident #108 was admitted by OT on 8/07/23. Review of the evaluation revealed: Clinical Impressions on 8/07/23 Patient has increased contractures at L hand/digits specifically. Since the last treatment period, seems from OT opinion that hands have become more contracture to the point where fingers are digging in palm which is causing deficits with skin breakdown and joint integrity and overall hygiene within the hand.
Record review of OT discharge summary revealed Resident #108 was discharged from Occupational Therapy on 8/31/23 with Occupational Therapy documentation revealing that the patient is tolerating wearing splint for up to 8 hours without any complaints of pain and skin integrity intact with no redness or swelling. The discharge recommendations were for Restorative Program = Restorative Splint and Brace Program.
A review of an OT evaluation dated 10/31/23 revealed OT readmitted the resident back to therapy with the following Clinical Impressions: Based on clinical assessment and analysis of the documented physical impairments and functional deficits: patient has severe contracture of left hand, due to non-compliance with past splinting schedule.
A review of the facility face sheet for Resident #108 revealed that she admitted to the facility on [DATE] with a diagnosis of Hemiplegia to left side, Contracture of left hand, Hyperlipidemia and Hypertension
A review of the Minimal Data Set (MDS) with an Assessment Reference Date (ARD) of 08/23/23 revealed a Brief Interview for Mental Status (BIMS) score of nine (9) which indicated Resident #108 was cognitively impaired.
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 resident and staff interview, record review, and facility policy review, the facility failed to ensure a resident's call light was placed within reach as evidenced by the call light laying on...
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Based on resident and staff interview, record review, and facility policy review, the facility failed to ensure a resident's call light was placed within reach as evidenced by the call light laying on the floor not in reach of the resident for (1) one of 26 sampled residents, Resident #102.
Findings include:
A review of the facility policy titled, Call Lights: Accessibility and Timely Response, revealed Policy Explanation and Compliance Guidelines: 6.) The call system will be accessible to residents while in bed or other sleeping accommodations within the resident's room.
During initial tour rounds on 10/30/23 at 10:29 AM, the State Survey Agency (SA) heard a resident state loudly, I have to go to the bathroom right now right now. Hurry before I wet this bed. The SA entered the resident's room and observed Resident #102's call light lying on the floor underneath the bed. Resident #102 stated inablity to call for assistance due to the call light not being reach.
On 10/30/23 at 10:31 AM, Certified Nurse Assistant (CNA) #3 entered Resident #102's room and confirmed the call light was under the bed on the floor. CNA #3 stated that Resident #102 was unable to use the call light. CNA #3 handed Resident #102 the call light and Resident #102 immediately pushed the call light. CNA #3 confirmed Resident #102's call light should be in reach at all times to alert alert staff of needing help.
An interview with the Administrator on 10/30/23 at 10:45 AM confirmed all call lights should be in reach of residents and call lights not being in place may delay care.
Record review of the admission Record revealed that the facility admitted Resident #102 on 12/06/22 with diagnoses of Adult Failure to Thrive and Cerebral Infarction.
Record review of the Minimum Data Set (MDS) Section C with an Assessment Reference Date (ARD) of 9/28/23, revealed Resident #102 had a Brief Interview of Mental Status (BIMS) score of 06 which indicated that the resident was severely cognitively impaired.
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
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to notify the resident's physician of an elevated blood sugar of...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to notify the resident's physician of an elevated blood sugar of 466 for (1) one of 26 sampled residents reviewed for provider notification of change in condition. Resident # 15
Findings include:
A record review of the facility's Acute Management: Diabetic Resident protocol, with no onset date, revealed to communicate with resident's provider if resident's blood glucose level was greater than or equal to 300.
A record review of Resident #15's Blood Sugar Summary and Medication Administration Record (MAR) for October revealed that on 10/26/23 at 5:27 AM the resident's blood sugar was 466.
A record review of Resident #15's progress notes for 10/26/23 through 10/27/23 revealed that there was no documentation that the resident's physician was notified of the 466 blood sugar result.
During an interview with Licensed Practical Nurse #1 (LPN) on 10/31/23 at 8:00 AM, LPN #1 stated that the Nurse Practitioner (NP) should be notified for a blood sugar over 400; and there should be documentation in the progress notes that the NP was notified, and any new orders received. She stated the facility has a standing order of blood sugar parameters for NP. She stated that the standing order should be on the MAR.
During a record review of the October MAR, LPN #1 verified that there was no standing order on the MAR for NP notification of blood sugars.
During an interview with the Director of Nursing (DON), on 10/ 31/23 at 11:15 AM, the DON stated that the resident should have blood sugar notification parameters ordered and the nurse should notify the NP based on the parameters ordered.
During an interview with the DON, on 10/ 31/23 at 2:20 PM, the DON verified that in the absence of ordered blood sugar parameters, LPN #3 should have followed the Acute Management: Diabetic Resident protocol for a resident and notified the NP of the resident's blood sugar of 466.
During a telephone interview on 10/31/23 at 3:19 PM, with the NP she stated that this particular resident's blood sugars are a little different, as she is usually non-compliant with her diet, but that at the time of the 466 blood sugar the resident was being treated for a urinary tract infection (UTI) and she would expect the nurse to notify her. She stated she was not notified of the blood sugar results for Resident # 15.
During a telephone interview on 11/1/23 at 11:34 AM, with LPN #3 she stated that she did not notify the NP of the Resident # 15's blood sugar of 466. LPN #3 agreed that untreated blood sugar of 466 could delay resolution of the resident's UTI.
During an interview with the DON on 11/1/23 at 2:25 PM, the DON agreed that failure to notify the NP of the resident's blood sugar for treatment changes could affect the resident.
A record review of Resident #15's admission Record revealed that she was readmitted to the facility on [DATE]. Resident #15's active diagnoses include Type 2 Diabetes Mellitus and Urinary Tract Infection.
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 interview, and facility policy review, the facility failed to ensure a resident was fre...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, resident and staff interview, and facility policy review, the facility failed to ensure a resident was free from accident hazards as evidenced by an unsecured free standing portable oxygen cylinder for one (1) of 12 residents with portable oxygen cylinders. Resident # 49
Findings include:
A review of the facility policy titled, Oxygen Safety revealed, Policy: It is the policy of this facility to provide a safe environment for residents, staff, and the public.Policy Explanation and Compliance Guidelines: 4.) Oxygen Storage-c. Cylinders will be properly chained or supported in racks or other fastening (i.e. (example) sturdy portable carts, approved stands) to secure all cylinders from falling, whether connected, unconnected, full, or empty.
An observation of Resident #49's room on 10/30/23 at 11:20 AM, revealed a free-standing oxygen (O2) cylinder standing upright not secured near Resident #49's closet.
A review of Resident #49's physician's orders revealed an order for O2 @ (at) 3L/min (liters/minuite) via BNC (bi-nasal cannula) continiously.
An observation on 10/31/23 at 8:33 AM, revealed the Portable oxygen cylinder remained free standing near the closet unsecured.
An observation and interview with Licensed Practical Nurse (LPN) #2 on 10/31/23 at 8:35 AM, she confirmed the oxygen cylinder was free-standing and not in a secure safe place and she revealed portable O2 cylinders should always be secured because it could fall and injure someone.
An observation and interview with The Director of Nursing (DON) on 10/31/23 at 8:40 AM, he confirmed the the portable O2 cylinder was improperly stored and should always be secured and revealed the tank could possibly fall and hurt someone because it was not secured and stable.
Record review of the admission Record revealed that the facility admitted Resident #49 to the facility on [DATE] with diagnoses of Chronic Obstructive Pulmonary Disease with acute exacerbation.
Record review of the Minimum Data Set (MDS) Section C with an Assessment Reference Date (ARD) of 7/29/23, revealed that Resident #49 had a Brief Interview of Mental Status (BIMS) score of 15 which indicated that she was cognitively intact.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, resident and staff interview, and facility policy review the facility failed to prevent the possible sprea...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, resident and staff interview, and facility policy review the facility failed to prevent the possible spread of infection when a residents oxygen tubing was laying on a resident's floor under her wheelchair and not stored in a plastic bag for (1) of 26 residents on oxygen therapy. Resident # 49
Findings include:
A review of a statement provided by the facility on company letter head dated 11/1/23, revealed The following respiratory equipment is to be cleaned q (every) week and prn (as needed). Change oxygen tubing and cannula, change prefilled water bottle, wash, and clean filter. Store in plastic bag when not in use.
An observation of Resident # 49's room on 10/30/23 at 11:20 AM, revealed Oxygen (O2) tubing attached to wheelchair portable cylinder tank laying on the floor underneath the wheelchair, an interview with Resident #49, she revealed she had not been up in the wheelchair all morning and revealed the tubing always falls in the floor and confirmed she was unaware of any type of storage bag.
An observation 10/31/23 at 8:33 AM O2 tubing attached to wheelchair concentrator laying on the floor underneath the wheelchair.
An observation and interview with Licensed Practical Nurse (LPN) #2 on 10/31/23 at 8:35 AM, she confirmed the oxygen tubing was laying on the floor underneath the wheel chair and revealed the oxygen tubing should not be on the floor and stored in a clean area and removed the tubing from the floor and stated she would discard and replace with new tubing and confirmed concerns from the tubing being on the floor is increased risk for infections from bacteria and dust.
An observation and interview with The Director of Nursing (DON) on 10/31/23 at 8:40 AM, he confirmed oxygen tubing not in use should be stored in a clean storage bag and never be on the floor and confirmed it is an infection control issue.
Record review of the admission Record revealed that the facility admitted Resident #49 to the facility on [DATE] with diagnoses of Chronic Obstructive Pulmonary Disease with acute exacerbation.
Record review of the Minimum Data Set (MDS) Section C with an Assessment Reference Date (ARD) of 7/29/23, revealed that Resident #49 had a Brief Interview of Mental Status (BIMS) score of 15 which indicated that she 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
Safe Environment
(Tag F0921)
Could have caused harm · This affected 1 resident
Based on observation, staff interview, and facility policy review the facility failed to provide a safe/functional/sanitary/comfortable environment as evidence by a gray/black residue on a residents r...
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Based on observation, staff interview, and facility policy review the facility failed to provide a safe/functional/sanitary/comfortable environment as evidence by a gray/black residue on a residents room wall and dirty air conditioner filter for three (3) of four (4) days of survey, for one (1) of 75 resident rooms observed. Resident #83
Findings Include:
A review of the facility policy titled Room Audit Effective Date: September 1, 2014, revealed: Purpose - To assess resident rooms to identify items that should be repaired, replaced, or addressed to ensure a home - like standard that meets acceptable standards. Guidelines: General Room Appearance - Housekeeping issues should be noted and reported to housekeeping. Damage drywall, furniture, or non-functioning equipment, etc. should be noted, a work order created and addressed according to priority.
A review of the facility policy titled Room Air Conditioner/Heating Units - PTAC Effective Date: September 1, 2014. Guidelines: Monthly Maintenance - Front Filters should be vacuumed and rinsed (replace when damaged). Front covers should be vacuumed with a soft brush attachment and cleaned with mild soap.
An observation on 10/30/23 at 11:30 AM of Resident #83's room revealed duct tape noted to the top of the air conditioner. The front of the air conditioner was off and laying on the floor and the filter was covered with dust. There was an area of the wall on the right front corner, next to the air conditioner approximately 3 feet by one foot area with a gray/black residue on the wall.
An observation, on 10/31/23 at 8:30 AM of Resident #83 room revealed, the area on the wall next to the air conditioner with the gray/black residue remains on the wall unchanged. The front cover of the air conditioner remained off and lying in the floor and filter remained dusty.
An interview, on 10/31/23 at 9:41 AM with Licensed Practical Nurse (LPN) #1 confirmed the area of gray/black residue on the wall in Resident #83's room and the front cover of the air conditioner lying in the floor. LPN #1 confirmed the buildup of dust inside the air conditioner. LPN #1 confirmed that it needs cleaning and that if it's left like that it could possibly cause respiratory issues.
An interview, on 10/31/23 at 10:00 AM with District Manager for Housekeeping confirmed the area of gray/black residue on the wall in Resident #83's room and the front cover of the air conditioner lying in the floor. The Housekeeping District Manager confirmed that it looks like a buildup of dirt, dust and water that blew out from the air conditioner and that they had cleaned it but it keeps coming back in the same spot. The Housekeeping Manager confirmed that if left there it could make the resident sick.
An interview, on 11/02/23 at 10:00 AM with the Administrator, she confirmed there is a gray/black residue on the wall in Resident #83's room and the air conditioner filter needed cleaning and confirmed if left unclean it could result in a resident becoming sick. The Administrator also revealed that this area has been repaired for the same issue and it came back and confirmed there was an issue with a water leak in this area.
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
ADL Care
(Tag F0677)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff, resident and responsible party interview, and facility policy review the facility failed to provide...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff, resident and responsible party interview, and facility policy review the facility failed to provide activities of daily living (ADL) care, shaving, for two (2) of 125 residents reviewed on initial tour. Resident #90 and Resident #173
Findings include:
Review of the facility policy title, Activities of Daily Living (ADLs), undated, revealed the facility will, based on the the resident's comprehensive assessment and consistent with the resident's needs and choices, ensure a resident's abilities in ADL's do not deteriorate unless deterioration is unavoidable. The policy explanation and guidelines include a resident who is unable to carry out activities of daily living will receive the necessary services to maintain good nutrition, grooming, and personal and oral hygiene.
Resident #90
An observation on 10/30/23 at 11:25 AM revealed Resident #90 in wheelchair with a hard cervical collar in place and noted a long beard. Resident stated he wants to be shaved. He stated that he tried to do it himself last week but just couldn't.
An observation and interview, on 10/31/23 at 4:38 PM with Resident #90 and Licensed Practical Nurse (LPN) #1 confirmed the resident stated he wants to be shaved. Resident #90 stated he tried his best about a week ago to do it himself but just couldn't. LPN #1 told the resident he didn't have to do that because the staff should do that.
An interview, on 11/1/23 at 11:30 AM with CNA #4 revealed that she was assigned to Resident #90 this morning. She stated that residents should be shaved on their shower days or as needed unless they refuse. She stated that when she saw Resident #90 this morning the hair on his face was ridiculous. She stated that she shaved him first thing this morning.
Review of the admission Record resident information form revealed Resident #90 was admitted to the facility on [DATE] with diagnoses that included Hemiplegia and Hemiparesis following Cerebral Infarction affecting left dominate side, Anxiety disorder, Restlessness and Agitation, and Anemia.
Review of the quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 8/29/23 revealed a Brief Review for Mental Status (BIMS) score of 12 which indicated Resident #90 had moderate cognitive impairment.
Resident #173
An observation, on 10/30/23 at 01:20 PM revealed Resident #173 in bed, verbally unresponsive. Resident #173's wife was at the bedside. She stated they are good to bathe him, but he has not been shaved since he was admitted on [DATE]. She stated the staff had not offered to shave him. Resident #173's wife stated he does wear a moustache but always shaved his face.
An interview, on 10/31/23 at 8:15 AM with the Director of Nursing (DON) revealed the staff should offer to shave residents, and if they want to be shaved, they should do it. He stated that this was part of the resident's daily care. The DON stated all residents should be shaved if needed.
An interview, on 11/01/23 at 11:29 AM with Certified Nursing Assistant (CNA) #1 revealed when they give the residents a bath or shower, they should shave them if they have hair on their face.
Review of the admission Record resident information form revealed Resident #173 was admitted to the facility on [DATE] with diagnoses that included Essential Hypertension, Acute Embolism and Thrombosis of Unspecified Deep Veins of left lower extremity, Cognitive Communication Deficit, and Diabetes Mellitus Type 2.
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
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, staff interviews, record review, and facility policy review, the facility failed to clean the ice machine...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, staff interviews, record review, and facility policy review, the facility failed to clean the ice machine for one (1) of two (2) ice machines in the nursing facility, failed to check the water temperature of the dish water in the three-(3) compartment sink prior to use for six (6) days during September and October of 2023, and failed to label, date, clean, and remove expired food for three (3) of 3 resident nourishment refrigerators located on the nursing units.
Findings Include:
Review of the facility policy titled, Manuel Warewashing, with a revised date of 9/2017, revealed Policy Statement: All cookware, dishware, and serviceware that is not processed through the dish machine will be manually washed . Procedures: 1. The Dining Service staff will be knowledgeable in proper technique including: . Wash temperature at no less than 110 degrees F (Fahrenheit).
Review of the facility policy titled, Ice, with a revised date of 9/2017, revealed Policy Statement: Ice will be prepared and distributed in a . sanitary manner . 2. The Dining Services Director will coordinate with the Maintenance Director to ensure that the ice machine will be disconnected, cleaned and sanitized quarterly and as needed.
Review of the facility policy titled, DMS POLICY AND PROCEDURES: Food Service Manual, with an effective date of August 1, 2012, revealed POLICY: It is the policy of this facility to assign cleaning schedules on a daily, weekly, and monthly basis. PROCEDURE: All equipment will be identified for cleaning. Refrigerators - Weekly.
An observation and interview on 10/30/23 at 10:40 AM revealed the 3-compartment sink was just run and steam table pans and cutting boards were being washed by Dietary Aide #1. The District Dietary Manager took the temperature of the wash water, and it was 90 degrees. The Dietary Aide #1 revealed the water was too hot to stick her hands in, so she ran cold water in the sink. She revealed the temp was 135 degrees before she cooled it down. When asked what the water temp should be for dishwashing in the 3-compartment sink, she note the manual dishwashing water temperature should be between 150 degrees to 185 degrees. She then changed and revealed the manual dish washing temperature should be between 135 degrees and 150 degrees. She revealed she did not write the temperature down on the 3-compartment sink temperature log today and revealed that she did not take the temperature of the water every time she washed the dishes in the 3-compartment sink. She confirmed the process of washing the dishes should be followed to avoid residents becoming ill from food served from unclean pots and pans. The District Dietary Manager revealed the dietary staff was in-serviced the first of this month regarding the temperature of the 3-compartment sink and the Dietary Aide should have known the water temperature for the 3-compartment sink. The District Dietary Manager confirmed the water temperature was not high enough to wash dishes and the water temperature should be taken each time before dishes are washed in the 3-compartment sink.
An interview on 10/30/23 at 10:46 AM with Dietary Aide #2, revealed she did not know what the temperature of the water should be for the 3-compartment sink because she did not go on that side of the kitchen. She confirmed she had been to an in-service about the 3-compartment sink but did not remember what was said. She noted the temperature of the dish water for the 3-compartment sink should be between 175 degrees and 180 degrees.
Record review of the Three Compartment Sink Log, for September 2023 revealed there was no wash water temperature documented for the Dinner . Wash on 9/5/23 and for Breakfast . Wash on 9/16/23, 9/17/23, and 9/18/23. The Three Compartment Sink Log for October 2023 revealed there was no wash water temperature documentation for the Lunch . Wash and Dinner . Wash for 10/31/23.
Record review of the in-services for the dietary department, revealed Topic: Temperatures, Date: 10/11/2023 . Three compartment sink temps: Wash 110, take the temperature each time you wash pots and pans . Date: 10/19 . All temp logs . must be filled out daily.
An observation and interview on 10/30/23 at 11:10 AM with the Maintenance Director, of the ice machine located on the nursing unit revealed the white plastic area of the top, inside, of the ice maker surrounding the ice freezing element, was observed to have pink, yellow and dark coffee colored slim like substance on it where the water drained into the tray under the element. The tray holding the draining water was observed to have a shiny slimy substance around the inside edges of it. The Maintenance Director revealed he had just cleaned the top inside of the ice maker last month, but he did not take the outside panels off to see inside when he cleaned it. He revealed he was able to take the inside panel that covered the element off without removing the outside panel, was able to reach into the top of the ice machine and clean the area and none of this substance came out when he cleaned the machine. He noted he had never removed the side panel of the ice machine and looked inside it.
An observation and interview on 10/30/23 at 11:15 AM with the District Dietary Manager confirmed there was pink, yellow, and dark coffee colored slim like substance on the white plastic area in the top, inside of the ice maker surrounding the ice freezing element, and a shiny slimy looking substance around the edges of the tray holding the water that drained into the tray that ran off the ice freezing element. She revealed the ice machine was used by the floor staff and not the kitchen, and she was not aware the ice machine was not clean.
An observation and interview on 10/30/23 at 11:30 AM with the Administrator, confirmed there was pink, yellow, and dark coffee colored slime like substance on the white plastic area in the top, inside of the ice maker surrounding the ice freezing element, and a shiny slimy looking substance around the edges of the tray holding the water that drained into the tray that ran off the ice freezing element. She confirmed there was a possibility for growth of a water borne pathogen in the ice machine that could have possibly caused illness for a resident. The Administrator also confirmed the water temperature to wash dishes in the 3-compartment sink should have been no less than 110 degrees, that the dishes were being washed at an inappropriate temperature, which could present the possibility of illness to a resident being served food from unclean dishes.
Record review of the LOGBOOK DOCUMENTATION, noting the last date the ice machine on the nursing unit was cleaned, revealed, Ice Machines . sanitize interior . Marked done on-time . September 26, 2023, . Sanitize Interior: 1. Sanitize interior of ice machine per manufacturer's instruction.
An observation and interview on 11/01/23 at 08:52 AM with Unit Secretary #1 on the [NAME] Wing, revealed the resident nourishment refrigerator to contain:
- 2 bottles of hot sauce (not labeled)
- 4 containers of yogurt (1 was opened in the freezer and were not labeled)
- 4 to go trays from outside the nursing facility (not labeled)
- 2 Sandwiches for resident snacks dated 10/13/23
- 1 opened jar of French Onion Dip (not labeled)
- 1 small pizza box (not labeled)
- 1 zip lock bag of muscadines (not labeled)
- 1 opened bottle of Dr. Pepper soda (not labeled)
- 1 opened bottle of Faygo soda (not labeled)
- 1 opened jar of Ranch Dip (not labeled)
Unit Secretary #1 confirmed none of the listed items in the resident nourishment refrigerator were properly labeled. She confirmed that every food and drink item placed in the resident nourishment refrigerator should belong to a resident, should have the resident's name on it, and the date it was placed in the refrigerator to ensure items do not remain in the refrigerator past the allowed time for each item. She revealed she was not responsible for the cleaning of this refrigerator because she was only filling in on this unit for the day and she did keep her refrigerator clean on the Rehabilitation Unit.
An observation and interview on 11/01/23 at 9:05 AM with Licensed Practical Nurse (LPN)#1 on the East Wing, revealed the resident nourishment refrigerator had light and dark streaks of residue running down in the outside of the door and had spots of brown residue covering the top of the door. When the resident nourishment refrigerator was opened by the LPN #1, a strong, sour smell came out of the refrigerator. The observation revealed bags filled with containers that were piled into the resident nourishment refrigerator. The observation also revealed brown stains covering the shelf inside the door of the refrigerator. LPN #1 revealed she was not aware of who was responsible to clean the resident nourishment refrigerator, but it appeared to not have been cleaned in a long time.
An observation and interview on 11/01/23 at 9:10 AM with Certified Nurse Aide (CNA) #2 confirmed the resident nourishment refrigerator was not clean, had a strong sour smell coming out of it, and revealed she did not know who was responsible for cleaning it. She also revealed she did not know the resident nourishment refrigerator was not clean.
An observation on 11/01/23 at 09:14 AM with the Administrator of items in the resident nourishment refrigerator on the East Wing revealed:
- 1 container of [NAME] Ice Cream (not in the freezer of the refrigerator and not labeled)
- 1 unopened hot pocket - not labeled
- 1 bottle of mayonnaise - not labeled
- pudding for a resident from the supper meal (no name on container, but dated 10/31/23)
- 1 1/2 eaten salad (the salad was noted as the food item with the loud sour smell - not labeled)
- 1 bowl of spaghetti with a puffy grey substance covering the top of the spaghetti in the to go tray from outside the nursing facility (not labeled)
- 1 Kentucky Fried Chicken bag containing a box that was smashed underneath other items in the refrigerator (labeled with resident's name and no date)
- 1 container of yogurt (not labeled)
- 2 containers of Jell-O with expiration the date of 8/30/23
- 2 boxes of white milk with the expiration date of 8/25/23
- 1 store bought container of chicken salad dated 5/16/23 (not labeled with a resident's name)
- 1 sandwich from the resident snack cart (no date of preparation)
- 1 bottle of water frozen in a block of ice in the freezer
The observation also revealed there were plastic bags stuck to the surface of the inside of the resident nourishment refrigerator that could not be pulled out, revealed the brown stains of residue on the shelf in the inside door, revealed the light and dark brown residue spots that were located on the top edge of the refrigerator door, and the light and dark brown streaks of residue that ran down the front of the refrigerator door
An observation and interview on 11/01/23 at 9:18 AM with Unit Secretary #2 on the East Wing, revealed she cleaned the inside of the resident nourishment refrigerator a month ago and all those items removed during the observation were not in the refrigerator at that time. She revealed she was responsible for ensuring the refrigerator was clean.
An observation and interview on 11/01/23 at 9:21 AM with the Administrator of the resident nourishment refrigerator on the Rehabilitation Unit revealed:
- black residue covering the bottom of the freezer door handle and covering the top of the refrigerator door handle
- an unidentifiable food item that had a very loud and foul odor (not labeled)
- 1 jar of a jelly like substance (not labeled)
- 2 boxes of expired white milk
- 1 box of expired chocolate milk
- 1 store bought salad (not labeled)
- 2 yogurts (not labeled)
- 1 2L bottle of Pepsi (not labeled)
- 1 large bottle of coffee creamer (not labeled)
The Administrator confirmed on 11/01/23 at 9:21 AM all expired items should be removed from the resident nourishment refrigerators, that the Unit Secretaries are responsible to check the refrigerators every Friday to ensure items in the refrigerator are properly labeled for the residents and items not labeled or belonged to employees are removed. She confirmed that 3 of 3 of the nursing facility's resident nourishment refrigerators were not clean, that they contained spoiled/outdated foods/drinks, and that they contained unlabeled or improperly labeled foods/drinks. She also confirmed that this could have possibly presented an incident where a resident could possibly have become ill from being given improperly labeled food or drink. She confirmed the facility failed to maintain clean resident nourishment refrigerators, failed to prohibit employees from using the resident nourishment refrigerators, failed to properly label food and drink items for the residents, and failed to timely dispose of expired food and drink items from the resident nourishment refrigerators.
An interview on 11/02/23 at 10:57 AM with the Assistant Director of Nursing revealed she was responsible for ensuring the Unit Secretaries cleaned the resident nourishment refrigerators on each nursing unit. She confirmed she rounded and checked all 3 resident nourishment refrigerators earlier this month, saw they were not clean, saw they had expired food/drinks, saw there were food and drink items not labeled, and smelled the odors inside the refrigerators. She revealed she informed the Unit Secretaries of the need to clean the refrigerators and checked the task off as being completed because she trusted they would clean the refrigerators when she told them. She also revealed she did not follow up to see if the resident nourishment refrigerators were cleaned.
Record review of the Med Room Refrigerator Audit, dated 10/10/2023, revealed West Med Room: Clean . Outside Food: No . East Med Room: Clean . Outside Food: No . Rehab Med Room: Clean . Outside Food: No.
Dec 2022
1 deficiency
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Safe Environment
(Tag F0584)
Could have caused harm · This affected multiple residents
Based on observation, staff and resident interviews, record review and facility policy review, the facility failed to maintain a clean, comfortable environment as evidenced by thick, pink, and black s...
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Based on observation, staff and resident interviews, record review and facility policy review, the facility failed to maintain a clean, comfortable environment as evidenced by thick, pink, and black substances in and around toilets for and thick pink and black substance surrounding the bathtub drain for four (4) of 75 bathrooms observed.
Findings include:
A review of the facility policy titled Bathroom Cleaning under B. Follow 7-Step Method, WET Steps, Number 5. Sanitize commode, tank, bowl & base.
A record review of the facility Daily Work Routine indicates 7 Step (Washroom Cleaning).
An observation on 12/28/2022 at 10:00 AM of the bathroom and toilet for room W32 revealed a thick, pink colored ring in the bowl of the toilet with dark, black colored specks around the ring.
An observation on 12/28/2022 at 10:05 AM of the bathroom and toilet for room W19 revealed a thick, black colored, irregular shaped ring in the bowl of the toilet.
An interview with the Administrator and Housekeeping Supervisor on 12/28/22 at 10:05 AM, confirmed that the thick, pink and black substances were present in the toilet bowl of rooms W32 and W19 and should not be there. The Housekeeping Supervisor stated that the toilets are to be cleaned daily and agreed that it had been a while since the toilets had been cleaned.
An observation of the bathroom for room E8 on 12/28/22 at 10:15 AM, revealed a dark black substance surrounding the base of the toilet.
An interview with the Housekeeping Supervisor on 12/28/22 at 1:30 PM, confirmed there was a black substance around the base of the toilet in room E8 and agreed it should not be there.
An observation of the bathroom for room W24 on 12/28/22 on 11:00 AM, revealed the bathtub had a dried, black and pink colored substance surrounding the drain area, as well as a dried pink and black colored film ring inside the toilet bowl.
An interview with Registered Nurse #1 (RN) on 12/28/22 at 11:05 AM, confirmed the black and pink substance in the bathtub and toilet in room W24 and confirmed it needed to be cleaned.
An interview with Floor Technician #1 on 12/28/22 at 11:10 AM, confirmed the dried black and pink substance in the bathtub, and toilet W24 and revealed the bathroom appeared to not have been cleaned.
An interview on 12/28/22 at 1:54 PM with the Housekeeping District Manager revealed potential problems for the residents, from the unsanitary conditions of the toilets, could be breathing problems and infections.
An interview on 12/28/22 at 1:56 PM the Administrator revealed a potential problem from the dirty toilets is that it could make the resident sick.
Jul 2022
7 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Safe Environment
(Tag F0584)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, record review and facility policy review, the facility failed to provide a clean and safe...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, record review and facility policy review, the facility failed to provide a clean and safe environment as evidenced by missing tiles, missing baseboard, missing air conditioner vent cover, damaged furniture and standing water on the floor in a resident's room with electrical cords running through the water for two (2) of 32 rooms observed on the East Wing.
Findings Include:
room [ROOM NUMBER] East Wing
Review of the facility policy titled, Diversicare Healthcare Services Maintenance Policy and Procedure with a revision date of 9/1/2014 revealed under, Purpose .This procedure should assist the Maintenance Department in prioritizing the center's everyday needs to ensure a safe and secure environment for residents, visitors, and employees.
An observation on 07/18/22 at 10:45 AM, of room [ROOM NUMBER] on the East Wing revealed one square foot of tile missing from under the Intravenous (IV) pole and approximately four (4) feet of brown vinyl baseboard are disconnected from the wall and laying behind the bed. This observation revealed a dark brown, reddish substance covers the entire bottom of metal areas to the bedside table. There were six (6) vent cover slats missing from the front of the air conditioner which is visible to the hallway. The window curtain was disconnected from the curtain rod on the right side of the window exposing the outside and a small three-drawer chest was missing the front on the first and third drawers.
An observation on 7/19/22 at 10:25 AM, of room [ROOM NUMBER] on the East Wing revealed the condition of the room remained the same as the initial observation on 7/18/22 with no apparent repairs.
An observation on 7/20/22 at 4:25 PM, of room [ROOM NUMBER] on the East Wing revealed the condition of the room remained the same as the observation on 7/18/22 with no apparent repairs. An observation of the bathroom in the resident's room revealed approximately three (3) feet of brown vinyl baseboard off behind the toilet.
On 07/20/22 at 5:45 PM, an interview with the Maintenance Director revealed that he makes rounds once a month to look for problems in the building. The Maintenance Director confirmed that he has not had an assistant in a year and has recently just gotten some help and that he does not make rounds daily. He reported that he has his assistant make rounds every week and he is supposed to fix any issues that he sees.
An interview on 7/21/22 at 8:50 AM, with Housekeeper#3, revealed when a problem is found in a room, she writes it down and gives it to the Housekeeping Supervisor, and the Housekeeping Supervisor gets the message to the Maintenance Supervisor. She revealed that she does not have access to the electronic system for requesting repairs that the facility uses because she is a contracted worker.
An interview on 7/21/22 at 8:55 AM, with Licensed Practical Nurse (LPN) #8 revealed when there is an issue in a room, they enter it into the electronic reporting system for repairs and it notifies maintenance of the issue. She revealed she wasn't sure if anything had been put in the electronic reporting system about the condition of the room.
During an interview and observation on 7/21/22 at 9:05 AM, with the Facility Administrator, she confirmed the curtain was off the right side of the window and the room was in disrepair and the bathroom baseboards needed to be replaced. She stated, the room will be fixed today.
An interview on 7/21/22 at 1:25 PM, with the facility Administrator revealed the facility did not have a specific policy on a homelike environment. She revealed the Resident [NAME] of Rights was used for homelike environment concerns. She revealed that the facility's homelike environment policy is included in our residents' rights because each resident is entitled to a homelike environment.
room [ROOM NUMBER] East Wing
An observation of room [ROOM NUMBER] East on 07/18/22 at 11:05 AM, and again at 3:43 PM, revealed several wet towels with a brown and green substance on towels lying up against the left wall in front of the air conditioner. An approximate 2-foot-wide area of water was standing on the floor in front of the wet towels. A white electrical air conditioner cord and a black cable cord were laying in the water.
An observation on 07/19/22 at 10:00 AM, and again at 3:55 PM, revealed several wet towels with brown and green substance on the towels lying up against the left wall in front of the air conditioner. An approximate 2-foot-wide area of water was standing on the floor in front of the wet towels.
An interview and observation on 7/19/22 at 3:55 PM, with Licensed Practical Nurse (LPN) #7, confirmed that this is an accident waiting to happen, the resident could slip and fall, and it is also a fire hazard. She confirmed that the Certified Nurse Assistants (CNAs) are supposed to make rounds on residents at least every two (2) hours and this should have been found.
An interview on 7/19/22 at 4:00 PM, with Licensed Practical Nurse (LPN) #8 confirmed that housekeeping was cleaning the rooms on the east hall today and room [ROOM NUMBER] East should have been cleaned.
An interview and observation on 7/19/22 at 4:15 PM, with the Housekeeping Supervisor revealed that the east hall was cleaned today by Housekeeper #4. The Housekeeping Supervisor revealed that each room is cleaned daily, including floors mopped and she knew that the housekeeper had cleaned room [ROOM NUMBER] East. Upon observation with the Housekeeping Supervisor of room [ROOM NUMBER] East, several dry white towels were lying on the floor and no water was noted. A white air conditioner cord and black cable cord were noted lying on the dry white towels. The House Supervisor revealed that honestly, this has been a problem for quite some time and that she has reported this to the Maintenance Supervisor. She revealed the way they are supposed to report issues is through the electronic documentation system, however, she was a contracted employee and did not have access to the system. She revealed that she either texts or calls the maintenance supervisor when there are issues, and she has spoken with the Maintenance Supervisor several times to report this issue to him verbally.
An interview and observation on 7/19/22 at 4:40 PM, with the Maintenance Supervisor revealed that he thought it was the air conditioner leaking then he determined it was something leaking from the boiler room which is adjacent to room [ROOM NUMBER] East. He did confirm that if an electrical cord was laid down on the wet floor that it could be a problem and that if water was on the floor that it is a trip hazard for the resident in that room.
An interview on 7/19/22 at 5:05 PM, with the facility Administrator revealed that the air conditioner unit was broken a while back and the Maintenance Supervisor fixed it. She revealed it has been working fine until it was reported to her yesterday that it was leaking. The Administrator revealed the facility has an electronic work order system that all employees including contracted workers have access to. The Administrator revealed whenever there's an environmental issue in the facility all staff knows to report it through the electronic work order system.
An observation on 7/20/22 at 2:20 PM, by State Agency (SA) revealed water on the floor approximately 2 feet wide in front of the air conditioner unit. There were also two (2) square foot tiles missing where the wet towels had been laying previously.
A record review of the Work order report from 11/1/2021-7/20/2022 revealed no work orders were submitted for water leakage in room [ROOM NUMBER] East.
In an interview and observation on 07/21/22 at 9:20 AM, the facility Administrator confirmed the water on the floor of room [ROOM NUMBER] East was from an issue in the boiler room where a water leak had begun and traveled to the resident's room and was observed on the floor in front of the air conditioning unit. She revealed that she has instructed her staff to monitor the area every 15-30 minutes and to avoid placing towels on the floor. Observation of a wet caution sign was placed at this time.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Transfer Notice
(Tag F0623)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview and record review the facility failed to provide the responsible party with a notice of transfer to the...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview and record review the facility failed to provide the responsible party with a notice of transfer to the hospital for one (1) of three (3) residents transferred to the hospital. Resident # 27
Findings include:
Record review of a typed document dated 7/21/22, on facility letterhead and signed by the Administrator revealed, Diversicare of Southaven do not have a former policy for notification of Transfer to the hospital.
An interview on 7/19/22 at 12:23 PM, with Resident #27 revealed he was recently in the hospital.
An interview on 7/21/22 at 11:20 AM, with Social Services revealed that she has not been sending any written notification to the family when residents go to the hospital. She stated that she found out about the form yesterday.
An interview on 7/21/22 at 11:40 AM, with the Administrator (ADM) revealed she was aware of the regulation concerning transfer to an acute care facility but was not aware that the staff did not know because this regulation occurred before she came to this facility.
Record review of the facility Progress Notes dated 6/23/22 revealed Resident #27 was sent out to the hospital on 6/23/22.
Record review of the Transfer/Discharge Report revealed Resident #27 was admitted to the facility on [DATE] with diagnoses including Cerebral Infarction, Other Signs and Symptoms involving Cognitive Functions following Cerebral Infarction, Major Depressive Disorder, and Cutaneous Abscess, unspecified.
Review of the Minimum Data Set (MDS) with an Advanced Reference Date (ARD) of 5/2/22 revealed a Brief Interview for Mental Status (BIMS) score of eight (8) which indicated Resident #27 had moderately impaired 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
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview, record review and facility policy review, the facility failed to develop a comprehensive care plan for...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview, record review and facility policy review, the facility failed to develop a comprehensive care plan for refusal of Activities of Daily Living (ADL) care for one (1) of 27 resident care plans reviewed. Resident # 27.
Findings include:
Record review of the facility policy, Care Plans, undated, revealed Policy: Care plans will be developed for all patients and residents based upon the Resident Assessment Instrument (RAI) manual guidelines. Care plans are developed by the interdisciplinary team and revised as needed according to resident and patient status or change.
An observation on 07/18/22 at 03:31 PM, revealed Resident #27's fingernails were trimmed but had yellowish brown material under all nails and facial hair.
An observation on 7/20/22 at 9:15 AM, with Registered Nurse (RN) #1 confirmed Resident #27 needed a shave and his fingernails needed cleaning.
During an interview, on 7/20/22 at 11:15 AM, with Registered Nurse (RN) #1 stated that Resident #27 refuses care. She stated that he refuses care and curses staff. RN #1 confirmed she did not see a care plan for refusal of Activities of Daily Living (ADL) care.
An interview, on 7/20/22 at 11:30 AM, with the Minimum Data Set (MDS) nurse confirmed that the resident did not have a care plan for refusal of ADL care. She stated that she is responsible for care plans and develops them from documentation in the record or from discussion of residents during their stand-up meetings.
An observation and interview on 7/20/22 at 11:45 AM, with the Assistant Administrator confirmed Resident #27 needed to be shaved. She stated that if he refuses care it should be documented and care planned.
Record review of Progress Notes dated 4/21/22, 6/15/22, and 6/16/22 for Resident #27 revealed documentation of refusal of care.
Record review of Resident #27's care plan revealed there was no care plan developed for refusal of ADL care.
Record review of the Transfer/Discharge Report dated 7/21/22, revealed Resident #27 was admitted to the facility on [DATE] with diagnoses including Cerebral Infarction, Other Signs and Symptoms involving Cognitive Functions following Cerebral Infarction, Major Depressive Disorder, and Need for Assistance with Personal Care.
Record review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 5/2/22 revealed a Brief Interview for Mental Status (BIMS) score of eight (8) which indicated Resident #27 had moderately impaired cognition.
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, staff interview, and record review the facility failed to provide a dependent resident with nail care for ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, and record review the facility failed to provide a dependent resident with nail care for one (1) of five (5) residents reviewed. Resident #125
Findings include:
During an interview with the Registered Nurse (RN)/Clinical Director on 7/21/22 at 9:30 AM, she stated the facility adopted Edition 10, Clinical Nursing Skills and Techniques Manual as our policy and procedure care guide for shaving and nail care, specifically pages 541 through 550.
An observation on 07/18/22 at 03:40 PM, revealed Resident #125 had a brownish material under her fingernails.
An observation on 07/19/22 at 10:15 AM, revealed Resident #125's fingernails continued to be dirty with a brownish material under her nails.
An observation on 07/20/22 at 09:00 AM, revealed Resident #125's fingernails continued to be dirty with a brownish material under her nails
An observation and interview, on 7/20/22 at 9:50 AM, with Certified Nursing Assistant (CNA) #1 revealed she had already given Resident #125 her bath this morning and that the resident's fingernails were dirty with brownish material under the nails. She stated that she should have already gotten to it (cleaning the resident's nails).
An interview on 7/20/22 at 9:58 AM, with RN #1 confirmed Resident #125's nails needed to be taken care of because dirty nails could lead to skin breakdown or infection.
Record review of Section G of the Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 6/27/22 revealed Resident # 125 requires extensive assist of one (1) for personal hygiene. Section C revealed the resident did not have a Brief Interview for Mental Status score because she was rarely/never understood.
Record Review of the Transfer/Discharge Report dated 7/21/22 for Resident #125 revealed she was admitted to the facility on [DATE] with diagnoses including Unspecified Dementia without Behavioral Disturbance, Cerebral Infarction, Pseudobulbar Effect, Major Depressive Disorder, and Mixed Receptive-Expressive Language Disorder.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Pressure Ulcer Prevention
(Tag F0686)
Could have caused harm · This affected 1 resident
Based on observation, staff interview, record review, facility policy review and Mississippi State Board of Nursing review (Section 30 Miss. Admin. Code Pt. 2830, Chapter I) the facility failed to pro...
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Based on observation, staff interview, record review, facility policy review and Mississippi State Board of Nursing review (Section 30 Miss. Admin. Code Pt. 2830, Chapter I) the facility failed to provide a Registered Nurse (RN) for assessment of pressure ulcers for one (1) of eight (8) residents reviewed for RN wound assessments. Resident # 24.
Findings Include:
Review of the facility policy titled, Skin Care Guideline with a revision date of July 2018 revealed Purpose To provide a system for evaluation of skin to identify risk and identify individual interventions to address risk and a process for care of changes/disruption in skin integrity .
An interview on 07/19/22 at 10:47 AM, with the Resident #24 revealed he developed a pressure ulcer on his right heel since he has been at the facility.
An interview on 07/20/22 at 07:47 AM, with the Resident #24 revealed he did not have this sore on his foot when he got here, but he fell and developed cellulitis in that leg. He revealed this spot is like a soft spot that just has not completely healed. He revealed he is independent of self-propelling in his wheelchair, wears tennis shoes, has a leg rest on the right side of his wheelchair now and tries not to use his right foot to propel his chair. He confirms that the staff treat the sore on his right heel but is not sure if they measure and he is not certain of how often.
An observation on 7/20/22 at 9:45 AM, revealed Licensed Practical Nurse (LPN) # 3 provided pressure ulcer treatment and dressing change as ordered. This observation revealed no measurement of the pressure ulcer.
An interview on 7/20/22 at 10:00 AM, with Licensed Practical Nurse (LPN) # 3 revealed she works 11 PM-7 AM shift, but since their treatment nurse quit on Friday, she has come to days to help with treatments. She revealed she is not certified, but she has done treatments in another facility before. She revealed the LPN's have been doing the measurements of the wounds by using their IPAD that takes a picture and does the measurements. She revealed that a Registered Nurse (RN), Nurse Practitioner (NP) or physician does not assess the wounds on a regular basis. She revealed they have a full time NP in the facility Monday through Friday, but he just looks at the wounds when we ask. She confirmed that an LPN is the only one measuring the wounds.
An interview on 7/20/22 at 10:45 AM, with the NP revealed he works at the facility Monday through Friday and a physician comes to the facility every Monday. He confirmed he does not have a lot to do with wounds or pressure ulcers. He confirmed he is just there for guidance and will assess a pressure ulcer if asked.
An interview on 7/20/22 at 10:55 AM, with the Assistant Director of Nurses (ADON) confirmed she does not do wound assessments, measurements, or treatments. She revealed that the Director of Nurses (DON) does the wound evaluations and checks orders. She confirmed that LPN # 3 is going to day shift to do treatment, since our treatment nurses last day was Friday. She confirmed that the treatment nurse uses an electronic tablet to take pictures of the pressure ulcers and that does the measurements for them. She revealed that the facility uses the NP as needed and a wound clinic in town to send residents out for wound care. She revealed that the NP will assess new admits that come in with pressure ulcers.
An interview on 7/20/22 at 11:10 AM, with the Director of Nurses (DON) revealed that the facilities treatment nurses last day was Friday 7/15/22 and that LPN # 3 from the night shift is helping with treatments because she has done them before. She confirmed that no one in the facility is certified to do pressure ulcer treatments and measurements. She confirmed that she does not measure the pressure ulcers. She confirmed that the treatment nurse, which is an LPN, is the one doing the measurements. She confirmed that the LPN uses a tablet to take a picture and obtain the measurements.
An interview on 07/20/22 at 03:05 PM, with the RN/Clinical Director confirmed that there was not a nurse that was certified for pressure ulcers in the facility. She confirmed that an RN is supposed to verify measurements of pressure ulcers after the LPN and measure for depth. She revealed the DON and ADON were aware this needed to be done.
An interview on 07/20/22 at 03:10 PM, with the RN/Clinical Director, DON and ADON confirmed they nor any other RN or clinician have been measuring the pressure ulcers after the LPN's have measured. The DON revealed she has been viewing the picture that the LPN puts in the record with the measurements and signing behind her. The DON and ADON confirmed that an RN or Clinician has not been going behind the LPN and confirming the measurements or measuring for depth, but they should have. The DON confirmed that an RN needs to measure the depth and confirm the LPN's measurements for accuracy.
An observation on 7/21/22 at 10:45 AM, with the Director of Nursing (DON) revealed she measured the resident's pressure ulcer with a measurement of 0.3 centimeters (cm) x 0.2 cm with no depth.
An interview on 7/21/22 at 11:00 AM, with the DON confirmed she realizes the importance of an RN assessing a pressure ulcer with or after an LPN. She revealed she does not know when an RN last measured or assessed a pressure ulcer in this facility. She confirmed her measurement today was .35 cm x .2 cm and the last measurement by an LPN was on 7/11/22 of 0.25 cm x 0.3 cm with no depth. She confirmed that it is important for an RN to observe the wound, because she can see things that maybe the LPN missed.
An interview on 7/21/22 at 3:30 PM, with RN-Infection Control Nurse confirmed that the residents Skin & Wound Evaluations V5.0 were completed by an LPN.
A record review of the facility Pressure Ulcer Record confirmed that weekly skin audits were being performed by the LPN.
Record review of the resident's admission Record revealed an admission date of 11/29/18 with medical diagnoses that included Cellulitis of the right lower limb and Dementia.
Record review of Resident #24's Skin & Wound Evaluation V5.0 revealed the following:
6/28/22-skin & wound evaluation completed by an LPN indicated the resident had a pressure ulcer staged as a deep tissue injury (DTI) that was in-house acquired.
7/4/22-skin & wound evaluation completed by an LPN indicated the resident had a pressure ulcer staged as a DTI that was in-house acquired.
7/11/22-skin & wound evaluation completed by an LPN indicated the resident had a pressure ulcer staged as a DTI that was in-house acquired.
Record review of Physician's Orders revealed the following order:
Order dated 7/13/22; Pro Heal Critical Care two times a day for Wound healing until 08/14/2022 23:59.
Review of the residents Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 5/3/22 revealed in Section M the resident is at risk for developing pressure ulcers/injuries with no pressure ulcers at present. Section C revealed a Brief Interview for Mental Status (BIMS) with a score of 14, which indicates the resident is cognitively intact.
Record review of the Mississippi State Board of Nursing Section 30 Miss. Admin. Code Pt. 2830, Chapter I and pursuant to the Mississippi Nursing Practice Law revealed the following:
Is it within the scope of practice of the licensed practical nurse to perform assessments?
Nursing assessment is outside the scope of practice of the licensed practical nurse. As stated in 30 Miss. Admin. Code Pt. 2830, Chapter I and pursuant to the Mississippi Nursing Practice Law, The registered nurse shall be held accountable for the quality of nursing care given to patients. This includes assessing the patient's needs, formulating a nursing diagnosis, planning for, implementing, and evaluating the patient's care . It is further stated that the licensed practical nurse may assist the registered nurse in the planning, implementation and evaluation of nursing care by, in part, observing, recording and reporting to the appropriate person the signs and symptoms that may be indicative of change in the patient's condition. Therefore, it is the registered nurse's responsibility to perform the initial systems and collective assessment of the patient. The licensed practical nurse may assist the registered nurse with collecting data for that initial assessment and must document and sign the portion of the assessment he/she did. The registered nurse must document and sign the portion of the assessment which he/she completed. The registered nurse may delegate the observation and recording of a patient's ongoing or subsequent status to the appropriately educated and competent licensed practical nurse. However, the registered nurse is held accountable for the quality of nursing care given by self or others being supervised.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0761
(Tag F0761)
Could have caused harm · This affected multiple residents
Based on observation, staff interviews and facility policy review the facility failed to store narcotics in a permanently fixed locked box for two (2) of three (3) medication rooms reviewed.
Findings ...
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Based on observation, staff interviews and facility policy review the facility failed to store narcotics in a permanently fixed locked box for two (2) of three (3) medication rooms reviewed.
Findings Include:
Record review of the Facility Policy, Storage and Expiration Dating of Medications, Biologicals with revision date of 01/01/22 revealed under, Procedure number 3. General Storage Procedures: 3.1.1 Store all drugs and biologicals in locked compartments, including the storage of Schedule II - V medications in separately locked, permanently affixed compartments, permitting only authorized personnel to have access.
An observation on 07/20/22 at 5:00 PM, of the medication storage room on the east hall with Licensed Practical Nurse (LPN) #1 revealed a locked refrigerator with a small locked box inside located on the top shelf. This lock box was empty and not permanently affixed.
An observation on 07/20/22 at 5:10 PM, of the medication storage room on the west hall with Registered Nurse (RN) #1, revealed a small refrigerator with 2 small unopened vials of injectable lorazepam in a clear bag on the second shelf inside.
An observation on 07/20/22 at 5:20 PM, of the medication storage room in the Rehabilitation Wing, revealed a lock box inside the refrigerator not permanently affixed. Nine small vials of injectable lorazepam, a bottle of liquid morphine and a bottle of liquid lorazepam for oral use were observed inside locked box.
An interview on 07/20/22 at 5:05 PM, with LPN #1 revealed that she was not aware that the lock box was supposed to be permanently attached.
An interview on 07/20/22 at 5:15 PM, with RN #1 revealed that she did not know that narcotics were supposed to be in a lock box and permanently secured. She also revealed that the medication room is always locked and only the Medication Nurses have the keys to access the room.
An interview on 07/20/22 at 5:25 PM, with LPN #2, revealed that she did not know that lock boxes containing narcotics had to be permanently attached.
An interview on 07/20/22 at 5:30 PM, with the Assistant Director of Nursing (ADON) revealed that she was not aware of the federal regulation that required lock boxes containing Schedule II-V narcotics to be permanently affixed.
An interview on 07/21/22 at 9:40 AM, with the Director of Nursing (DON), revealed that she was aware that locked boxes are required in some states but was not certain about in Mississippi. She revealed that she did know that the lock boxes should be welded into the refrigerator to prevent anyone from walking out with the whole box.
An interview on 07/21/22 at 9:45 AM, with the Administrator revealed that she was not aware of the federal regulation that required locked boxes containing narcotics to be secured. She also revealed that she understands the risk of not having a secured locked box which could allow someone to take the whole box out and leave with it.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0919
(Tag F0919)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interviews and facility policy review the facility failed to maintain a properly functioning call sy...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interviews and facility policy review the facility failed to maintain a properly functioning call system for one (1) of two (2) wings observed. East Wing
Findings Include:
Review of facility policy titled, Nurse Call System dated September 1, 2014, revealed, Purpose: To maintain center nurse call systems in an ideal mechanical condition to ensure optimum performance when residents request assistance from staff .Monthly the Nurse Call system should be checked for the following: 4. Any component that does not function should be repaired as soon as practically feasible. 5. Systems with audio functions should be tested monthly. Any non-operating components should be repaired as soon as practically feasible.
An observation on 7/19/22 at 10:42 AM, revealed the call light above resident room [ROOM NUMBER] and on the control box at the nurse's desk of the East Wing were both on, but no audible sound was noted.
An observation on 7/19/22 at 10:44 AM, revealed the call light above resident room [ROOM NUMBER] and the light on the control box at the nurse's desk of the East Wing were both on, but no audible sound was noted.
An interview on 7/19/22 at 11:45 AM, with Certified Nursing Assistant (CNA) #1 revealed the audible alarm goes off at the nurse's station but she cannot hear it at the end of the hall. She stated she looks above the doors when she exits a room to see if another resident is needing assistance and since she relies on the lights more than the audible alarm, she is uncertain how long the alarm has not been sounding. She revealed the call system is needed to help the residents get the assistance they need.
An interview on 7/19/22 at 11:55 AM, with CNA #2 revealed when the call system button is pressed in the resident's room, the light above their door turns on and the alarm sound goes off at the nurse's station to alert staff a call light has been activated. The interview revealed she relies on the lights being lit above the resident's room and is unaware of the sound not working.
An interview and observation on 7/19/22 at 12:05 PM, with the Administrator revealed the staff should answer the call light within 3-5 minutes. She stated the call system consists of lights and sound to alert the staff that a resident needs assistance. The State Agency (SA) asked the Administrator to activate a call light and demonstrate what occurs when light is activated. The Administrator went into room [ROOM NUMBER] on the East Wing and activated the call system. The light above door and on control panel both turned on, but no audible alarm was heard. The Administrator stated they previously had a problem with the call light system, but she thought that was resolved since she had not been informed of other issues. The Administrator confirmed the audible alert is needed to notify the staff of a resident needing assistance and this system not functioning properly could lead to a delay in receiving needed care for the residents.
An interview on 7/19/22 at 5:30 PM, with Licensed Practical Nurse (LPN) #5 revealed the audible alarm on the call system has not been working properly for several weeks or months. She revealed the light above the resident's door and on the control panel light up, but no audible alarm is made. She stated she relies on the lights and the audible alarm especially when she is in a room with a resident. If she continues to hear an alarm it alerts her that all of the staff must be providing care and she should step away as soon as possible to find out what resident needs assistance. She stated that without the audible alarm to alert staff of assistance needed, she feels that it is possible that some residents might have waited longer than they should have to for care. She stated bells were given to the residents today for them to use when assistance is needed.
An interview on 7/20/22 at 8:35 AM, with LPN #7 revealed the audible alarm on the call system has not been working right for 2 - 3 months and it is like a short in the wire since it will work at times. She stated they have now given the residents bells to use and have in-serviced the CNA staff to do 15-minute checks and the nurse staff to document every hour on the residents that cannot use the bell.
An interview on 7/20/22 at 8:40 AM, with CNA #3 revealed the call system sound alarm has not been working on the call light system for a while, but she is unsure how long. She stated the audible alarm is helpful, but she mainly goes by the lights above each resident's door to know which residents need assistance. She stated that yesterday the staff handed out bells for the residents to use.
An interview on 7/20/22 at 11:45 AM, with LPN #6 revealed the residents were given bells yesterday to use while the sound on the call system was not working. She stated the lights on the call system are working, but the audible alarm has not been working properly for several weeks. She stated in the past, bells would be given to a resident if his/her call light was not working properly.
An interview and observation on 7/20/22 at 2:10 PM. with the Maintenance Director revealed on 2/2/22, the motherboard of the East Wing call system was making a constant abnormal sound and he called the technician from the call system's repair unit and the technician walked him through the steps to remove the clicking noise. The Maintenance Director showed texts and pictures on his phone with that date of his communication with the technician. He followed these instructions and the clicking noise stopped. He stated on that date, he was checking for the abnormal sound and not servicing the system for the audible alarm not functioning when call system was activated and he was not notified any other time of the system not making an audible sound when call system activated. He revealed he does not keep paper records of his maintenance, but it is recorded in the maintenance log of the computer system. He stated he checked the system when a concern was reported and rounded monthly but did not find concern with the call system.
An interview on 7/20/22 at 4:35 PM, with the Maintenance Director to clarify his work on the call system on the East Wing revealed on the computerized maintenance report, there was an open date of 1/21/22 and closed date of 2/7/22 (with closed by staff listed as Maintenance Director), for the request for call light system is not working - making a ticking noise at desk on East wing - nurses station. He confirmed that was the date of 2/2/22 repair mentioned previously. SA asked about another submission for maintenance with open date of 2/16/22 and closed date of 2/23/22 (with closed by staff listed as Maintenance Director) for call lights are not sounding with location of east wing. He confirmed he did not work on the system at that time and has no idea why it has his name listed as closed by him. He stated the only time he worked on the system was when the clicking noise was heard or when individual lights were not working properly but did not know until we arrived that there was a concern with the audible alarm not working.
An interview on 7/20/22 at 4:40 PM, with the Administrator, revealed each resident should have the assurance that the call system functions properly and that they will receive the assistance needed. She confirmed the facility failed to ensure all portions of the call system were functioning properly and the residents need a properly functioning system to ensure they receive timely assistance.
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
- • 35% turnover. Below Mississippi's 48% average. Good staff retention means consistent care.
Concerns
- • Multiple safety concerns identified: 2 life-threatening violation(s), 5 harm violation(s), $59,175 in fines, Payment denial on record. Review inspection reports carefully.
- • 40 deficiencies on record, including 2 critical (life-threatening) violations. These warrant careful review before choosing this facility.
- • $59,175 in fines. Extremely high, among the most fined facilities in Mississippi. Major compliance failures.
- • Grade F (0/100). Below average facility with significant concerns.
Bottom line: Trust Score of 0/100 indicates significant concerns. Thoroughly evaluate alternatives.
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About This Facility
What is Diversicare Of Southaven's CMS Rating?
CMS assigns DIVERSICARE OF SOUTHAVEN an overall rating of 1 out of 5 stars, which is considered much below average nationally. Within Mississippi, this rating places the facility higher than 0% of the state's 100 nursing homes. A rating at this level reflects concerns identified through health inspections, staffing assessments, or quality measures that families should carefully consider.
How is Diversicare Of Southaven Staffed?
CMS rates DIVERSICARE OF SOUTHAVEN's staffing level at 3 out of 5 stars, which is average compared to other nursing homes. Staff turnover is 35%, compared to the Mississippi average of 46%. This relatively stable workforce can support continuity of care.
What Have Inspectors Found at Diversicare Of Southaven?
State health inspectors documented 40 deficiencies at DIVERSICARE OF SOUTHAVEN during 2022 to 2025. These included: 2 Immediate Jeopardy (the most serious level, indicating potential for serious harm or death), 5 that caused actual resident harm, and 33 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 Diversicare Of Southaven?
DIVERSICARE OF SOUTHAVEN 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 DIVERSICARE HEALTHCARE, a chain that manages multiple nursing homes. With 140 certified beds and approximately 132 residents (about 94% occupancy), it is a mid-sized facility located in SOUTHAVEN, Mississippi.
How Does Diversicare Of Southaven Compare to Other Mississippi Nursing Homes?
Compared to the 100 nursing homes in Mississippi, DIVERSICARE OF SOUTHAVEN's overall rating (1 stars) is below the state average of 2.6, staff turnover (35%) is significantly lower than the state average of 46%, and health inspection rating (1 stars) is much below the national benchmark.
What Should Families Ask When Visiting Diversicare Of Southaven?
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 Diversicare Of Southaven Safe?
Based on CMS inspection data, DIVERSICARE OF SOUTHAVEN has documented safety concerns. Inspectors have issued 2 Immediate Jeopardy citations (the most serious violation level indicating risk of serious injury or death). The facility has a 1-star overall rating and ranks #100 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 Diversicare Of Southaven Stick Around?
DIVERSICARE OF SOUTHAVEN has a staff turnover rate of 35%, 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 Diversicare Of Southaven Ever Fined?
DIVERSICARE OF SOUTHAVEN has been fined $59,175 across 7 penalty actions. This is above the Mississippi average of $33,671. Fines in this range indicate compliance issues significant enough for CMS to impose meaningful financial consequences. Common causes include delayed correction of deficiencies, repeat violations, or care failures affecting resident safety. Families should ask facility leadership what changes have been made since these penalties.
Is Diversicare Of Southaven on Any Federal Watch List?
DIVERSICARE OF SOUTHAVEN 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.