BELLEVIEW VALLEY NURSING HOME
For profit - Limited Liability company
109 Beds
Independent
Data: November 2025
5 Immediate Jeopardy citations
Trust Grade
0/100
Last Inspection: April 2025
Within standard 12-15 month inspection cycle. Federal law requires annual inspections.
Overview
Belleview Valley Nursing Home has received an F grade for trust, indicating significant concerns about the facility's quality of care. It ranks at the bottom in Missouri and Iron County, showing that there are no better options nearby. Although the facility's issues have improved over time, dropping from 46 incidents in 2024 to 16 in 2025, it still reported a concerning 81 total issues, including critical failures in infection control and resident safety. Staffing appears to be a weakness, with 59% turnover and less RN coverage than 84% of state facilities, which limits consistent care. Specific incidents include a lack of proper infection control measures that could lead to COVID-19 exposure among residents and instances of physical abuse, which raise serious red flags about the safety and well-being of residents.
- Trust Score
- F
- In Missouri
- #112/223
- Safety Record
- High Risk
- Inspections
- Getting Better
- Staff Stability ⚠ Watch
- 59% turnover. Above average. Higher turnover means staff may not know residents' routines.
- Penalties ✓ Good
- $206,655 in fines. Lower than most Missouri facilities. Relatively clean record.
- Skilled Nurses ⚠ Watch
- Each resident gets only 10 minutes of Registered Nurse (RN) attention daily — below average for Missouri. Fewer RN minutes means fewer trained eyes watching for problems.
- Violations ⚠ Watch
- 81 deficiencies on record. Higher than average. Multiple issues found across inspections.
0/100
Top 50%
Review needed
46 → 16 violations
☆☆☆☆☆
0.0
Overall Rating
☆☆☆☆☆
0.0
Staff Levels
☆☆☆☆☆
0.0
Care Quality
☆☆☆☆☆
0.0
Inspection Score
↔
Stable
2024: 46 issues
2025: 16 issues
The Good
-
Full Sprinkler Coverage · Fire safety systems throughout facility
-
No fines on record
Facility shows strength in fire safety.
The Bad
Staff Turnover: 59%
13pts above Missouri avg (46%)
Frequent staff changes - ask about care continuity
Federal Fines: $206,655
Well above median ($33,413)
Significant penalties indicating serious issues
Staff turnover is elevated (59%)
11 points above Missouri average of 48%
The Ugly 81 deficiencies on record
5 life-threatening 2 actual harm
Apr 2025
16 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0569
(Tag F0569)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to complete a final accounting of resident personal funds within 30 da...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to complete a final accounting of resident personal funds within 30 days of discharge for one resident (Resident #250) of three sampled residents and failed to refund resident funds within 30 days of when a resident expired for one resident (Resident #95) outside the sample. The facility census was 91.
Review of the facility's policy titled, Policy and Procedures for Maintaining the Resident Trust Fund Account, undated, showed:
- Required by law to submit a written account of the remaining personal funds for any deceased resident who has received aid, care, assistance or services paid by the Department of Social Services;
- For purposes of this policy, personal funds of the deceased resident shall include all the resident's remaining personal funds held in whatever title the account of accounts may be known, this includes the general account;
- To report remaining funds of a deceased Medicaid recipient, you fill out the Personal Funds Account Balance Report provided by the state, and you need to send the report as well as a copy of their statement that supports the balance being reported, even if the balance is zero;
- The regulation requires this is done within 30 days of death, the regulation should not be violated;
- If a resident is discharged with no return anticipated, the regulation requires this is done within five days of discharge.
1. Review of Resident #95's closed medical record showed:
- The resident expired on [DATE].
Review of the discharged resident's Trust Transaction History, printed on [DATE], showed:
- On [DATE], the resident's remaining fund balance was $85.00.
2. Review of Resident #250's closed medical record showed:
- The resident discharged to another facility on [DATE].
Review of the discharged resident's Trust Transaction History, printed on [DATE], showed:
-On [DATE], the resident's remaining fund balance was $1,786.00.
During an interview on [DATE] at 9:40 A.M., the Business Office Manager (BOM) said he/she was not aware a resident should have a final accounting of personal funds and be provided the balance of those funds within five days after discharge. He/she didn't know why the corporate office waited.
During an interview on [DATE] at 3:10 P.M., the Social Services Designee (SSD) said he/she would expect resident funds to be transferred back to the resident or their legal representative once a resident had discharged to another facility or expired.
During an interview on [DATE] at 3:14 P.M., the Administrator said she would expect a resident to have a final accounting of their personal funds and be provided the balance of those funds within 30 days after discharge.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0578
(Tag F0578)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to consistently document a resident's code status with c...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to consistently document a resident's code status with cardiopulmonary resuscitation (CPR- an emergency procedure consisting of chest compressions if the heart stops beating or the person stops breathing) or Do Not Resuscitate (DNR - does not want CPR) for two residents (Residents #21 and #52) out of 19 sampled residents. The facility census was 91.
Review of the facility's policy titled, Advanced Directives, undated, showed:
- The facility will provide to each resident or surrogate his/her rights under State law to formulate advance directives. The facility is permitted to contract with other entities to furnish this information but is still legally responsible. The facility will document in a prominent part of the resident's current record whether or not the resident has executed an advance directive;
- Advance Directives describe what health care decisions the resident will want to be made it he/she loses the ability to make decisions later, and may include specific treatment directives, a living will, orders to not resuscitate, or the appointment of a durable power of attorney;
- There must be an order from the resident's physician for the initiation or change of the status Do Not Resuscitate;
- The Unit Nurse will send a copy of all orders for the initiation or change of status of Do Not Resuscitate to the Social Services Director (SSD);
- The SSD will indicate the resident's resuscitation status in the resident's record and is the only staff authorized to make changes to that entry;
- The SSD will review the resident's advance directives with every scheduled resident assessment and make sure that the status is maintained in accordance with the resident's wishes;
1. Review of Resident #21's Physician's Order Sheet (POS), dated [DATE], showed:
- An admission date of [DATE];
- An order of DNR, dated [DATE].
Review of the resident's Care Plan, dated [DATE], showed:
- A DNR code status.
Observation on [DATE] at 10:00 A.M., of the resident's name plate outside of the resident's room showed a a green dot next to the resident's name.
2. Review of Resident #52's medical record showed:
- An admission date of [DATE];
- The face sheet with a full code status;
- An Outside the Hospital Do Not Resuscitate Order (OHDNR) form signed by the guardian and the attending physician, dated [DATE].
Review of the resident's [DATE] POS showed:
- An order of full code, dated [DATE].
Review of the resident's Care Plan, last reviewed on [DATE], showed:
- A full code status.
Observations on [DATE] at 11:00 A.M., [DATE] at 10:32 A.M., [DATE] at 2:10 P.M., and on [DATE] at 1:45 P.M., of the resident's name plate outside of the resident's room showed a green dot next to the resident's name.
During an interview on [DATE] at 1:00 P.M., Certified Medication Technician (CMT) A said he/she was not sure what the dots on the door meant, but wanted to clarify it with the nurse. There were several places where the resident's code status was documented. If he/she found an unresponsive resident, he/she would look in the computer if close enough to it. If not, he/she would look at the resident's door if closer to it.
During an interview on [DATE] at 9:35 A.M., CMT B said he/she would look at the dot on the name plate outside of the resident's room. A green dot indicated a Full Code and a red dot indicated DNR.
During an interview on [DATE] at 9:45 A.M., Licensed Practical Nurse (LPN) C said a resident's code status was found in the computer, a hospice binder if on hospice, and the colored dot on the name plate. All code status documentation should match for each resident.
During an interview on [DATE] at 2:58 P.M., the Director of Nursing said the code status for each resident could be found on the name plate outside of the resident's room. The dots next to the resident name indicated their code status. [NAME] dots were full code and red dots were DNR. There was a list of each resident and their code status on the crash cart in the break room. This list was updated nightly. The computer face sheet was another place the code status could be found. The code status should be consistent throughout the medical record. An OHDNR form applied at the facility and meant DNR.
During an interview on [DATE] at 3:30 P.M., the Administrator said a resident's code status should match in all the places the code status was found.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0655
(Tag F0655)
Could have caused harm · This affected 1 resident
Based on interview and record review, the facility failed to implement an accurate baseline care plan (the minimum healthcare information necessary to properly care for a resident) upon admission with...
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Based on interview and record review, the facility failed to implement an accurate baseline care plan (the minimum healthcare information necessary to properly care for a resident) upon admission with specific interventions for two residents (Residents #138 and #288) out of seven sampled residents. The facility's census was 91.
Review of the facility's policy titled, Care Plan Completion, undated, showed:
- The facility will develop and implement a Baseline Care Plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care;
- The baseline care plan must be developed within 48 hours of a resident's admission and include the minimum information needed to properly care for a resident including, but not limited to, initial goals based on admission orders, physician orders, dietary orders, therapy services, Preadmission Screening and Resident Review (PASARR - a process that helps ensure people with mental health or developmental disabilities are not unnecessarily placed in nursing homes) recommendations, if applicable;
- The facility must provide the resident and his/her representative with a summary of the baseline care plan that includes, but is not limited to, the initial goals of the resident, a summary of the resident's medications and dietary instructions, any services and treatments, any updated information based on the comprehensive care plan, as needed.
1. Review of Resident #138's medical record showed:
- An admission date of 03/06/25;
- Diagnoses of schizophrenia (a disorder that affects a person's ability to think, feel and behave clearly), urinary tract infection (infection of the lower urinary system), hypertension (high blood pressure), major depressive disorder (characterized by persistent low mood, loss of interest in activities), insomnia (difficulty sleeping), and chronic pain syndrome (persistent pain that lasts for long periods of time).
- No baseline care plan.
2. Review of Resident #288's medical record showed:
- An admission date of 04/03/25;
- Diagnoses of unspecified convulsions (a condition in which muscles contract and relax quickly and cause uncontrolled shaking of the body), hemiplegia (paralysis of one side of the body) and hemiparesis (one-sided muscle weakness), bipolar disorder (a mental disorder that causes unusual shifts in mood), obsessive-compulsive disorder (OCD - a disorder marked by uncontrollable and recurring thoughts, repetitive and excessive behaviors, or both), mild intellectual disability (involves deficits in theoretical thinking/learning), epilepsy (a disease that causes recurrent seizures), cerebral palsy (damage to the motor center of the brain), unspecified open wound to the right lower leg, constipation, and muscle weakness generalized.
- No baseline care plan.
Review of the resident's Level II PASARR, dated 06/11/2014, showed:
- Required rehabilitative services of a lesser intensity which can be provided by the nursing facility;
- Indicated occupational therapy, individual/group/family therapy, drug therapy, daily living skills, personal support networks, physician services, medically related social services, pharmaceutical services, dental services, regional office referral/continued services.
During an interview on 04/16/25 at 1:10 P.M., the Director of Nursing (DON) said the baseline care plan should be in the resident's medical record. The nurse that admitted the residents should be the one completing the baseline care plans.
During an interview on 04/17/25 at 2:46 P.M., the Minimum Data Set (MDS - a federally mandated assessment instrument completed by the facility staff), Coordinator said the admitting nurse should fill out a baseline care plan on newly admitted residents promptly upon arrival. The residents should sign the baseline care plan and receive a copy.
During an interview on 04/17/25 at 2:55 P.M., the Administrator said she would expect baseline care plans to be completed within the required time frame. The residents should receive a copy and sign the baseline care plan.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0658
(Tag F0658)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to assess and obtain physician's orders for wound care for one residen...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to assess and obtain physician's orders for wound care for one resident (Resident #25) out of three sampled residents. The facility also failed to ensure staff followed professional standards of practice when staff did not follow through with the collection of urine and report lab results in a timely manner for two residents (Residents #35 and #138) out three sampled residents. The facility census was 91.
Review of the facility's policy titled, Skin Conditions, undated, showed:
- Did not address when staff should obtain physician orders for wounds or skin conditions.
Review of the facility's policy titled, Laboratory Services, undated, showed:
- The facility will provide or obtain laboratory services to meet the needs of its residents, and will promote practices to ensure the quality and timeliness of laboratory services;
- Laboratory services may only be provided or obtained when ordered by the resident's physician, physician assistant, nurse practitioner, or clinical nurse specialist;
The Day Shift Unit Nurse will: Fill out and send laboratory requests for newly ordered laboratory tests; Obtain specimens as needed; Promptly inform the resident's physician of all abnormal test results by telephone or fax; Document in the resident's record and on the 24 hour report that the results were sent to the physician; Keep laboratory test results on the 24 hour report until the physician has responded; When the physician responds, document the response in the resident's record;
The Charge Nurse will: Monitor the log of all regularly scheduled laboratory tests to ensure that all of the scheduled tests were obtained, ordering physician or assistant was notified of all abnormal results, and document in the nurses' notes.
1. Review of Resident #25's Physician Order Sheet (POS), dated April 2025, showed:
- admitted to the facility on [DATE];
- An order for weekly skin assessments, dated 10/14/22;
- An order for a wound care referral, dated 04/09/25;
- No orders for any wound care treatments.
Review of the resident's Shower Sheets, dated April 2025, showed:
- On 04/07/25, skin dry, fair, edema, intact, showered/assist. Bottoms of both feet possible ulcers starting;
- On 04/14/25, skin dry, edema, intact. Galled (irritated) in groin area;
- Shower sheets did not address any skin issues with the right buttock area.
Review of the resident's Nurse's Note dated 04/09/25 at 12:28 P.M., showed:
- Returned from going to have a colonoscopy (a medical procedure that examines the large intestine and the rectum). The colonoscopy was unable to be completed due to poor preparation and the physician ordered a wound care nurse/physician referral due to an observed wound to the resident's right buttock.
Review of the resident's Progress Notes, dated 04/09/25 at 2:50 P.M., showed:
- Buttock with redness in the inner fold of the right side and a crease on the buttock with some yellow/brown drainage on the crease on the right buttock and a small hardened area. Applied zinc ointment. No need for a dressing. Will continue to have the patient follow up with wound physician regarding the drainage and hardened area;
- Referral to the wound nurse/physician due to the wound to the buttock observed by the physician.
Review of the resident's Nursing Skin Assessments, dated April 2025, showed:
- On 04/05/25, no current skin issues;
- On 04/12/25, no current skin issues;
- Skin assessments did not address any skin issues with the right buttock area.
Review of the resident's Treatment Administration Record (TAR), dated April 2025, showed:
- No treatment orders for the wound to the right buttock area.
During an interview on 04/16/25 at 11:16 A.M., the Director of Nursing (DON) said the wound care company came to the facility once a week.
During an interview on 04/17/25 at 9:00 A.M., Licensed Practical Nurse (LPN) C said that he/she had noticed the hardened area before. It was draining but not warm to the touch and was putting facility stock cream and Nystatin (an antibiotic used to treat fungal infections) powder on it without a physician's order. The resident never complained about it causing the resident pain.
During an interview on 04/17/25 10:56 A.M., the Wound Care Nurse Practitioner (WCNP) said he/she saw the resident on 04/16/25, as a first visit. The area was on the right back sciatica (buttock) area. The resident reported the hardened area had been causing him/her pain for months. The resident reported it was a prior surgery cite. It appeared the scar had produced an extra skin fold. The WCNP said he/she observed Nystatin powder in the abdominal folds and didn't believe it was an abscess. It wasn't tender and had no redness. He/She gave an order for an ultrasound to rule out a cyst (a small pocket of tissue filled with fluid or pus) versus a lipoma (a non-cancerous tumor made up of fatty tissue).
2. Review of Resident #35's medical record showed:
- admitted to the facility on [DATE];
- Diagnosis of urinary tract infection (UTI).
Review of the resident's Progress Notes, dated 03/25/25 through 04/06/25, showed:
- On 03/25/25, an order for urine analysis (UA);
- On 03/25/25, the urine was collected;
- On 03/26/25, the UA results were reported to the facility;
- On 03/27/25, the UA results were faxed to the physician;
- On 03/30/25, an order for amoxicillin (an antibiotic) 500 milligram (mg) by mouth three times daily for UTI for seven days was received;
- On 03/31/25, the resident started the amoxicillin, six days after the urine was collected;
- The facility failed to obtain urine as ordered and report lab results to the physician in a timely manner.
Review of the resident's April 2025 POS showed:
- An order, for a UA and culture and sensitivity (a lab procedure to identify bacteria causing an infection and determine which antibiotics are effective in treating the bacteria) for a follow up UA, completed antibiotic and complaints of burning with urination continued, dated 04/11/25;
- An order for Cipro (an antibiotic) 500 mg by mouth two times a day for UTI for 10 days, order received on 4/15/25;
- The lab picked up the urine on 04/16/25;
- The facility failed to obtain urine as ordered and report lab results to the physician in a timely manner.
During an interview on 04/16/25 at 2:00 P.M., the DON said labs were only picked up on Tuesday and Thursday. She was not sure what day the urine was collected and picked up. She said it just depended on when the lab came.
3. Review of Resident #138's medical record showed:
- admitted to the facility on [DATE];
- Diagnosis of UTI.
Review of the resident's April 2025 POS showed:
- An order for a UA due to complaints of UTI, dated 04/07/25;
- On 04/16/25, the lab picked up the UA;
- The facility failed to obtain urine as ordered and report lab results to the physician in a timely manner.
Review of the resident's Progress Notes, dated 04/09/25, showed:
- UA specimen in the specimen refrigerator, awaiting pick up from lab.
During an interview on 04/17/25 at 3:05 P.M., the Assistant Director of Nursing (ADON) and the DON said there should be just a day turn around for urine result, however if a culture and sensitivity was ordered, then the results might take a couple of days. The ADON said she was responsible for pulling the lab results and put the orders in if needed after the physician was notified. The ADON said the lab company had been on vacation from 04/03/25 through 04/15/25, and the facility did not have a back up for labs. The ADON said the only way the facility could get any labs done any other way was to receive an order from the physician and take it to the nearest hospital.
During an interview on 04/17/25 at 3:58 P.M., the Administrator said labs should be prompt and the lab they were using at this time was not as prompt as they would like.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Pressure Ulcer Prevention
(Tag F0686)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide ongoing skin assessments, perform and document treatments, ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide ongoing skin assessments, perform and document treatments, and monitor progression of a pressure ulcer (areas of localized damage to the skin and underlying tissue generally the result of pressure, shear, and/or friction) for two residents (Residents #1 and #18) out of three sampled residents. The facility census was 91.
Review of the facility's policy titled, Pressure Ulcers, undated, showed:
- The facility will ensure that a resident who enters the facility without pressure ulcers does not develop pressure ulcers unless the resident's clinical condition indicates that they were unavoidable;
- The facility will ensure that all residents at risk for pressure ulcers are identified to be at risk and given care to prevent the development of pressure ulcers. See the policy: Skin Assessment;
- The facility will ensure that a resident with pressure ulcers receives necessary treatment and services to promote healing, prevent infection and prevent new sores from developing;
- The Unit Nurse will: Instruct and supervise Nursing Assistants to ensure in care and interventions to prevent skin breakdown. Provide wound care as prescribed by the physician. Track the healing progress of pressure ulcers, and work with the care plan team to alter the plan of care and treatment when needed. Evaluate pressure ulcer treatment weekly and inform the resident's physician of pressure ulcer status.
Review of the facility's policy titled, Skin Care, undated, showed:
- The facility will ensure that a resident who enters the facility without pressure ulcers does not develop pressure ulcers unless the resident's clinical condition demonstrates that they were unavoidable;
- The Unit Nurse will: Assess the resident's skin on day one of admission, and immediately implement care planning for any resident at risk for pressure ulcers. Complete a comprehensive head to toe assessment of the resident's skin with each scheduled assessment and with any significant change of condition, that includes evaluating Risk Factors such as: Bad positioning in a chair, bad positioning of braces, casts, or other devices, contractures, dementia, diseases such as diabetes or renal failure, drugs like steroids that impair wound healing, excessive moisture on skin, friction and shearing, history of skin breakdown, ill-fitting shoes, impaired blood flow, impaired mobility, incontinence, nutrition or hydration deficit, peripheral vascular disease, remaining too long in one position, restraint, skin desensitized to pain or pressure.
1. Review of Resident #1's quarterly Minimum Data Set (MDS - a federally mandated assessment instrument completed by facility staff), dated 03/06/25, showed:
- admitted on [DATE];
- Diagnoses of right above the knee amputation, diabetes mellitus (DM - a condition that affects the way the body processes blood sugar), dementia (a disorder marked by memory loss, personality changes, and impaired reasoning that interferes with daily functioning), schizophrenia (a long term mental disorder that affects a person's ability to think, feel, or behave clearly, sometimes including delusions or hallucinations), and chronic obstructive pulmonary disease (COPD - a chronic inflammatory lung disease that causes obstructed airflow from the lungs);
- Severe cognitive impairment;
- Unclear speech;
- Impairment to one side of lower extremities;
- Incontinent of bowel and bladder;
- Required partial to substantial assistance for all activities of daily living (ADL's);
- One stage II, (a partial thickness loss of dermis (second layer of skin) presenting as a shallow open ulcer with a red pink wound bed, without slough (non-viable tissue) or bruising) pressure ulcer.
Review of the resident's Physician Order Sheet (POS), dated April 2025, showed:
- An order to apply skin prep (a wipe that leaves a protective film over skin) to the inner and outer ankle and heel twice daily for redness every day and night shift, dated 04/11/25;
- An order for weekly skin assessment every Saturday day shift for skin integrity, dated 12/07/24.
Review of the resident's Licensed Nurse Weekly Skin Assessments, dated 01/01/25 - 04/15/25, showed:
- On 01/12/25, an open area related to cellulitis (a skin infection) to both the left inner and outer ankle with a measurement of 3.0 centimeters (cm) x 3.0 cm x 0.00 cm depth;
- On 04/01/25, a stage one (intact skin with non-blanchable redness of a localized area usually over a bony prominence) non-blanchable pressure injury to the heel wound with and old dressing to the heel, unable to assess the wound due to resident cursing staff;
- No other skin assessments with 13 missed opportunities out of 15 skin assessment opportunities.
Review of the resident's Treatment Administration Record (TAR), dated April 2025, showed:
- An order to apply skin prep to the ankle and heel twice daily for redness every day and night shift, dated 04/11/25 - 04/15/25;
- An order to cleanse the open area on the left medial (middle) ankle with wound cleanser. Apply skin prep around the peri wound (tissue around the wound) area, apply Medihoney (a gel used as a wound dressing to promote healing) to the wound bed and cover with a clean dressing every day and as needed (PRN) for a saturated or soiled dressing, dated 02/04/25 - 04/11/25, with one treatment completed on 04/07/25, and 11 missed opportunities out of 12 treatment opportunities;
- No order for weekly skin assessments.
Review of the resident's Nurse's Notes showed:
- On 04/11/25, hospice (health care that focuses on the quality of life of a terminally ill person) staff visited the resident and the ankle was not open but had redness on both sides and to the heel. New orders to apply skin prep twice daily and discontinue the dry dressing treatment to the ankle.
Observations of the resident's wound treatment on 04/15/25 at 9:00 A.M., showed:
- Registered Nurse (RN) A removed the sock from the left foot revealing an undated dressing to the resident's left heel;
- RN A removed the resident's pants revealing a dime size open red area with an old scab and active bleeding to the left knee;
- RN A applied skin prep to both the inner and outer left ankle as ordered;
- RN A removed the dressing to the left heel revealing a red open area. RN A put Medihoney on the wound and covered with a border bandage on the left heel without an order.
During an interview on 04/15/25 at 9:10 A.M., RN A said since Resident #1's heel now had an open area, it would require a dressing and a physician's order for a treatment. RN A said he/she did not know who applied the dressing removed during the treatment, but there had been no order for it and looked as if it had been there a while. Whoever did that treatment should have gotten an order at the time. RN A said he/she had obtained an order for the dressing after the treatment was completed. The left knee should also had a dressing since the area was open.
2. Review of Resident #18's annual MDS, dated [DATE], showed:
- admitted on [DATE];
- Diagnoses of DM and multiple sclerosis (MS - a disease of the central nervous system resulting in muscle weakness and loss of coordination);
- Cognition intact;
- Clear speech and ability to understand and be understood;
- Impairment to both sides of upper and lower extremities;
- Incontinent of bowel and bladder;
- Colostomy (a surgical opening into the intestines for bowel elimination) and suprapubic catheter (a urinary catheter inserted through a small incision in the lower abdomen, directly into the bladder);
- Dependent for all activities of daily living;
- One stage two pressure ulcer.
Review of the resident's POS, dated April 2025, showed:
- An order to apply Santyl (medicine that removes dead tissue from wounds so they can start to heal) to the bilateral (both) ischiums (paired bone forming the lower and back part of the hip bone) topically one time a day for wound care. Cleanse with wound cleaner, pat dry, apply Santyl nickel thick and edge to edge, cover with silver alginate (a wound dressings combining the high absorption of alginate with the antimicrobial properties of silver) and a bordered foam dressing, change daily and PRN every day shift for wound, dated 4/15/25;
- An order for Santyl apply to the bilateral ischiums topically one time a day for wound care. Cleanse with wound cleaner, pat dry, apply Santyl nickel thick and edge to edge, cover with silver alginate and a bordered foam. change daily and PRN, dated 04/13/25;
- An order to cleanse the wound, pack the wound with Dakin's (a topical antiseptic used to treat and prevent infections in wounds) soaked gauze wet to dry, cover with bordered gauze two times a day. For the wound to the buttock, cleanse the wound, pack the wound with Dakin's soaked gauze wet to dry, Cover with bordered gauze, dated 03/17/25 through 04/12/25.
Review of the resident's TAR, dated April 2025, showed:
- An order to apply Santyl to the bilateral ischiums topically one time a day for wound care. Cleanse with wound cleaner, pat dry, apply Santyl nickel thick and edge to edge, cover with silver alginate and a bordered foam dressing, change daily and PRN every day shift, dated 4/15/25;
- An order for Santyl apply to bilateral ischiums topically one time a day for wound care. Cleanse with wound cleaner, pat dry, apply Santyl nickel thick and edge to edge, cover with silver alginate and a bordered foam dressing, change daily and PRN, dated 04/13/25;
- No documentation treatment administered on 04/13/25 and 04/14/25.
- Two out of three opportunities missed.
Observation of the resident's wound treatment on 04/15/25 at 9:45 A.M., showed:
- RN A removed the undated dressing to the resident's ischiums showing no silver alginate applied to the wound;
- The the outside peri wound areas to both wounds were white and macerated (a wound edge softened and broken down due to prolonged exposure to moisture) deep open wounds with shiny grayish-white slough in the wounds.
During an interview on 04/15/25 at 9:47 A.M., RN A said the removed dressing had no date and no silver alginate. The outside edges of the wound appeared white and macerated.
During an interview on 04/17/25 at 2:30 P.M., the Director of Nursing (DON) said skin assessments should be done weekly and documented. If new or worsening wounds were found, orders should be obtained and entered. Dressings should not be placed on the resident without orders. Orders should be documented when completed.
During an interview on 04/17/25 at 2:40 P.M., the Administrator said skin assessments should be completed as per policy and an order. Any new wounds should be addressed by nursing and orders obtained from the physician. Wound care should be completed as ordered.
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, interview, and record review, the facility failed to implement protective measures for smoking and failed ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to implement protective measures for smoking and failed to accurately complete a smoking assessment per facility policy for one resident (Resident #1) out of three sampled residents. The facility census was 91.
Review of the facility's policy titled, Smoking, undated, showed:
- The smoking supervising staff member will hand out and light the residents' cigarettes and supervise the safety of the residents during smoking. Will notify the Unit Nurse when a resident's ability to smoke safely is in question;
- On admission the Unit Nurse will assess the resident's ability to smoke safely by completing a smoking assessment that includes an evaluation of the resident's safety awareness, judgement, cognitive ability, and manual dexterity;
- The Minimum Data Set (MDS - a federally mandated assessment instrument required to be completed by facility staff) Nurse will evaluate each resident who smokes for smoking safety with every MDS assessment, and document the resident's needs for supervision in the care plan, and update with any change of the resident's capabilities and needs.
1. Review of Resident #1's medical record showed:
- admission date of 11/20/24;
- Diagnoses of unspecified dementia with other behavioral disturbance (a group of symptoms affecting memory, thinking and social abilities), anxiety disorder (intense, excessive and persistent worry and fear about every day situations), border intellectual functioning (below average cognitive ability), intermittent explosive disorder (a mental and behavioral disorder characterized by explosive outbursts of anger or violence, often to the point of rage that are disproportionate to the situation), traumatic brain injury (TBI - usually from a violent blow or jolt to the head or body), right leg above the knee amputation, and schizoaffective disorder (a mental health condition marked by a mix of schizophrenia symptoms, such as hallucinations and delusions, and mood disorder symptoms, such as depression, mania);
- admitted to hospice (care for those terminally ill that choose comfort care instead of cure or treatment) on 03/18/25;
- No Smoking Assessment completed on or near the quarterly MDS, dated [DATE].
Review of the resident's Smoking Assessment, dated 11/21/24, showed:
- The resident assessed as capable of smoking safely;
- The resident to follow the facility's policy on location, times, and safety concerns;
- Observe clothing and skin for signs of cigarette burns.
Review of the resident's quarterly MDS, dated [DATE], showed:
- Cognitive impairment;
- Partial to substantial dependency for activities of daily living;
- Impairment to one side of lower extremity.
Review of the resident's medical record showed no current smoking assessment completed during the most recent MDS assessment of 03/06/25 per facility policy.
Review of the resident's Care Plan, dated 03/10/25, showed:
- Resident smoked;
- Instruct about smoking risks and hazards and about smoking cessation aids that are available;
- Instruct about the facility policy on smoking: locations, times, safety concerns;
- Notify charge nurse immediately if it is suspected the resident has violated facility smoking policy;
- Observe clothing and skin for signs of cigarette burns;
- Did not address the resident's capabilities and needs for smoking.
Observation on 04/15/25 at 10:58 A.M., of the resident showed:
- Sat in a high back wheelchair and pushed outside by another resident to the smoking area;
- No smoking apron applied or offered to the resident by staff;
- Staff lit a cigarette for the resident;
- The resident placed the lit cigarette in his/her mouth, smoked it a few times, and dropped it on the ground;
- Another resident picked up the lit cigarette and gave it back to the resident;
- The resident dropped ashes on his/her lap twice;
- Staff took the lit cigarette from the resident and disposed of it;
- Staff pushed the resident back inside the facility.
Observation on 04/16/25 at 9:45 A.M., of the resident showed:
- Sat in a high back wheelchair and pushed outside by another resident to the smoking area;
- No smoking apron applied or offered to the resident by staff;
- Another resident lit a cigarette for Resident #1;
- The resident placed the lit cigarette in his/her mouth and dropped it on the ground;
- Another resident picked up the lit cigarette and gave it back to the resident;
- Staff took the lit cigarette from the resident and disposed of it;
- Staff pushed the resident back inside the facility.
Observation on 04/17/25 at 9:50 A.M., of the resident showed:
- Sat in a high back wheelchair and pushed outside by another resident to the smoking area;
- No smoking apron applied or offered to the resident by staff;
- Staff lit the resident's cigarette;
- The resident placed the lit cigarette in his/her mouth and dropped it on the ground;
- Staff picked up the lit cigarette and handed it back to the resident;
- The resident leaned over to the left with his/her head hung over the side of the wheelchair with the lit cigarette in his/her mouth;
- Staff took the lit cigarette from the resident and disposed of it;
- Staff pushed the resident back inside the facility.
During an interview on 04/17/25 at 1:40 P.M., Certified Nursing Assistant (CNA) M said Resident #1 didn't require a smoking apron. The resident did drop the cigarettes at times. Staff lit the cigarettes for the resident. The resident was usually pushed in and out of the building now in the wheelchair. Staff also disposes of the cigarettes. The resident had ashes on him/her a few times.
During an interview on 04/17/25 at 2:00 P.M., the Director of Nursing (DON) said if a resident was not safe smoking, it should be brought to the nursing staff's attention so a new assessment could be completed. Smoking assessments should be done per policy or if there was a change in condition.
During an interview on 04/17/25 at 2:15 P.M., the Administrator said nursing staff should be alerted anytime a resident had issues with smoking. Smoking assessments should be done per policy and with a change in condition to ensure safety. The resident care plan should reflect the resident's needs.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0692
(Tag F0692)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to obtain a physician's order for recommendation made by...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to obtain a physician's order for recommendation made by the registered dietician (RD) for two residents (Residents #1 and #18) out of three sampled residents. The facility census was 91.
The facility did not provide a policy regarding RD recommendations.
1. Review of Resident #1's medical record showed:
- admitted on [DATE];
- Diagnoses of diabetes mellitus (DM - a condition that affects the way the body processes blood sugar), dementia (a disorder marked by memory loss, personality changes, and impaired reasoning that interferes with daily functioning), schizophrenia (a long term mental disorder that affects a person's ability to think, feel, or behave clearly, sometimes including delusions or hallucinations), chronic obstructive pulmonary disease (COPD - a chronic inflammatory lung disease that causes obstructed airflow from the lungs), borderline intellectual functioning, gastroesophageal reflux disease (GERD - stomach acid being forced back into the throat region), and traumatic brain injury (TBI - a type of injury to the brain that results from a sudden, external physical force, such as a blow to the head or an object penetrating the skull).
Review of the resident's RD nutrition progress notes, dated 12/09/24 and 03/11/25, showed:
- A recommendation to add 30 milliliters (ml) of liquid protein supplement twice daily (BID).
Review of the resident's April 2025 Physician's Order Summary (POS), showed:
- An order for regular diet, regular texture, thin consistency liquids, dated 11/21/24;
- No order for 30 ml of liquid protein supplement BID.
Review of the resident's Care Plan, dated 03/10/25, showed:
- Prescribed regular diet with thin liquids with a history of choking, so needs reminders to take small bites and eat slowly;
- Dietary consult monthly and as needed;
Observations on 04/15/25 at 12:15 P.M., 04/16/25 at 12:25 P.M., and 04/17/25 at 12:20 P.M., of the resident in his/her room showed:
- The resident sat in the wheelchair pushed sideways up to a dresser beside the sink and with his/her feet under the sink. The resident's food sat two to three feet away from the resident. The resident had to stretch his/her right arm across his/her body to reach the food two to three feet away to the left of him/her to eat;
- No liquid protein supplement provided.
2. Review of Resident #18's medical record showed:
- admitted on [DATE];
- Diagnoses of major depressive disorder (persistent feelings of sadness, hopelessness and loss of interest), anxiety (feelings of unease, worry, fear or apprehension), and multiple sclerosis (MS - a chronic autoimmune disease of the central nervous system where the body's immune system mistakenly attacks the protective myelin sheath around the nerve fibers, causing communication disruptions between the brain and body).
Review of the resident's weights showed:
- On 09/04/24, 189 lbs.;
- On 11/04/24, 172.8 lbs.;
- On 01/09/25, 175 lbs.;
- On 03/03/25, 176.2 lbs.;
- On 04/02/25, 172.8 lbs;
- An 8% weight loss in six months.
Review of the resident's RD Progress Notes, dated 01/22/25, showed:
- A recommendation to add 60 ml of liquid protein BID.
Review of the resident's April 2025 POS showed:
- An order for a regular diet, regular texture, regular/thin consistency, dated 08/19/24;
- No order for 60 ml of liquid protein supplement BID.
Observations on 04/15/25 at 12:15 P.M., 04/16/25 at 12:25 P.M., and 04/17/25 at 12:20 P.M., showed:
- The resident sat in his/her room in a wheelchair and ate the meal with no liquid protein supplement provided.
During an interview on 04/17/2 at 4:28 P.M., the Dietary Manager said he/she considered the RD's recommendations and tried to accommodate. He/She did pretty much what the RD asked them to do, double portions, health shake, etc. He/She received the RD recommendations by email, but the RD usually met with him/her before leaving the facility.
During an interview on 04/17/25 at 4:20 P.M., the Director of Nursing (DON) said the RD emails her, the Administrator, and the two Dietary Managers with the recommendations. She thought the RD put the orders in but found out the Dietary Managers put the orders in, unless it was medications, then the DON would put the order in for medications.
During an interview on 04/17/25 at 4:24 P.M., the Administrator said recommendations should be discussed with the Dietary Manager and the RD's recommendations should be followed.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0699
(Tag F0699)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to identify, assess, and provide supportive intervention...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to identify, assess, and provide supportive interventions for three residents (Residents #52, #62, and #81) out of seven sampled residents, with a diagnosis of post traumatic stress disorder (PTSD - a mental health condition triggered by a terrifying event - either experiencing it or witnessing it; symptoms may include flashbacks, nightmares and severe anxiety, as well as uncontrollable thoughts about the event). The facility's census was 91.
Review of the facility's policy titled, PTSD, undated, showed:
- The facility must ensure that residents who are trauma survivors receive culturally competent, trauma-informed care in accordance with professional standards of practice and accounting for residents' experiences and preferences in order to eliminate or mitigate triggers that may cause re-traumatization of the resident;
- Using a multi-pronged approach to identify a resident's history of trauma and cultural preferences, facilities should ask the resident about a history of trauma, observe the resident, use screening and assessment tools, and obtain social history/assessment;
- To ensure each resident's person-centered comprehensive care plan includes approaches that address the resident's cultural preferences and reflects trauma-informed care when appropriate;
- Review the care plan to determine if it describes interventions which take into account the resident's experiences and preferences in order to eliminate or mitigate triggers that may cause re-traumatization and psychosocial harm;
- When care planning to address a resident's history of trauma and/or a resident's cultural preferences, there should be evidence that the facility collaborated with other trauma survivors, family, friends, and health care professionals to understand the resident's trauma experience. This includes finding out triggers that may re-traumatize the resident and developing interventions to help avoid these triggers. With regard to care planning to address cultural needs and preferences, nursing home staff should consider aspects of cultural preferences which may include: communication, food preparation, clothing preferences, physical contact or provision of care by a person of the opposite sex, cultural etiquette (voice volume, eye contact).
1. Review of Resident #52's medical record showed:
- admission date of 07/12/23;
- Diagnoses of PTSD, autism (a lifelong neurodevelopmental disability that affects how people interact with and experience the world), anxiety (persistent worry and fear about everyday situations), schizoaffective disorder (a mental health condition characterized by symptoms of both schizophrenia (a long term mental disorder that affects a person's ability to think, feel, or behave clearly, sometimes including delusions or hallucinations) and a mood disorder (like depression or mania), and insomnia;
- Moderate intellectual disabilities, personality disorder;
- No trauma informed care assessment completed.
Review of the resident's Care Plan, dated 03/24/25, showed:
- Takes a psychotropic (medications that affect mental function, behavior, and experience) medication related to PTSD;
- Did not address triggers that would cause resident trauma;
- Did not address the resident had past trauma or any triggers that would cause the resident to have behaviors.
2. Review of Resident #62's medical record showed:
- admission date of 11/22/23;
- Diagnoses of PTSD, schizophrenia, anxiety disorder, insomnia, and depression (a serious medical illness that negatively affects how you feel, the way you think and how you act).
Review of the resident's Trauma Informed Care Assessment, dated 09/27/24, showed:
- Experienced a frightening, horrible, or traumatic event;
- Experienced nightmares about the event(s), or thought about the event(s) when he/she did not want to;
- Tried hard not to think about the event(s), or went out of his/her way to avoid situations that remind him/her of the event(s);
- Experienced guilt or unable to stop blaming his/herself or others for the event(s) or any problems the event(s) may have caused.
Review of the resident's POS, dated April 2025, showed:
- An order for fluoxetine (an antidepressant medication) 60 mg by mouth in the morning related to depression, dated 02/23/24;
- An order for Invega (an antipsychotic medication) 546 MG/1.75 milliliter (ml) one syringe intramuscularly (injection into the muscle) every day shift every 84 days related to schizophrenia, give injection now then every 84 days thereafter, dated 01/05/25;
- An order for nortriptyline (an antidepressant medication) 25 mg by mouth in the evening related to insomnia, dated 11/05/24.
Review of the resident's Care Plan, dated 04/14/25, showed:
- Diagnoses of PTSD from childhood trauma. Goals include: resident will have no behaviors related to his/her PTSD through his/her next review. Interventions include: resident will consult with psychiatry as recommended and take his/her ordered medications as prescribed;
- Did not address the resident's past trauma, or any triggers that would cause the resident trauma;
- Did not address for how the facility would address these behaviors if they occurred or how the facility would provide support to the resident.
3. Review of Resident #81's medical record showed:
- admission date of 02/24/25;
- Diagnosis of PTSD, MDD, suicidal ideations, and insomnia;
- No trauma informed care assessment completed after readmission on [DATE].
Review of the resident's Trauma Informed Care Assessment, dated 06/06/24, showed:
- Had a traumatic event, had nightmares, tried not to think about the event, constantly on guard or easily startled, and felt numb or detached from people, activities, or surroundings.
Review of the resident's Psychiatry Note, dated 02/01/25, showed:
- Had a history of being physically and sexually abused resulting in PTSD.
Review of the resident's POS, dated April 2025, showed:
- An order for clonazepam tablet 0.5 mg by mouth three times a day for anti-convulsant, dated 03/12/25;
- An order for Seroquel (an antipsychotic medication) 200 mg by mouth at bedtime for general anxiety disorder and MDD, dated 02/25/25;
- An order for bupropion (an antidepressant medication) Extended Release (ER) 150 mg by mouth in the afternoon for MDD after lunch, dated 02/25/25;
- An order for bupropion ER 24 300 mg one tablet by mouth in the morning for MDD, dated 02/25/25;
- An order for Seroquel 400 mg by mouth in the evening related to schizoaffective disorder, dated 11/05/24;
- An order for Effexor (an antidepressant medication) Extended Release (XR) 150 mg by mouth in the morning related to MDD and give with the Effexor XR 75 mg, dated 09/01/24;
- An order for Effexor XR 75 mg by mouth in the morning related to MDD and give with Effexor XR capsule 150 mg, dated 09/01/24.
Review of the resident's Care Plan, dated 01/24/25, showed:
- Resident uses psychotropic medications related to behavior management, PTSD;
- Did not address PTSD;
- Did not address the resident had past trauma, or any triggers that would cause the resident trauma;
- Did not address how the facility would address these behaviors if they occurred or how the facility would provide support to the resident.
During an interview on 04/17/25 at 1:30 P.M., the Director of Nursing (DON) said the residents should have a trauma assessment and they should be individually care planned for PTSD.
During an interview on 04/17/25 at 2:30 P.M., the Administrator said all residents should receive a trauma assessment. The residents' care plans should address their individual triggers and interventions.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0883
(Tag F0883)
Could have caused harm · This affected 1 resident
Based on interview and record review, the facility failed to document pertinent education and consent or declination of the influenza (a viral respiratory infection) vaccine was provided to the reside...
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Based on interview and record review, the facility failed to document pertinent education and consent or declination of the influenza (a viral respiratory infection) vaccine was provided to the resident or the resident's representative, and failed to document the administration or declination of the influenza vaccine for three residents (Residents #29, #54, and #138) out of five sampled residents. The facility's census was 91.
Review of the facility's policy titled, Influenza Vaccine, undated, showed:
- The facility will offer an influenza immunization to every resident and staff member each year at the beginning of flu season October I through March 31;
- The Infection Control Nurse will: Initiate an Immunization Log of all residents that includes resident name and room number, that resident was given information about benefits and possible side effects, date vaccine administered, vaccine refused or contraindicated, and reason why;
-The Unit Nurse will: Review the resident's record to determine whether an influenza vaccination was received during the flu season. If the vaccination status is unknown, ask the resident if he/she received a dose of the influenza vaccine outside of the facility for this year's influenza season.
1. Review of Resident #29's medical record showed:
- admission date of 02/16/24;
- No documentation the facility provided information and education for the influenza vaccination to the resident and/or the resident representative for this year's influenza season;
- No documentation of the consent or refusal for the influenza vaccination for this year's influenza season;
- No documentation the influenza vaccination was administered or declined for this year's influenza season.
2. Review of Resident #54's medical record showed:
- admission date of 12/23/24;
- No documentation of the resident's influenza immunization history for this year's influenza season;
- No documentation the facility provided information and education for the influenza vaccination to the resident and/or the resident representative for this year's influenza season;
- No documentation of the consent or refusal for the influenza vaccination for this year's influenza season;
- No documentation the influenza vaccination was administered or declined for this year's influenza season.
3. Review of Resident #138's medical record showed:
- admission date of 03/26/25;
- No documentation of the resident's influenza immunization history for this year's influenza season;
- No documentation the facility provided information and education for the influenza vaccination to the resident and/or the resident representative for this year's influenza season
- No documentation of the consent or refusal for the influenza vaccination for this year's influenza season;
- No documentation the influenza vaccination was administered or declined for this year's influenza season.
During an interview on 04/17/25 at 11:24 A.M., the Director of Nursing (DON) said the Social Service Director (SSD) had the resident or their representative sign the consent for the vaccine administration record. The consents were sent to the pharmacy. When the pharmacy came to administer the vaccinations, they completed the form. The facility did not provide immunizations routinely for new admissions, just annually. The pharmacy administered all of the influenza immunizations.
During an interview on 04/17/25 at 3:30 P.M., the Administrator said nurses should complete vaccinations based on their policy and procedures and recommendations.
CONCERN
(E)
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, interview, and record review, the facility failed to provide a safe, clean, and comfortable homelike environment. This deficient practice had the potential to affect all resident...
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Based on observation, interview, and record review, the facility failed to provide a safe, clean, and comfortable homelike environment. This deficient practice had the potential to affect all residents in the facility. The facility's census was 91.
The facility did not provide a policy for a safe, clean, and comfortable homelike environment.
1. Observation on 04/14/25 at 11:01 A.M., of Room A15 showed:
- No cover over two fluorescent bulbs in the light fixture above the bed next to the door.
2. Observation on 04/17/25 at 9:51 A.M., of the A Hall shower room showed:
- A 2 ft. x 2 ft. vent with a build up of dust and debris next to the right side of the shower stall;
- The shower stall with a large floor area with 108 missing tiles and a rigid floor surface;
- A large floor area of the shower stall with rusty, brown-colored stains and a build up of dirt and grime;
- Several areas of peeled/chipped paint on the right, left, and back walls of the shower stall;
- The entrance door frame on the left side with an approximate 3 ft. area of vertical scrapes.
3. Observation on 04/17/25 at 9:59 A.M., of Room B36 showed:
- The front cover of the air conditioner/heater unit missing.
4. Observation on 04/17/25 at 10:10 A.M., in front of the nurses' station at the intersection of B and C Halls showed:
- Three 4 in. x 1 ft. ceiling tiles with dark circles;
- Five 1 ft. x 1 ft. ceiling tiles with large dark circles.
5. Observation on 04/17/25 at 10:25 A.M., of the back area of the main dining room showed:
- Six 2 ft. x 4 ft. ceiling tiles with large dark brown circles;
- One 2 ft. x 2 ft. ceiling tile with a small dark brown circle.
6. Observation on 04/17/25 at 10:55 A.M., of the B Hall shower room A showed:
- Two toilets with a non-intact caulk seal along the base and floor;
- The wall section above the right-side toilet had a 6 in. by 3 in. hole above the trim board about 4 ft. above the floor;
- A strong urine odor;
- A non-intact caulk seal between the backsplash area and a porcelain sink mounted against the wall;
- The approximately 20 in. x 24 in. mirror missing the bottom 1 in. of reflective coating;
- The wall adjacent to the shower near the trash can with a 2 ft. tile baseboard area in the floor with a black substance.
7. Observation on 04/17/25 at 1:54 P.M., of Room C42 showed:
- A non-intact metal bathroom door frame with sharp edges and a brown substance about 1 ft. above the floor;
- The sink countertop with a 1 in. front edge strip missing about 8 in.;
- The toilet with a non-intact caulk seal along the base and floor, no toilet tank lid, and a 1 in. gap between the water line and wall;
- The toilet seat with four 1 in. diameter damaged sections without a smooth painted surface.
8. Observation on 04/17/25 at 2:30 P.M., of the outdoor smoking area showed:
- Six strands of wire approximately 75 ft. in length along the exterior wall section left of the entry door hung loosely at least 4 ft. down the exterior wall area and obstructed the view from the resident room windows;
- One black wire approximately 25 ft. in length along the exterior wall section right of the entry door hung loosely at least 4 ft. down the exterior wall area.
During an interview on 04/15/25 at 9:16 A.M., Resident #65 said the shower rooms had some damage and smelled bad. It was frustrating.
During an interview on 04/15/25 at 9:20 A.M., Resident #62 said the shower rooms had odors and there was a hole in the wall. Some issues like that were frustrating at times.
During an interview on 04/15/25 at 9:40 A.M., Resident #67 said there were problems with the bathrooms in the facility and it was frustrating because he/she had mentioned it to staff.
During an interview on 04/15/25 at 9:45 A.M., Resident #68 said it was frustrating when the floors did not look clean in the shower room. There was damage to the wall behind the toilet and an odor.
During an interview on 04/15/25 at 9:53 A.M., Housekeeper G said there were problems in the shower room. Issues with damage in the facility should be reported to maintenance or the supervisor and there were forms.
During an interview on 04/17/25 at 10:30 A.M., Certified Medication Technician (CMT) A said when there was a need for repair, there was a clipboard on the maintenance staff door. Staff could fill it out and leave it there on the clipboard.
During an interview on 04/17/25 at 10:32 A.M., Licensed Practical Nurse (LPN) C said staff just told maintenance or staff could fill out the form and leave it on the maintenance door.
During an interview on 04/17/25 at 11:12 A.M., Housekeeper H said he/she would tell nursing or the charge nurse when he/she saw damage in the facility. He/she wasn't told to log the damage in a binder and hadn't reported any problems yet.
During an interview on 04/17/25 at 1:26 P.M., the Maintenance Supervisor said maintenance request forms were part of the repair process. If staff noticed concerns or heard problems from the residents, they should fill the form out and place it in one of four drop boxes. Once the requests were received and a repair was made, he/she completed a portion on the form on how the problem was addressed. Inspections for lighting and any kind of damage should also be completed by the maintenance department. There had been recent changes in the maintenance staffing that might have caused some issues. He/She hadn't been the supervisor for long. A faucet has been ordered for Room C42 but he/she wasn't aware of any other issues in that room or in Shower Room A.
During an interview on 04/17/25 at 3:05 P.M., the Administrator said damages in the resident rooms should be reported to the maintenance department. Several rooms had been redone so far but they had more they wanted to work on. If staff noticed problems with the facility environment or if residents complained, the staff should place the information on a maintenance request form. The completed maintenance request forms should be in the maintenance log. She expected the rooms and showers to be kept in good repair.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Transfer Notice
(Tag F0623)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to notify the resident and/or the resident's representative in writing...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to notify the resident and/or the resident's representative in writing of a transfer or discharge to a hospital, including the statement of appeal rights or the name, address, or telephone number of the office of the State Long Term Care Ombudsman (advocates for the residents in nursing facilities) within the transfer and discharge notices for six residents (Residents #18, #35, #46, #47, #54, and #62) out of seven sampled residents. The facility's census was 91.
Review of the facility's policy titled, Discharges, undated, showed:
- The facility must ensure the discharge is documented in the resident's medical record, including Physician's order for the discharge, basis for the transfer, specific resident needs that can't be met;
- Information provided to the receiving provider must include a minimum of contact information of the practitioner responsible for the care of the resident, resident representative information including contact information, advanced directive information, all special instructions or precautions for ongoing care, comprehensive care plan goals, all other necessary information, including a copy of the resident's discharge summary, and any other documentation, as applicable to ensure a safe and effective transition of care.
1. Review of Resident #18's medical record showed:
- admitted on [DATE];
- The resident transferred to the hospital on [DATE], and readmitted to the facility on [DATE].
- No documentation of the written notification to the resident and/or the resident's representative for the resident's transfer to the hospital.
2. Review of Resident #35's medical record showed:
- admitted on [DATE];
- The resident transferred to the hospital on [DATE], and returned to the facility on [DATE];
- The resident transferred to the hospital on [DATE], and returned to the facility on [DATE];
- No documentation of the written notifications to the resident and/or the resident's representative for the resident's transfer to the hospital.
3. Review of Resident #46's medical record showed:
- admitted on [DATE];
- The resident transferred to the hospital on [DATE], and returned to the facility on [DATE];
- No documentation of the written notifications to the resident and/or the resident's representative for the resident's transfer to the hospital.
4. Review of Resident #47's medical record showed:
- admitted on [DATE];
- The resident transferred to the hospital on [DATE], and returned to the facility on 2/28/25;
- The resident transferred to the hospital on [DATE], and returned to the facility on [DATE];
- No documentation of the written notifications to the resident and/or the resident's representative for the resident's transfer to the hospital.
5. Review of Resident #54's medical record showed:
- admitted on [DATE];
- The resident transferred to the hospital on [DATE], and returned to the facility on [DATE];
- The resident transferred to the hospital on [DATE], and returned to the facility on [DATE];
- No documentation of the written notifications to the resident and/or the resident's representative for the resident's transfers to the hospital.
6. Review of Resident #62's medical record showed:
- admitted on [DATE];
- The resident transferred to the hospital on [DATE], and returned to the facility on [DATE];
- No documentation of the written notification to the resident and/or the resident's representative for the resident's transfer to the hospital.
During an interview on 04/17/25 at 2:46 P.M., the Regional Administrator said the transfer and discharge notices should address the reason for the discharge along with some other information and the forms weren't detailed enough.
During an interview on 04/17/25 at 2:48 P.M., the Social Services Designee (SSD) said transfer and discharge notifications should be given in writing to the resident and/or the resident's representative upon discharge or transfer. The notices should include the appeal rights and information on contacting the Ombudsman which the current forms do not include those details.
During an interview on 04/17/25 at 2:51 P.M., the Administrator said she would expect transfer/discharge notifications to be given in writing to the resident and/or the resident's representative upon discharge or transfer. The notices should include the appeal rights and information on contacting the Ombudsman.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0637
(Tag F0637)
Could have caused harm · This affected multiple residents
Based on interview and record review, the facility failed to complete a significant change Minimum Data Set (MDS - a federally mandated assessment instrument required to be completed by facility staff...
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Based on interview and record review, the facility failed to complete a significant change Minimum Data Set (MDS - a federally mandated assessment instrument required to be completed by facility staff) assessment within 14 days of admission to hospice services for four residents (Residents #1, #34, #47, #52) out of four sampled residents. The facility census was 91.
The facility did not provide a policy regarding the completion of significant change MDS assessments.
1. Review of Resident #1's medical record showed:
- admitted to hospice services on 03/18/25;
- No significant change MDS dated on or after 03/18/25;
- The facility failed to complete a significant change MDS within 14 days of the resident's admission to hospice.
2. Review of Resident #34's medical record showed:
- admitted to hospice services on 12/27/24;
- No significant change MDS dated on or after 12/27/24;
- The facility failed to complete a significant change MDS within 14 days of the resident's admission to hospice.
3. Review of Resident #47's medical record showed:
- admitted to hospice services on 01/31/25;
- No significant change MDS dated on or after 01/31/25;
- The facility failed to complete a significant change MDS within 14 days of the resident's admission to hospice.
4. Review of Resident #52's medical record showed:
- admitted to hospice services on 03/18/25;
- No significant change MDS dated on or after 03/18/25;
- The facility failed to complete a significant change MDS within 14 days of the resident's admission to hospice.
During an interview on 04/17/25 at 1:40 P.M., the MDS Coordinator said a significant change MDS would be completed if there was a change or decline in a resident's condition or their activities of daily living (ADLs). He/She said that maybe a significant change should be done once a resident elected their hospice benefit. Even if a resident returned from the hospital at their baseline and elected hospice, this change did not trigger a significant change MDS.
During an interview on 04/17/25 at 2:30 P.M., the Administrator said a significant change MDS should be completed with an admission to hospice and per the facility's policy and procedure.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected multiple residents
Based on observation, interview, and record review, facility staff failed to provide infection prevention precautions by not following enhanced barrier precautions (EBP) for two residents (Residents #...
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Based on observation, interview, and record review, facility staff failed to provide infection prevention precautions by not following enhanced barrier precautions (EBP) for two residents (Residents #18 and #29) out of two sampled residents. The facility also failed to correctly screen three residents (Residents #18, #29, and #138) for tuberculosis (TB - an infectious disease characterized by the growth of nodules in the tissues, especially the lungs) out of five sampled residents required by state regulation 19 CSR 20-20.100. The facility's census was 91.
Review of the facility's policy titled, Enhanced Barrier Precaution Policy and Procedure, dated August 2024, showed:
- This facility's policy is to implement EBP for preventing transmission of multidrug-resistant organisms (MDROs - microorganisms, predominantly bacteria, that are resistant to one or more classes of antimicrobial agents);
- EBP involve gown and glove use during high-contact resident care activities for residents known to be colonized or infected with a MDRO as well as those at an increased risk of MDRO acquisition (e.g., residents with wounds or indwelling medical devices);
- High-contact resident activities include: dressing; bathing/showering; transferring; providing hygiene; changing linens; changing briefs or assisting with toileting; device care or use such as a central line, urinary catheter (a tube inserted into the bladder to drain urine), feeding tube, tracheostomy/ventilator, and wound care; any skin opening requiring a dressing;
- A physician order is obtained for EBP for residents with any of the following: infection or colonization with a Centers for Disease Control and Prevention (CDC)-targeted MDRO when contact precautions do not otherwise apply, or wounds and/or indwelling medical devices even if the resident is not known to be infected or colonized with a MDRO;
- Gowns and gloves will be available immediately near or outside of the resident's room. Face protection may also be needed if performing activity with risk of splash or spray (i.e., wound irrigation, tracheostomy care);
- Personal Protective Equipment (PPE) for EBP is only necessary when performing high-contact care activities and may not need to be put on prior to entering the resident's room;
- Position a trash can inside the resident room and near the exit for discarding PPE after removal, prior to exit of the room, or before providing care for another resident in the same room;
- EBP should be used for the duration of a resident's stay in the facility or until resolution of the wound or discontinuation of the indwelling medical device that placed them at a higher risk.
Review of the facility's policy titled, Tuberculosis (TB) Testing, Mantoux Purified Protein Derivative (PPD - a type of TB skin test) , undated, showed:
- All residents will be tested for Mycobacterium (a type of TB) TB upon admission and annually.
1. Review of Resident 18's medical record showed:
- admit date of 01/16/24;
- No documentation of a tuberculin skin test (TST) or screening completed.
2. Observation on 04/15/25 at 10:30 A.M., of Resident #18's wound care, urinary catheter care, irrigation of the catheter, and transfer showed:
- EBP signage not posted outside of the resident's room;
- The resident sat in wheelchair with the catheter in drainage bag attached to side of the wheelchair;
- Registered Nurse (RN) F entered the room, sat the supplies on a clean towel, did not put on a gown, performed hand hygiene, and put on gloves;
- RN F irrigated the resident's catheter and performed catheter care;
- Certified Medication Technician (CMT) B entered the room, did not put on a gown, performed hand hygiene, and put on gloves;
- RN F and CMT B transferred the resident to the bed;
- RN F removed the gloves, performed hand hygiene, put on new gloves, and performed the wound care;
- RN F and CMT B removed the gloves, performed hand hygiene, and exited the resident's room.
3. Review of Resident #29's medical record showed:
- admit date of 02/16/22;
- Annual TB administered 11/29/23, with no read date and no result;
- No documentation of an annual TST or screening completed.
4. Observation on 04/15/25 at 2:39 P.M., of Resident #29's wound care showed:
- EBP signage not posted outside of the resident's room;
- RN F did not put on a gown, entered the room, performed hand hygiene, and put on gloves;
- RN F performed the wound care;
- RN F performed hand hygiene and changed gloves;
- RN F removed the gloves, performed hand hygiene and exited the resident's room.
During an interview on 04/15/25 at 10:55 A.M., RN F said the facility did not follow EBP.
During an interview on 04/17/25 at 2:00 P.M., Certified Nursing Assistant (CNA) L said he/she did not know what EBP stood for or what would be required other than gloves like usual.
During an interview on 04/17/25 at 2:10 P.M., Licensed Practical Nurse (LPN) N said he/she did not know what EBP was.
During an interview on 04/17/25 at 2:31 P.M., the Director of Nursing (DON) and Assistant Director of Nursing (ADON) said during wound or catheter care, PPE, such as a gown and gloves, should be worn.
5. Review of Resident #138's medical record showed:
- admit date of 03/26/25;
- First step TST administered on 03/28/25, with no read date and no result;
- No documentation of a step two TST administration;
- No documentation of a screening completed.
During an interview on 04/17/25 at 2:26 P.M., the DON said a resident should receive the first TST on admission and be read 48-72 hours after. The second step should be administered two weeks later. The nurse doing the admission should put the orders in for the TST.
During an interview on 04/17/25 at 3:35 P.M., the Administrator said it was expected that nursing follow the policy and procedures and recommendations for administering the TST and for EBP.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Room Equipment
(Tag F0908)
Could have caused harm · This affected multiple residents
Based on observations, interviews, and record review, the facility failed to maintain essential equipment in a safe and operable working condition. This deficient practice had the potential to affect ...
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Based on observations, interviews, and record review, the facility failed to maintain essential equipment in a safe and operable working condition. This deficient practice had the potential to affect all residents. The facility census was 91.
The facility did not provide a policy for equipment maintenance.
Review of the facility's Maintenance Request showed:
- On 09/09/24, the top right dryer not working. Would have to reiterate to corporate about parts needing ordered;
- On 11/14/24, washer #2 (left) didn't work, trips the fuse when powered on or during a cycle. Needed cleaned and investigated. Corrected Action: Replaced the computer and door latch sensor and still threw the door code. Called and called the washers technician line and was now waiting for a call back with advice on the problem;
- On 01/13/25, right washer with a code of F8 for slow drain. Corrected Action: 01/14/25, found chain and fork jammed in the drain housing. Removed the obstruction and line to washer clear;
- On 03/20/25, the dryer not working. Corrected Action: Other ticket still open and had to wait for parts.
Review of the facility's Invoices showed:
- On 03/13/25, an order for an inverter motor control unit, but no details of actions taken;
- On 03/13/25 an order for a two pack of brand new washer door switch replacements, but no details of actions taken;
- On 03/13/25, an order for two pieces for washer door switch, but no details of actions taken.
Observation on 04/14/25 at 2:37 P.M., of the laundry room showed:
- Two commercial laundry washing machines, and 4 commercial dryers;
- One small red square bucket with color-safe liquid laundry oxygen bleach liquid and one small red square bucket with heavy-duty laundry detergent liquid sat on a towel to the left of the washing machines with a one cup measuring cup;
- Washing machine #2 (left) not in use due to needing repairs;
- Washing machine #1 (right) ran a load of laundry;
- Top right dryer with yellow sticky note taped to the door doesn't work due to needing repairs;
- Detergent dispensing equipment not in use.
During an interview on 04/14/25 at 2:37 P.M., Laundry Aide (LA) I said he/she had been a laundry employee for nine months and in that time, the detergent dispensing equipment had not been used. He/She was trained to fill the red buckets at the side of the washer with detergents, one with color-safe bleach that was clear and the other with detergent which was blue, from the five gallon buckets in the storage closet, did not know if that was the actual amount required. He/She used the one cup measuring cup to put one cup of of the color safe bleach and the detergent into the loaded washer at the top of the machine, unless the load was heavily soiled, then he/she put half a cup more. The washer to the left had not worked since November 2024, and was waiting on parts. Maintenance had the work order and said they were awaiting parts. LA I was unsure how long the top right dryer had not worked. There was a lot of laundry to do for the number of residents and he/she tried to make sure the linens were washed first, and then washed the residents' personal items. Sometimes it was hard to keep up with only one washer working and the machine usually ran from 6:00 A.M. - 9:00 P.M., every day.
During an interview on 04/16/25 at 1:35 P.M., LA I said the washer on the right had been showing a code F8, which meant it was not draining properly. The pump was not pumping out the water when the washer spun. The cycle had to run for a second and third cycle to drain the water to enable the items to be put into the dryer, or he/she would have to remove the items from inside the washer and run the cycle again for them to drain enough to be switched to the dryer. He/She said it was frustrating and time consuming.
During an interview on 04/17/25 at 10:00 A.M., LA J said the washing machine on the left had not worked since September or November 2024. There was a hole through one of the old dry, rotted hoses of the soap and bleach dispenser, so it was not in use. The laundry aides manually added the soap and bleach to the washer. At one time the, the working washer was down a few hours due to the drive went out during a lightening storm and maintenance took the one from the broke washer and put it on the now working washer to fix it. Currently the working washer was not draining like it should so he/she turned the breaker off and on to reset the control board. This was due to mainly overfilling the washer. The drains didn't work at least one time a shift. They did not drain properly since the other washer went down in September or November 2024, and the maintenance staff re-did the pipes.
During an interview on 04/17/25 at 2:20 P.M., the Maintenance Supervisor (MS) said the non-working washing machine had been repaired but still would not work. Now they were waiting on a repair company to come out. The repair was made prior to him/her becoming the MS about a month ago. He/She was unsure if the detergent dispenser worked but knew the laundry aides manually added soap to the washing machine. He/She said it was part of the safety feature to turn the breaker off and on to reset the washer.
During an interview on 04/17/25 at 2:40 P.M., the Administrator said she knew there was a washer down, and they just got a part that had been ordered a while ago, and now there's was a code something about the door not closing. Someone was scheduling to come look at it. If the detergent dispenser was broken, then she would expect staff to read the recommendation for the amount of detergent to be used. She was not aware the dispenser was down. She thought there was a part for the dryer.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0925
(Tag F0925)
Could have caused harm · This affected multiple residents
Based on observation, interview, and record review, the facility failed to maintain an effective pest control program to control the insect population in the facility. The facility census was 91.
The ...
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Based on observation, interview, and record review, the facility failed to maintain an effective pest control program to control the insect population in the facility. The facility census was 91.
The facility did not provide a policy on pest control.
Review of the facility's Pest Control Invoices for 2025 showed:
- No service invoices for January and February 2025;
- March 2025 service targeted the German roach and the house mouse;
- No services targeted flies.
1. Observation on 04/14/25 at 11:01 A.M., of Room A15 showed:
- Six flies flew around the room.
During an interview on 04/14/25 at 11:05 A.M., the resident in Room A15 said he/she kept a fly swatter hung on the wall near the bed so that he/she could try to kill the flies in the room. The flies got really bad, it was frustrating, and didn't feel clean, because they landed on the urinal and on the bedding.
2. Observation on 04/14/25 at 11:01 A.M., of Room A11 showed:
- Two flies flew around the room.
During an interview on 04/14/25 at 11:28 A.M., the resident in Room A11 said the flies were always bothering him/her in the room. The flies were also bad at night and was frustrating because they landed on the drink cups.
3. Observation on 04/14/25 at 12:17 P.M., of Room A7 showed:
- Four flies flew around the room.
4. Observations on 04/15/25 at 9:15 A.M., 04/16/25 at 1:22 P.M., and 04/17/25 at 11:01 A.M., of Room A9 showed:
- Six flies flew around the room.
During an interview on 04/17/25 at 11:04 A.M., the resident in Room A9 said he/she would like the flies to be removed, and he/she felt like the room was dirty because the flies were in there. The flies buzzed around him/her and landed on the bed and the drink cups. It was frustrating.
During an interview on 04/17/25 at 1:15 P.M., Licensed Practical Nurse (LPN) D said issues with flies in Room A9 had started to get worse since the weather changed. He/She had mentioned the concern during a staff meeting about a month ago. The issue had not been resolved and the flies were still in the room and on the halls.
5. Observations on 04/15/25 at 9:45 A.M., and 04/17/25 at 1:54 P.M., of Room C42 showed:
- Four flies flew around the room.
During an interview on 04/15/25 at 9:47 A.M., the resident in Room C42 said there had been an ongoing problem with flies and bugs in his/her room. It was frustrating because it was difficult to get rid of the bugs and he/she had mentioned it to staff already.
6. Observations on 04/15/25 at 9:55 A.M., and 04/17/25 at 2:00 P.M., of the C Hall dining area showed:
- Four flies flew around the room.
During an interview on 04/15/25 at 9:53 A.M., Housekeeper G said there were light traps in the kitchen and the dining area, but he/she was not sure if they worked. The flies were bad this time of year in the facility and the smoking door was left open. Flies were always in the building and the maintenance department oversaw checking the bug lights. Issues with pests in the facility should be reported to the maintenance department or the supervisor. There were forms where pest concerns should be logged.
During an interview on 04/17/25 at 10:36 A.M., the Maintenance Director said that he/she conducted inspections for lighting and pests. There were seven bug lights that should attract and kill the flies. One light in the kitchen was a different brand and he/she was not sure if the pest control company took care of it. There were six others on the halls, kitchen, and the dining room. There were two bug lights that were not working. There were four lights that weren't powered up. A light was replaced in one, but it still didn't work. The flies had not been out of control until it started warming up and they started coming in. It was a constant battle with the flies due to the environment.
During an interview on 04/17/25 at 11:12 A.M., Housekeeper H said he/she had told nursing staff when he/she had seen flies or pests but wasn't told to log pests in a binder.
During an interview on 04/17/25 at 3:05 P.M., the Administrator said the flies should be kept under control by the pest control company. The staff should be adding the fly and pest problems to the pest log since there was a problem with flies. They had been discussing the issue with pest control in meetings. The other pest control company was not satisfying the needs of the facility. They had a new pest control company starting tomorrow.
CONCERN
(F)
📢 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 F0727
(Tag F0727)
Could have caused harm · This affected most or all residents
Based on interview and record review, the facility failed to provide a Registered Nurse (RN) for eight consecutive hours per day, seven days a week. This deficiency had the potential to affect all res...
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Based on interview and record review, the facility failed to provide a Registered Nurse (RN) for eight consecutive hours per day, seven days a week. This deficiency had the potential to affect all residents residing in the facility. The facility census was 91.
Review of the facility's policy titled, Nursing Staff, undated, showed:
- The facility must use a RN for at least eight consecutive hours a day, seven days a week.
Review of the facility's Facility Assessment Tool, last reviewed 07/09/24, showed:
- Did not address RN staffing.
Review of the Center for Medicare & Medicaid Services (CMS) Payroll Based Journal (PBJ) staffing data Report from the Community Assessment for Public Health Emergency Response (CASPER) REPORT 1705D for the fiscal year quarter 1, 2025 (October 1, 2024 to December 31, 2024) showed:
- Triggered four or more days within the quarter with no RN hours;
- One day in October 2024 for 10/10/24;
- One day in November 2024 for 11/17/24;
- Four days in December 2024 for 12/13/24, 12/21/24, 12/25/24 and 12/27/24.
The facility did not provide Nursing Schedules for October and November 2024.
Review of the Nursing Assignment Sheets, dated 10/01/24 through 11/30/24, showed:
- No RN worked for eight consecutive hours on 10/23/24, 10/24/24, 10/25/24, 11/14/24, 11/17/24, 11/21/24, 11/22/24, 11/28/24 and 11/29/24;
- Nine opportunities out of 61 opportunities missed.
Review of the Nursing Schedules, dated 12/01/24 through 12/31/24, showed:
- No RN scheduled for eight consecutive hours on 12/15/24, 12/20/24, 12/21/24, 12/23/24, 12/24/24, and 12/25/24.
- Six opportunities out of 31 opportunities missed.
Review of the Nursing Schedules, dated 02/02/25 through 04/17/25, showed;
- No RN scheduled for eight consecutive hours on 02/14/25, 02/15/25, 02/16/25, 02/20/25, 02/21/25, 02/27/25, 02/28/25, 03/01/25, 03/02/25, 03/07/25, 03/12/25, 03/15/25, 03/21/25, 03/22/25, 03/23/25, 03/26/25, 03/27/25, 03/28/25, 03/29/25, 03/30/25, 04/01/25, 04/04/25, 04/08/25, 04/09/25, 04/10/25, 04/11/25, 04/16/25, and 04/17/25;
- 28 opportunities out of 75 opportunities missed.
Review of the Nursing Assignment Sheets and time sheets, dated 02/02/25 through 04/17/25 showed:
- No RN worked eight consecutive hours on 02/14/25, 02/15/25, 02/16/25, 02/20/25, 02/21/25, 02/27/25, 02/28/25, 03/01/25, 03/02/25, 03/07/25, 03/12/25, 03/15/25, 03/21/25, 03/22/25, 03/23/25, 03/26/25, 03/27/25, 03/28/25, 03/29/25, 03/30/25, 04/01/25, 04/04/25, 04/08/25, 04/09/25, 04/10/25, 04/11/25, 04/16/25, and 04/17/25;
- 28 opportunities out of 75 opportunities missed.
During an interview on 04/17/25 at 2:30 P.M., the Administrator said the facility did not have a RN scheduled on the listed dates. The facility had three RNs that only worked as needed or a few days a week. The facility had not used agency staff for a long time. The facility had RN openings which were advertised.
Oct 2024
1 deficiency
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Transfer Requirements
(Tag F0622)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide an appropriate facility-initiated discharge notice, failed ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide an appropriate facility-initiated discharge notice, failed to provide an appropriate discharge plan prior to providing the discharge notice, failed to reassess a resident's status after being discharged from an acute care hospital, and refused to allow one resident (Resident #1) to return to the facility. The sample size was five residents. The facility census was 80.
Record review of the facility's undated Discharge Policy showed:
1. The facility must permit each resident to remain in the facility, and not discharge the resident from the facility unless:
- The resident's welfare and needs cannot be met in the facility;
- The resident's health has improved sufficiently so no longer needs services provided by the facility;
- The safety of individuals in the facility is endangered due to the clinical or behavioral status of the resident;
- Health of individuals in the facility would otherwise be endangered.
- The resident has failed, after reasonable and appropriate notice, to pay for (or to have paid under Medicare or Medicaid) a stay at the facility;
- The facility ceases to operate.
2. The facility may not transfer or discharge the resident while an appeal is pending.
3. The facility must ensure the discharge is documented in the resident's medical record, including:
- Physician's order for the discharge;
- Basis for the transfer;
- Specific resident needs that cannot be met, facility attempts to meet the resident needs, and the service available at the receiving facility to meet the needs.
1. Review of Resident #1's Pre-admission Screening/Resident Review (PASRR) Level II Evaluation, dated 04/13/12, showed:
- The resident's needs could be met in a nursing facility;
- The resident did not need specialized services beyond those typically provided by a nursing facility;
- Diagnoses include schizoaffective disorder (a mental health condition where people experience psychosis as well as mood symptoms);
- A history of facility placement since childhood due to adult abuse;
- Had a legal guardian;
- History of verbal aggression.
Review of the resident's medical record showed:
- admitted on [DATE];
- Diagnoses of schizoaffective disorder (a mental health condition including schizophrenia and mood disorder symptoms), Type II Diabetes (a long-term condition resulting in too much sugar in the blood) Chronic Obstructive Pulmonary Disease (COPD) (a group of diseases that block airflow and make it difficult to breathe);
- Had a legal guardian (a court appointed person who had the authority to make decisions for a person);
- The resident was delusional and had episodes of reliving a family member's homicide;
- On 10/10/24, the nursing notes showed the resident was very happy and talking delusional. He/she was carrying a bag with a teddy bear and showing it to staff;
- On 10/11/24 the resident was sent to the hospital for evaluation and treatment of an altered mental status;
- No documentation of any harmful behaviors of the resident prior to discharge to the hospital;
- No documentation from the physician regarding the specific needs or services the current facility cannot meet;
- No documentation from the physician of the efforts the facility had attempted in meeting those needs;
- No documentation from the physician of the specific services the receiving facility would provide that the current facility could not;
- No documentation of a discharge plan prior to providing the discharge notice to the resident and/or the resident's legal guardian;
- No documentation of the facility's reassessment of the resident's status after being discharged from the hospital.
Review of the resident's discharge Minimum Data Set (MDS - a federally mandated assessment instrument required to be completed by the facility staff), dated 10/11/24 showed the resident was discharged with return not anticipated.
Review of the resident's Notice of Discharge for Emergency Situation - Safety of Individuals Endangered, dated 10/11/24, informed the resident and his/her legal representative the reason behind the discharge was the facility could no longer meet the resident's needs and the safety of others in the facility were endangered by the resident's continued presence. The letter went on to say the safety of others was compromised by Resident #1's refusal of treatments, need for security guards for safety during treatment at the hospital, altercations with other residents, false accusations against other residents and making threats to harm self and others. The resident was discharged to the hospital. There was nothing in the letter from the physician.
Review of the resident's Physician Order Sheet (POS) dated October 2024 showed:
- The resident Physician Order Sheet (POS) dated October 2024 showed on 10/11/24 an order to send to hospital for evaluation and treatment;
- An order dated 10/08/24 for Divalproex Delayed Release (a drug used to treat Schizophrenia) 500 Milligram (MG) three times daily:
- An order dated 04/18/24 for Amlodipine (a drug used to treat high blood pressure)10 mg in the morning;
- An order dated 10/08/24 for Clozapine (a drug used to treat Schizophrenia) 50 mg in the morning.
Review of the resident's Medication Treatment Record (MAR) dated October 2024 showed:
- Divalproex Time Delayed 500 mg - two missed doses out of three on 10/09/24 and two missed doses out of three on 10/11/24;
- Amlodipine 10 mg - one missed dose on 10/09/24;
- Clozapine 50 mg - one missed dose on 10/09/24.
During an interview on 10/31/24 at 1:00 P.M., the Director of Nurses (DON) said the resident was sent to the hospital for a mental status change evaluation. The resident was taken by a staff member to the hospital. The staff member reported the resident threatening to kill the staff member on the way to the hospital. The resident did not ever become physical with the staff member. The hospital security had to help remove the resident from the vehicle. The staff member called the corporate office and spoke with the corporate nurse (CN). It was then decided to do an emergency discharge with the resident.
During an interview on 10/31/24 at 1:25 P.M., Certified Nurse Aide (CNA A) said the resident was threatening to kill him/her on the drive to the hospital. At the hospital the security guard assisted the resident in the building because the resident would not allow CNA A to help. Originally, the resident refused care at the hospital but calmed and allowed it. CNA A said he/she called the CN. CNA A did not say why he/she called the CN instead of the DON. The CN told CNA A, the facility would not be taking the resident back.
During an interview on 10/31/24 at 2:00 P.M., the DON said when Resident #1 left the building it was the intention to bring him/her back. The resident had not exhibited any physical aggression with residents or staff. The resident was not considered a danger to self or others, was just exhibiting delusional behaviors. The hospital called and said the resident was fine to return. The DON said he/she was informed the CN had made the decision to not accept the resident back based on the resident's behavior at the hospital.
During an interview on 11/04/24 at 7:50 A.M., the Licensed Clinical Social Worker (LCSW) from the hospital said the resident was transported to the hospital. The resident was assisted from the car by a security guard into the hospital with no issue. The resident was seen and evaluated and found to be pleasantly delusional. The facility staff member stayed in the parking lot in a parked car. Upon determining that the resident would be discharged back to the facility the staff left the parking lot. At this time, the LCSW began to reach out to the facility and received no answer. The CN then sent information by fax to the hospital. The hospital tried to tell the facility the resident was fine to return to the facility and they refused to accept the resident back.
Complaint #MO243467
Oct 2024
1 deficiency
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Free from Abuse/Neglect
(Tag F0600)
Could have caused harm · This affected 1 resident
Refer to Event ID J4LN14 for SOD as F600 is part of uncorrected survey visit.
This deficiency is uncorrected. For previous examples, refer to the Statement of Deficiencies dated 07/18/24, and 09/20/2...
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Refer to Event ID J4LN14 for SOD as F600 is part of uncorrected survey visit.
This deficiency is uncorrected. For previous examples, refer to the Statement of Deficiencies dated 07/18/24, and 09/20/24.
Based on observation, interview, and record review, the facility failed to ensure two residents (Residents #2 and #4) were free from physical abuse when Resident #1 physically assaulted Resident #2 and Resident #4 in two separate incidents. Resident #2 was knocked out of his/her wheelchair, hitting their head on the brick building, and requiring an x-ray of their knee. Resident #4 was punched in the face, knocking the resident over with their walker, and requiring them to sent to the hospital for an evaluation for injuries and pain. The facility census was 82.
Sept 2024
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
Free from Abuse/Neglect
(Tag F0600)
A resident was harmed · This affected 1 resident
Refer to Event ID J4LN13 for SOD
Complaint #MO241216
This deficiency is uncorrected. For previous examples, refer to the Statement of Deficiencies dated 07/18/24.
Based on observation, interview, and ...
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Refer to Event ID J4LN13 for SOD
Complaint #MO241216
This deficiency is uncorrected. For previous examples, refer to the Statement of Deficiencies dated 07/18/24.
Based on observation, interview, and record review, the facility failed to ensure one resident (Resident #8) was free from physical abuse when Resident #7 punched Resident #8 in the back of the head after an earlier verbal altercation. This resulted in Resident #8's head going forward and smacking his/her face into the medication cart. This caused bruising and swelling to Resident #8's cheek bone. The facility census was 83.
SERIOUS
(G)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Actual Harm - a resident was hurt due to facility failures
Deficiency F0658
(Tag F0658)
A resident was harmed · This affected 1 resident
Refer to Event ID J4LN13 for SOD.
Complaint #MO241561 and 241643
This deficiency is uncorrected. For previous examples, refer to the Statement of Deficiencies dated 04/16/24 and 06/11/24.
Based on obs...
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Refer to Event ID J4LN13 for SOD.
Complaint #MO241561 and 241643
This deficiency is uncorrected. For previous examples, refer to the Statement of Deficiencies dated 04/16/24 and 06/11/24.
Based on observation, interview and record review, the facility failed to ensure staff followed professional standards of practice when staff did not check on one resident (Resident # 6) out of six sampled residents for over seven hours on the night shift. The resident had fallen around midnight and lay on the floor of his/her bedroom until staff entered the resident's room at 6:55 A.M. The facility also failed to identify, assess, and care plan interventions related to falls. The facility census was 83.
Jul 2024
3 deficiencies
1 IJ
CRITICAL
(J)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Immediate Jeopardy (IJ) - the most serious Medicare violation
Free from Abuse/Neglect
(Tag F0600)
Someone could have died · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview, the facility failed to ensure one resident (Resident #2) was free from physic...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview, the facility failed to ensure one resident (Resident #2) was free from physical abuse, and 11 other vulnerable residents at an increased likelihood for abuse to occur when facility staff placed residents with a history of physical and verbal altercations and unstable, aggressive behaviors towards other residents, on the secured unit which housed 12 residents with dementia, receiving hospice care, or requiring total care from staff. The aggressive residents were placed on the secured unit for 24 hours to 5 days until the administrator felt they were no longer a risk to residents outside the locked unit. Resident #1 was placed on the secured unit after returning from a hospital evaluation due to physical aggression. Resident #1 got in an altercation with Resident #2, a resident on the secured unit for safety and dementia care. Resident #1 pushed Resident #2 into the toilet. Resident #2 sustained bruising to his/her face. The census was 88.
On 07/09/24 at 4:00 P.M., the Administrator was notified of the immediate jeopardy (IJ) which began on 06/23/24. The IJ was removed on 07/09/24, as confirmed by surveyor onsite verification.
Record review of the facility undated Abuse policy showed:
- The facility will ensure that each resident is free from abuse, neglect, misappropriation of resident property, and exploitation. This includes but is not limited to freedom from verbal, mental, sexual, or physical abuse, corporal punishment, involuntary seclusion and physical or chemical restraint not required to treat a resident's medical symptoms;
- The facility will ensure the resident is free from physical or chemical restraints imposed for purpose of discipline or convenience and that are not required to treat the resident's medical symptoms.
The facility did not provide a policy regarding the criteria for placement on the secured unit.
1. Record review of Resident #1's annual Minimum Data Set (MDS), a federally mandated assessment instrument required to be completed by the facility staff, dated 05/28/24 showed:
- admission to facility on 09/10/22;
- Diagnoses of Schizophrenia (symptoms can include delusions, hallucinations, disorganized speech, trouble with thinking and lack of motivation), bipolar (a condition causing uncontrolled mood swings), depression, and Mild Intellectual Disability (significant impairment and adaptive functioning);
- Cognition intact;
- Requires supervision of one staff with activities of daily living (ADLs);
- Receives antipsychotic (medication that alter brain chemistry to help reduce psychotic symptoms like hallucinations, delusions and disordered thinking), depression, and antidepressant medications seven days a week on a routine basis;
- Guardian in place.
Review of Resident #1's care plan, originally developed on 06/02/22 and updated on 03/01/24, showed:
- The resident has the potential to be physically aggressive (outbursts, impatient, agitated at others and a history of verbal and physical altercations) related to anger. History of harm to other and poor impulse control;
- The resident has the potential to be verbally aggressive (yelling, screaming) related to ineffective coping skills, mental/emotional illness, poor impulse control, outbursts at others when not getting what asked for right away due to forgetfulness and repetition;
- The resident has a communication problem related to language barrier, unspecified intellectual disabilities, and short-term memory loss;
- No new interventions since 06/02/22;
- No mention of assessing for the appropriateness of placement on the secured unit.
- Record review of Resident #1's emergency room record dated 6/23/2024 showed:
- The resident was sent to the emergency room for aggression with other residents;
- The resident returned to the facility the same date with a diagnosis of medically cleared to return.
Record review of the Resident #1's emergency room record dated 7/4/2024 showed:
- The resident was sent to the emergency room for aggressive behavior with a resident on the secured unit;
- The resident told the hospital he/she had been in a physical altercation with a resident and had exposed him/herself to the facility staff and said suck my dick;
- The resident displayed poor ability to handle stressors;
- The resident was discharged back to the facility as chronic schizophrenia with aggressive response.
During an interview on 07/09/24, at 12:15 P.M., Resident #1 said he/she had been placed on the unit 06/23/24 through 07/04/24 because of previous aggressive behaviors with other residents. He/she said when a resident is aggressive, they are sent out to the emergency room and when they come back are placed on the secured unit. He/she said this is to keep residents on the regular hall safe until the resident can calm down. Resident #1 said he/she does not remember hitting Resident #2 on 07/04/24. The resident said he/she probably did hurt Resident #2, but does not remember.
2. Review of Resident #2's medical record showed:
- admission date of 02/02/24;
- Diagnoses included alcohol induced persistant dementia, dementia with severe behavioral disturbances
Record review of Resident #2's quarterly MDS, dated [DATE] showed:
- Severe cognitive impairment;
- Requires supervision of one to two staff with ADLs;
- Receives antipsychotic, depression, and antidepressant medications seven days a week on a routine basis;
- Guardian in place.
Review of Resident #2's care plan, updated 02/04/24, showed the resident cannot communicate, wanders and has the potential to be physically aggressive (hit, kick, push others) related to dementia. Interventions included to anticipate needs and monitor/document/report as needed any sign or symptom of resident posing a threat to him/herself or others.
Review of Resident #2's Skin Evaluation note, dated 07/05/24, showed noted bruising to the resident's face from a previous altercation with another resident.
Observation on 07/09/24 at 5:15 P.M., showed the resident wandering on the secured unit hallway. The resident was confused and unable to communicate. The resident wandered into other resident's rooms and had to be redirected by staff.
Review of the facility's self-report of resident to resident abuse, dated and received in the regional office on 07/04/24 showed:
- A written statement by Housekeeping Staff (HS) A, dated 07/04/24 at 10:30 A.M. HS A heard a commotion in the bathroom between rooms [ROOM NUMBERS] on the secured unit. HS A immediately went and found staff, Certified Nurse Aid (CNA) A;
- A written statement by CNA A, dated 07/04/24 at 10:30 A.M., showed HS A reported to CNA A of hearing loud banging in the bathroom between rooms [ROOM NUMBERS]. CNA A and HS A immediately went to the room and found Resident #1 had Resident #2 shut in the bathroom saying Stay the fuck out of my room. CNA A attempted to explain to Resident #1 that Resident #2 had dementia and was very confused, but Resident #1 did not seem to care and continued to be very angry about the situation;
- The administrator and investigator concluded Resident #1 pushed/shoved Resident #2 into his/her bathroom onto the toilet when Resident #2 went into his room by accident. There were no witnesses for the incident, however, HS A did hear and report this immediately. No injuries noted for Resident #1. Resident #2 noted to have faded bruising to face after the altercation;
- Final interventions included:
- Separated both residents
- Resident #1 sent out for an evaluation
- Resident #1 moved to B-Hall (non-secured unit)
- Resident #1 placed on 15 min face checks for 24-Hours following re-admission from evaluation
- Both residents assessed by nursing for injuries
- Residents' doctor and responsible parties made aware of incident.
Observation on 07/09/24 at 5:15 P.M., showed the resident wandering on the secured unit hallway. The resident was confused and unable to communicate. The resident wandered into other resident's rooms and had to be redirected by staff.
During an interview on 07/03/24 at 5:15 P.M., Licensed Practical Nurse (LPN) A said Resident #2 wanders the hallway on the secured unit. He/she does have to be redirected when he/she enters other resident rooms.
During an interview on 08/07/24 at 9:00 A.M., CNA A said on 07/04/24 HS A called out to him/her due to a commotion and noise in the adjoining bathroom between rooms [ROOM NUMBERS]. CNA A went to the room to find Resident #1 holding the bathroom door shut, trapping Resident #2 in while yelling stay the fuck out of my room. CNA A attempted to redirect Resident #1, but the resident remained angry. Resident #1 was able to be removed and the residents were separated. Resident #2 appeared to have red marks on his/her wrist. CNA A said it appeared Resident #1 had grabbed and held Resident #2's wrist and forced Resident #2 into the bathroom and held the door shut. CNA A said Resident #2 wanders all the time. CNA A said it does not seem safe to place the aggressive residents on the secured unit. The staff do 15 minute checks on the secured unit.
3. Review of the resident room roster, provided by the facility, showed a total of 15 residents on the secured unit. The roster showed Residents #1, #3, #4, and #5 on the unit for temporary behavior monitoring. Resident #2 and 11 additional residents lived on the secured unit on a full time basis. Review of the records for those 11 residents showed the following:
- All 11 residents had moderate to severe cognitive impairment;
- All 11 residents needed the secured unit for increased supervision;
- Three of the 11 residents wandered and had to be redirected;
- Two of the 11 residents received hospice care for terminal illness.
Observations and interviews showed:
- On 07/09/24 from 11:30 A.M., through 6:30 P.M., Resident #3 resided on the secured unit. During an interview on 07/09/24 at 11:30 A.M., Resident #3 said he/she will be on the secured unit until Friday of this week due to being in an altercation with other residents on the unsecured hall. Resident #3 said the residents who live on the secured unit all the time are really confused or really sick. Resident #3's medical record showed no documentation or an assessment showing why the resident was placed on the secured/locked unit and no care plan for placement on the secured unit.
- On 07/09/24, Resident #4 resided on the secured unit. During an interview on 07/09/24 at 11:20 A.M., Resident #4 said he/she was placed on the secured unit as punishment for hitting another resident. The resident said he/she was not asked or given a choice of moving on the unit or not. Resident #4 said the residents who live full time on the secured unit are very confused and can't do much for themselves. The resident's record showed no documentation or an assessment showing why the resident was placed on the secured/locked unit and no care plan for placement on the secured unit;
- On 07/09/24, Resident #5 resided on the secured unit. During an interview on 07/09/24 at 11:45 A.M., Resident #5 said he/she was placed on the secured unit as punishment for hitting another resident. The resident's record showed no documentation or an assessment showing why the resident was placed on the secured/locked unit and no care plan for placement on the secured unit.
4. During an interview on 07/09/24 at 2:15 P.M., LPN A said every resident who is the aggressor in an altercation is placed on the secured unit for a minimum of 24 hours with 15-minute checks by staff on the unit. This is done under the direction of the Administrator, and he/she is the only staff who can decide if the resident is removed from the unit after 24 hours. There is no criteria that he/she is aware of that is used for placement on the secured/locked unit. The normal placement of residents on that unit are hospice residents, residents who need increased supervision due to wandering, confusion and/or medically increased need for assistance with ADLs. The residents who reside on the secured unit full time are the most vulnerable.
During an interview on 07/09/24 at 3:00 P.M., the Administrator said residents who are the aggressors in a situation or incident are automatically placed on the secured unit. Residents are not given a choice. The facility does not have the capability to provide one on one care to keep residents separated and or safe from one another after an altercation. The Administrator said he had not thought of the safety of the other vulnerable residents residing on the secured unit due to aggressors are medically cleared before being placed on the unit. There is no criteria for placement and/or when removed from unit, it is at his discretion. The administrator said he/she does not a background in psychiatric care and has not received any special training.
During an interview on 07/09/2024 at 3:45 P.M., the Director of Nursing said he/she has concerns related to aggressive residents being placed on the secured unit with other residents who are incapable of protecting themselves, although it is the Administrator's direction to do so after an altercation. The Administrator told him/her, moving the residents to their secured unit is an intervention for bad behavior and not intended to be punishment.
During an interview on 7/11/2024 at 5:20 P.M., the facility Psychiartrist said he was not aware that all residents who are aggressive were being placed on the secured unit after going to the emergency room. He believes this is not a good practice, but believes the Administrator is attempting to keep residents on the regular hall safe. He stated placing a resident on one one one is a better practice. When asked, he agreed taking a resident with a psychiatric diagnosis and forcing them to a locked unit and secluding them without a choice could promote aggressive behaviors. He stated he believes he can work with the facility to try to find a safer method to keeping the aggressive residents from harming others.
NOTE: At the time of the survey, the violation was determined to be at the immediate and serious jeopardy level J. Based on interview and record review completed during the onsite visit, it was determined the facility had implemented corrective action to address and lower the violation at the time. A revisit will be conducted to determine if the facility is in substantial compliance with participation requirements.
At the time of exit, the severity of the deficiency was lowered to the D level. This statement does not denote that the facility has complied with State law (Section 198.026.1 RSMo.) requiring that prompt remedial action be taken to address Class I violation(s).
Complaint # MO238516
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 F0603
(Tag F0603)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure three residents (Residents #3, #4, and #5) of 1...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure three residents (Residents #3, #4, and #5) of 10 sampled residents were free from involuntary seclusion. The facility failed to have a policy or system in place to identify clinical criteria for placing a resident in a secured/locked area. The facility failed to ensure placement on the unit was not for staff convenience or discipline. The facility to document clinical criteria in the resident's record for placement on the secured unit and ensure the resident's physician and members of the interdisciplinary team were involved in the assessment. The facility census was 88.
1. Record review of the facility undated Abuse policy showed:
- The facility will ensure that each resident is free from abuse, neglect, misappropriation of resident property, and exploitation. This includes but is not limited to freedom from verbal, mental, sexual, or physical abuse, corporal punishment, involuntary seclusion and physical or chemical restraint not required to treat a resident's medical symptoms;
- The facility will ensure the resident is free from physical or chemical restraints imposed for purpose of discipline or convenience and that are not required to treat the resident's medical symptoms.
The facility did not provide a policy on the criteria for admission to the secured unit.
2. Record review of Resident #3's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument required to be completed by the facility staff, dated 06/28/24 showed:
- admission to facility on 12/14/23;
- Diagnoses of schizophrenia (symptoms can include delusions, hallucinations, disorganized speech, trouble with thinking and lack of motivation), bipolar (a condition causing uncontrolled mood swings), and depression;
- Cognition intact;
- No hallucinations or delusions;
- Physical and verbal behavioral symptoms 1-3 days a week;
- Requires supervision of one staff with activities of daily living (ADLs);
- Receives antipsychotic (medication that alter brain chemistry to help reduce psychotic symptoms like hallucinations, delusions and disordered thinking), depression, and antidepressant medications seven days a week on a routine basis;
- Guardian in place.
Observations on 07/09/24 showed from 11:30 A.M., through 6:30 P.M., the resident resided on the secured unit.
During an interview on 07/09/24 at 11:30 A.M., Resident #3 said he/she will be on the secured unit until Friday of this week due to being in an altercation with other residents. The resident said he/she was not asked if he/she wanted to be placed on the secured unit and was unsure if his/her guardian was aware of the placement. Resident #3 said the facility always puts him/her on the unit after altercations if he/she is the one doing the hitting.
Review of #3's resident medical record showed no documentation for:
- An assessment to be placed on the secured unit;
- The resident/guardian involvement in the decision for placement on the secured unit;
- No documentation on the resident's care plan for interventions for placement on the secured unit or criteria to be placed on the secured unit.
3. Review of Resident #4's quarterly MDS, dated [DATE], showed:
- admission to facility on 12/23/21;
- Diagnoses of schizophrenia, anxiety, and post-traumatic stress disorder (PTSD) (a disorder that develops in some people who have experienced a shocking, scary, or dangerous event);
- Cognition intact;
- No hallucinations or delusions;
- No physical, verbal, and or other behavioral symptoms;
- Requires supervision of one staff with ADLs;
- Receives antipsychotic, depression, and antidepressant medications seven days a week on a routine basis;
- Guardian in place.
Review of Resident #4's medical record showed no documentation for:
- An assessment to be placed on the secured unit;
- The resident/guardian involvement in the decision for placement on the secured unit;
- No documentation on the resident care plan for interventions for placement on the secured unit or criteria to be placed on the secured unit.
During an interview on 07/09/24 at 11:20 A.M., Resident #4 said he/she was placed on the secured unit as punishment for hitting another resident. The resident said he/she was not asked or given a choice of moving on the unit or not.
4. Review of Resident #5's quarterly MDS, dated [DATE], showed:
- admission to facility on 01/13/23;
- Diagnoses of schizophrenia, anxiety, and seizure disorder;
- Cognition intact;
- No hallucinations or delusions;
- No physical, verbal, and or other behavioral symptoms;
- Requires supervision of one staff with ADLs;
- Receives antipsychotic, depression, and antidepressant medications seven days a week on a routine basis;
- Guardian in place.
Review of Resident #5's medical record showed no documentation for:
- Criteria to be placed on the secured unit;
- The resident/guardian involvement in the decision for placement on the secured unit;
- No documentation on the resident care plan for interventions for placement on the secured unit or criteria to be placed on the secured unit.
During an interview on 07/09/24 at 11:45 A.M., Resident #5 said he/she was placed on the secured unit as punishment for hitting another resident.
During an interview on 7/18/24 at 9:15 A.M., Resident #5's guardian said he/she was aware of the facility placing the resident on the locked unit, but was under the understanding this was the only option the facility had to use. He/she would like to see other interventions used before locking the resident up.
5. During an interview on 07/09/24, Licensed Practical Nurse (LPN) A said every resident who is the aggressor in an altercation, is placed on the secured unit for a minimum of 24 hours with 15-minute checks by staff on the unit. This is done under the direction of the Administrator, and he/she is the only staff who can decide if the resident is removed from the unit after 24 hours. There is no criteria that he/she is aware of that is used for placement on the secured unit. The normal placement of residents on that unit are hospice residents, residents who are in need of increased supervision due to wandering, confusion and/or medically increased need in assistance with ADLs. The residents who live on the secured unit full time are those most vulnerable in the facility's population.
During an interview on 07/09/24 at 3:00 P.M., the Administrator said residents who are the aggressors in an altercation are automatically placed on the secured unit, residents are not given a choice. The facility does not have the capability to provide one on one care to keep residents separated and or safe from one another after an altercation. The Administrator said he had not thought of the safety of the more vulnerable residents residing on the unit due to aggressors are medically cleared before being placed on the unit. There is no criteria for placement and/or when removed from unit, it is at his discretion. The administrator said he/she does not a background in psychiatric care and has not received any special training.
During an interview on 07/09/24 at 3:45 P.M., the Director of Nursing (DON) said she has concerns related to aggressive residents being placed on the secured unit with residents who are incapable of protecting themselves. The DON said she had not been at the facility very long, but understood putting residents on the unit after an altercation was an intervention for bad behavior and not intended to be punishment.
During an interview on 07/09/24 at 4:00 P.M., Resident #10 said when any residents get into fights, the one who hits first gets placed in the hole referring to the secured unit for punishment.
During an interview on 7/11/24 at 5:20 P.M., Psychiatrist A said he/she was not aware that all residents who act as the aggressor in an altercation were being placed on the secured unit after going to the emergency room. He/She said that is not a good practice, but believed the Administrator is attempting to keep residents on the regular hall safe. He/She agreed that placing a resident on one one one is a better practice. He/She said placing a resident with a psychiatric diagnosis on a locked unit and secluding them without a choice could promote the aggressive behavior. He/She will work with the facility to try to find a safer method to keeping the aggressive residents from harming others.
MO238516, MO238659, MO238661
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Transfer Requirements
(Tag F0622)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide an appropriate facility-initiated discharge notice, failed ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide an appropriate facility-initiated discharge notice, failed to provide an appropriate discharge plan prior to providing the discharge notice, failed to reassess a resident's status after being discharged from an acute care hospital, and refused to allow the resident (Resident #1) to return to the facility out of three sampled residents. The facility census was 88.
The facility did not provide a policy regarding transfers and discharges.
1. Review of Resident #1's Pre-admission Screening/Resident Review (PASRR) Level II Evaluation, dated 08/10/22, showed:
- The resident's needs could be met in a nursing facility;
- The resident did not need specialized services beyond those typically provided by a nursing facility;
- The support services to be provided by the nursing facility were a safe structured environment, developing effective coping skills to proper handle issues with anger, physical aggression and poor impulse control, medication therapy, and a personal support network;
- Diagnoses include schizoaffective disorder (a mental health condition where people experience psychosis as well as mood symptoms), bipolar mood disorder (a mental disorder with periods of elevated moods and depression), epilepsy (a disorder in which nerve cell activity in the brain is disturbed, causing seizures), autistic disorder (a serious developmental disorder that impairs the ability to communicate and interact), developmental disorder of scholastic skills (a condition of significant discrepancy between an individuals perceived level of intellect and their ability to acquire new language and other cognitive skills);
- Had a legal guardian;
- History of aggression and suicidal/homicidal ideation.
Review of the resident's medical record showed:
- admitted on [DATE];
- Diagnoses of bipolar disorder,schizoaffective disorder (a mental health condition including schizophrenia and mood disorder symptoms), epilepsy, autistic disorder, developmental disorder of scholastic skills;
- Had a legal guardian (a court appointed person who had the authority to make decisions for a person);
- The resident was alert, oriented, and cognitive abilities were moderately impaired;
- On 06/18/24 at 7:41 P.M., the resident made his/her way out the dining room door of the unit to the courtyard. He/She went to the smoking courtyard of the open halls and started tearing boards from the fence. A nurse stepped between him/her and the fence to impede his/her destruction. The nurse had his/her back turned toward the resident and he/she struck the nurse with his/her first in the back. Another staff member was able to redirect the resident back into the facility;
- On 06/21/24 at 7:23 P.M., the charge nurse received a call from the hospital the resident would be discharged on back to the facility 06/24/24. The contact information for the Administrator was provided to the hospital and informed hospital staff to contact the Administrator on the morning of 06/24/24, prior to discharge back to the facility;
- The resident's Order Summary, dated 06/18/24, showed it was a necessary discharge from the facility for the resident's welfare and the facility being unable to meet the resident's safety needs. The resident's behavioral status endangered the health and safety of him/herself and others in the facility. The facility was unable to prevent the resident from destroying the fencing, using a fire extinguisher, and using broken fencing to attack staff and him/herself. Other facility residents were endangered by the resident's violent behaviors. Another facility would be better able to Intervene and keep the resident safe;
- No documentation from the physician regarding the specific needs or services the current facility cannot meet;
- No documentation from the physician of the efforts the facility had attempted in meeting those needs;
- No documentation from the physician of the specific services the receiving facility would provide that the current facility could not;
- No documentation of a discharge plan prior to providing the discharge notice to the resident and/or the resident's legal guardian;
- No documentation of the facility's reassessment of the resident's status after being discharged from the hospital;
- No documentation of a written facility initiated discharge notice provided to the resident and/or legal representative upon discharge to the hospital on [DATE].
Review of the resident's discharge Minimum Data Set (MDS - a federally mandated assessment instrument required to be completed by the facility staff), dated 06/19/24, showed:
- discharged to a short-term hospital;
- Unplanned discharge;
- Return to the facility not anticipated.
Review of the resident's Notice of Discharge for Emergency Situation - Safety of Individuals Endangered, dated 06/24/24, showed:
- The notice was addressed to the resident and the resident's legal guardian;
- The notice was faxed and mailed to the resident at the hospital, and emailed and mailed to the resident's legal guardian on 06/24/24;
- This letter is a notice of discharge. After careful evaluation and in consultation with your attending physician, the facility concluded that the safety of other individuals in the facility is endangered by your continued residence and the facility can no longer meet your needs. The reason the safety of individuals in the facility is endangered by your continued residence is evidenced by on June 18, 2024, you tore boards from the fence, expressed physical anger towards a nurse that attempted to redirect you from destructing the facility's property and you struck the nurse on the back with your fist. On June 16, 2024, you broke planks off the exterior fence, removed a fire extinguisher, made threats, exited the facility multiple times, refused to return to the facility while standing along a wooded area outside the facility and were sent to the hospital. On June 15, 2024, you made threats to harm another resident, removed a fire extinguisher and threatened to use it to harm another resident, and were transported by officers to the hospital. On June 12, 2024, you made threats to physically harm another resident with a fire extinguisher and were sent to hospital. It is the responsibility of the facility to provide a safe environment for all residents in which to live. The reason the facility can no longer meet your needs is evidenced by the resident inflicting self harm and suicide threats with actions. It is the responsibility of the facility to provide a safe environment for all residents in which to live. The facility can no longer meet your needs as evidenced by your continued leaving of the facility by pushing through the unit gate, breaking down the exterior fence, walking towards the highway and wooded area outside the property, and threats or acts of violence towards other residents and staff;
- The effective date of the discharge is 06/24/24. The facility deems this discharge to be an emergency. The location discharged to is the acute care hospital;
- Discharge location was the hospital;
- No documentation from the physician of the efforts the facility attempted in meeting the resident's needs;
- No documentation from the physician of the specific services the receiving facility would provide that the current facility could not;
- No documentation of a discharge plan prior to providing the discharge notice to the resident and/or the resident's legal guardian.
During an interview on 07/02/24 at 9:40 A.M., the Administrator said the resident had been sent out repeatedly due to behaviors. The resident went to the courtyard and tried to break the boards off the fence. He/She attacked a staff member with a broken board, tried to elope from the facility and attacked others with the fire extinguishers. The resident was sent out to the hospital and when the facility was contacted by the hospital for the resident to be sent back to the facility on [DATE], he contacted an attorney to issue an emergency discharge on [DATE]. He realized they could not prevent the resident from trying to hurt himself/herself and others and from trying to escape outside. The resident really needed to be in a lock down unit. The resident was not allowed to returned to the facility. The resident was still at the hospital as far he knew.
During an interview on 07/02/24 at 11:45 A.M., the Social Services Director said he/she had sent out numerous referrals for the resident, but had not had anyone accept him/her.
During an interview on 08/09/24 at 8:02 A.M., the resident's legal guardian said the resident was still at the hospital and had been there for over a month. The resident didn't need to be at the hospital, but he/she was still there because the legal guardian and the hospital still couldn't find placement for the resident. The facility did not notify him/her of the resident's discharge to the hospital in a timely manner. Multiple times the facility would let him/her know the resident had been sent out to the hospital a few days after he/she had returned back to the facility. The staff said they were busy and didn't have time to notify him/her. The legal guardian did receive the resident's emergency discharge notice from the facility by email on 06/24/24. The legal guardian wanted the resident to go back to the facility from the hospital since he/she had no where else to go.
Complaint #MO238081 and #MO238356
Apr 2024
39 deficiencies
3 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
Free from Abuse/Neglect
(Tag F0600)
Someone could have died · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility staff failed to ensure residents were free from abuse when the ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility staff failed to ensure residents were free from abuse when the maintenance supervisor (MS) grabbed the arm and wrist of one resident (Resident #91) out of 20 sampled residents. The resident had a history of mental health support needs, including behavioral problems. During a behavioral episode, the MS grabbed the resident's arms/wrists and struggled to physically restrain the resident which resulted in bruising to the resident's right upper arm. The facility failed to take appropriate steps to protect the resident from additional abuse and allowed the MS to continue to work around the residents. The facility census was 96.
The administrator was notified on 04/09/24 at 9:50 A.M., of an Immediate Jeopardy (IJ) which began on 04/03/24. The IJ was removed on 04/10/24, as confirmed by surveyor onsite verification.
Review of the facility's policy titled, Abuse, undated, showed:
- Ensure that each resident is free from abuse;
- Abuse - the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish;
- Staff members will observe for possible indicators of abuse;
- Every staff member must immediately report any observed or suspected abuse of a resident;
- The Director of Nursing (DON) will ensure all alleged violations are reported immediately, but not later than two hours after the allegation if the events alleged involve abuse or result in serious bodily injury;
- The facility will ensure that all alleged violations are thoroughly investigated;
- To protect the residents during the abuse investigation, the DON and/or Administrator will reassign or suspend the involved employee at their discretion.
Review of Resident #91's medical record showed:
- admitted on [DATE];
- Diagnoses of post traumatic stress disorder ((PTSD - a mental health condition triggered by a terrifying event), autistic disorder (a serious developmental disorder that impairs the ability to communicate and interact), borderline personality disorder (a mental disorder characterized by unstable moods, behavior and relationships), oppositional defiant disorder (a disorder marked by defiant and disobedient behavior to authority figures), disruptive mood disorder (a condition in which children or adolescents experience ongoing irritability, anger, and frequent, intense temper outbursts), anxiety, and attention deficit hyperactive disorder (ADHD - a chronic condition including attention difficulty, hyperactivity and impulsiveness).
Review of the resident's care plan, updated 03/22/24, showed:
- Behavioral problems (history of manipulation, aggression, aggressive toward others);
- Intervene as necessary to protect the rights and safety of others;
- Approach/speak in a calm manner and divert attention;
- Potential to be physically aggressive;
- When resident becomes agitated, intervene before agitation escalates, guide away from source of distress, engage calmly in conversation;
- If response is aggressive, staff is to walk calmly away and approach later.
Review of the resident's progress notes showed:
- Nurse's note, created on 04/04/24 at 10:09 P.M., showed on 04/03/24 at 7:20 A.M., this nurse was at the B hall nurse's station when he/she heard yelling near the dining area. As he/she walked toward the dining area, the resident was blocking the path of the medication cart and yelling at Certified Medication Technician (CMT) E;
- No additional documentation related to the resident/staff incident on 04/03/24;
- On 04/10/24 at 2:26 P.M., documentation showed a skin evaluation was completed with bruising to the back of the right arm, yellow to green in color, three centimeter (cm) x four cm.
Review of the Administrative Investigation Form, completed on 04/04/24 at 10:30 A.M., showed:
- Resident #91 as the involved resident in an allegation of abuse;
- The Assistant Director of Nursing (ADON) notified the Administrator that a resident said a staff member grabbed him/her by the arm. The Administrator instructed the ADON to watch the camera system, gather statements and have a full body assessment done on the resident;
- The ADON reported he/she watched the camera and there was no indication staff grabbed the resident. Nurse's notes stated no skin issues and did not note bruising;
- The form indicated the State Agency was not contacted;
- The form had no signature of who completed the investigation;
- The Administrator signed the form on 04/09/24.
Review of the Administrative Investigation Form, completed on 04/09/24, showed:
- Follow up from the event 04/04/24, involving Resident #91 and Staff MS;
- The Administrator watched the camera system footage and noted MS did grab Resident #91's arms. MS suspended pending investigation;
- The MS's employment was terminated effective immediately;
- The Administrator signed the form on 04/10/24.
Review of the MS employee record showed:
- Date of hire 12/07/05;
- Last abuse and neglect training 04/28/23;
- No training related to behavior management.
Review of the facility payroll detail for the period of 04/01/24-04/30/24, showed the MS worked the following dates:
- 04/03/24;
- 04/04/24;
- 04/05/24;
- 04/08/24;
- 04/09/24.
Observation on 04/09/24 at 1:00 P.M., of the facility security camera footage, dated 04/03/24, showed:
- At 7:22 A.M., CMT E and Resident #91 walked out of the dining room. CMT E pushed the medication cart down the hall as Resident #91 walked alongside the cart;
- At 7:23:04 A.M., Resident #91 hurriedly walked in front of the medication cart and blocked the movement of the cart. CMT E attempted to move the cart a couple of times, then pushed the cart against the wall. CMT E stood next to Resident #91 talking;
- At 7:23:13 A.M., Licensed Practical Nurse (LPN) H approached CMT E and Resident #91 and walked away at 7:23:40;
- At 7:23:30 A.M., the MS approached and stood to the right of Resident #91;
- At 7:23:45 A.M., the MS walked to the left side of Resident #91 as other staff approached. CMT E moved the medication cart away from the wall, and as he/she turned the cart, the MS stepped in between the medication cart and Resident #91;
- At 7:23:52 A.M., Resident #91 shoved the MS away from the medication cart and the MS stumbled. The MS immediately turned toward Resident #91 and grabbed his/her right upper arm then right wrist. The MS continued to hold onto the resident's wrist until 7:24:06 A.M.;
- At 7:24:19 A.M., the MS walked away.
During an interview on 04/09/24 at 9:50 A.M., the resident said:
- Last week, the resident was very upset and stood in the way of CMT E moving the medication cart;
- The MS grabbed the resident by the arms and left a bruise;
- He/she reported the incident to LPN F on the morning of 04/04/24;
- On the morning of 04/04/24, the day after the incident, LPN F took a picture of the bruise;
- No other staff had interviewed the resident other than LPN F on 04/04/24;
- He/she didn't know if LPN F forgot to report it as he/she had not heard anything.
Observation on 04/09/24 at 9:50 A.M., showed a large bruise on the back of Resident #91's upper right arm.
During an interview on 04/10/24 at 3:59 P.M., CMT E said on 04/03/24, the resident was having behaviors and blocking the medication cart. The MS stepped in to assist in letting him/her move the cart. The resident then shoved the MS, and the MS turned and grabbed the resident's wrist.
During an interview on 04/09/24 at 11:02 A.M., the MS said, I help with behaviors. I'm pretty good at de-escalating the situation. I can usually calm them down. The MS said on 04/03/24 at 7:20 A.M., the resident got loud and blocked CMT E from moving the medication cart. While assisting, the resident shoved the MS and the MS got a hold of the resident's wrists. The MS said he/she had never done anything like that before.
During an interview on 04/09/24 at 11:30 A.M., Certified Nursing Assistant (CNA) G said on 04/03/24 at 7:20 A.M., he/she was bringing breakfast trays back to the kitchen and the resident was blocking CMT E from moving the medication cart and yelling. The MS was trying to block the resident and the resident shoved the MS. The MS turned and grabbed the resident's wrists. A kitchen worker was yelling at the MS to stop.
During an interview on 04/09/24 at 11:39 A.M., the Assistant Dietary Manager (ADM) said on 04/03/24 at 7:20 A.M., the resident was blocking the CMT from moving the medication cart and staff tried to divert him/her. The MS stepped between the resident and the medication cart. The resident shoved the MS, and the MS turned and grabbed the resident's wrist.
During an interview on 04/09/24 at 11:10 A.M., LPN H said on 04/03/24 at 7:20 A.M., he/she was at the nurse's station and heard yelling by the dining room. The resident blocked CMT E from moving the medication cart. There were a lot of people jumbled all around and someone yelled out to let him/her go. LPN H said there were too many people around to see anything. The ADON was not there, and they didn't have a DON. A staff member called and reported it to the ADON the next morning. If staff saw something that was out of line or questionable, they should intervene and notify the ADON or DON immediately.
During an interview on 04/09/24 at 1:20 P.M., the ADON said the incident was reported to him/her on 04/04/24 at 10:29 A.M., via a text by LPN F. The ADON reported the incident to the Administrator. The ADON completed his/her part of the investigation by getting statements and viewing the video. He/She saw nothing on the video to make him/her feel like it was abuse or a reportable incident. He/She did not interview the resident or staff and did not assess the resident.
During an interview on 04/09/24 at 2:32 P.M., the Administrator said her part of the investigation was the follow-up. The ADON had reviewed the video and informed the Administrator it did not show the MS put his/her hands on the resident. It was decided it was not a reportable incident. The Administrator said she honestly believed it did not occur.
During an interview on 04/09/24 at 2:57 P.M., the ADON said he/she was the only person that reviewed the video and missed the part where the resident was grabbed by his/her upper arm. The ADON said the text from LPN F did contain a picture of the bruise on the resident's arm. The ADON did not document anything about it in the medical record and did not make an observation.
During an interview on 04/16/24 at 02:59 P.M., the Medical Director (MD) said he had not been notified of the altercation, and was not aware an abusive situation had occurred between the resident and staff. The MD said he/she did not think the facility could adequately care for some of the resident's behaviors.
NOTE: At the time of the survey, the violation was determined to be at the immediate and serious jeopardy level J. Based on interview and record review completed during the onsite visit, it was determined the facility had implemented corrective action to address and lower the violation at the time. A revisit will be conducted to determine if the facility is in substantial compliance with participation requirements.
At the time of exit, the severity of the deficiency was lowered to the D level. This statement does not denote that the facility has complied with State law (Section 198.026.1 RSMo.) requiring that prompt remedial action be taken to address Class I violation(s).
Complaint #MO235359
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
Investigate Abuse
(Tag F0610)
Someone could have died · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to thoroughly investigate an allegation of staff to resid...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to thoroughly investigate an allegation of staff to resident abuse and failed to implement interventions to prevent further abuse from occurring for one resident (Resident #91) out of 20 sampled residents after the Maintenance Supervisor (MS) grabbed the resident's arm and wrist in a restraining manner that resulted in a physical struggle and bruising to the resident's right upper arm. The facility also failed to follow their policy, resulting in the MS continuing to work around the resident. The facility census was 96.
The administrator was notified on 04/09/24 at 9:50 A.M. of an Immediate Jeopardy (IJ) which began on 04/03/24. The IJ was removed on 04/10/24, as confirmed by surveyor onsite verification.
Review of the facility's abuse policy, undated, showed:
- Ensure that each resident is free from abuse;
- Abuse- the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish;
- Staff members will observe for possible indicators of abuse;
- Every staff member must immediately report any observed or suspected abuse of a resident;
- The Director of Nursing (DON) will ensure all alleged violations are reported immediately, but not later than two hours after the allegation if the events alleged involve abuse or result in serious bodily injury;
- The facility will ensure that all alleged violations are thoroughly investigated;
- To protect the residents during the abuse investigation, the DON and/or Administrator will reassign or suspend the involved employee at their discretion.
Review of Resident #91's medical record showed:
- admitted on [DATE];
- Diagnoses of Post-Traumatic Stress Disorder ((PTSD) a mental health condition triggered by a terrifying event), autistic disorder (a serious developmental disorder that impairs the ability to communicate and interact), borderline personality disorder (a mental disorder characterized by unstable moods, behavior and relationships), oppositional defiant disorder (a disorder marked by defiant and disobedient behavior to authority figures), disruptive mood disorder (a condition in which children or adolescents experience ongoing irritability, anger, and frequent, intense temper outbursts), anxiety, attention deficit hyperactive disorder (a chronic condition including attention difficulty, hyperactivity and impulsiveness).
Review of the resident's care plan, updated 03/22/24, showed:
- Resident #91 has behavioral problems (history of manipulation, aggression, aggressive toward others);
- Intervene as necessary to protect the rights and safety of others;
- Approach/speak in a calm manner; divert attention;
- Resident #91 has potential to be physically aggressive;
- When resident becomes agitated, intervene before agitation escalates, guide away from source of distress, engage calmly in conversation;
- If response is aggressive, staff is to walk calmly away and approach later.
Review of the resident's progress notes showed:
- Weekly skin assessment completed on 04/03/24 at 2:51 P.M., showed no skin issues;
- Nurse's note created on 04/04/24 at 10:09 P.M., (regarding incident on 04/03/24), showed this nurse was at the B hall nurse's station when he/she heard yelling near the dining area. As he/she walked toward the dining area, the resident was blocking the path of the medication cart and yelling at Certified Medication Technician (CMT) E;
- Skin evaluation completed on 04/10/24 at 2:26 P.M., with bruising noted to back of right arm, yellow to green in color, three centimeter (cm) x four cm.
Review of the Administrative Investigation Form, completed on 04/04/24 at 10:30 A.M., showed:
- Resident #91 as the involved resident in an allegation of abuse;
- The Assistant Director of Nurses (ADON) notified Administrator that a resident stated a staff member grabbed him/her by the arm. Administrator instructed ADON to watch the camera system, gather statements and have a full body assessment done on the resident;
- The ADON reported that he/she watched the camera and that there was no indication staff grabbed the resident. Nurse's notes stated no skin issues, did not note bruising;
- The form indicated the State Agency was not contacted;
- The form had no signature of who completed the investigation;
- The Administrator signed the form on 04/09/24.
Review of the Administrative Investigation Form, completed on 04/09/24, showed:
- Follow up from event 04/04/24 involving Resident #91 and staff MS;
- The Administrator watched the camera system footage and noted MS did grab Resident #91's arms. MS suspended pending investigation;
- The MS's employment was terminated effective immediately;
- The Administrator signed the form on 04/10/24.
Review of the facility payroll detail for the period of 04/01/24-04/30/24 showed the MS worked the following dates:
- 04/03/24;
- 04/04/24;
- 04/05/24;
- 04/08/24;
- 04/09/24.
Observation on 04/09/24 at 1:00 P.M., of the facility security camera footage, dated 04/03/24, showed:
- At 7:22 A.M., CMT E and Resident #91 walked out of the dining room. CMT E pushed the medication cart down the hall as Resident #91 walked alongside the cart;
- At 7:23:04 A.M., Resident #91 hurriedly walked in front of the medication cart and blocked movement of the cart. CMT E attempted to move the cart a couple of times then pushed the cart against the wall. CMT E stood next to Resident #91 talking;
- At 7:23:13 A.M., LPN H approached CMT E and Resident #1 and walked away at 7:23:40;
- At 7:23:30 A.M., MS approached and stood to the right of Resident #91;
- At 7:23:45 A.M., MS walked to the left side of Resident #91 as other staff approached. CMT E moved the medication cart away from the wall, and as he/she turned the cart the MS stepped in between the medication cart and Resident #91;
- At 7:23:52 A.M., Resident #91 shoved the MS away from the medication cart and MS stumbled. The MS immediately turned toward Resident #91 and grabbed his/her right upper arm then right wrist. MS continued to hold onto the resident's wrist until 7:24:06 A.M.;
- At 7:24:19 A.M., MS walked away.
During an interview on 04/09/24 at 9:50 A.M., the resident said:
- Last week, the resident was very upset and stood in the way of the CMT E moving the medication cart;
- MS grabbed the resident by the arms and left a bruise;
- He/she said it was reported to Licensed Practical Nurse (LPN) F the next morning;
- The resident stated a picture was taken of the bruise;
- The resident said he/she didn't know if LPN F forgot to report it as he/she had not heard anything.
Observation on 04/09/24 at 9:50 A.M., showed a large bruise on the back of Resident #91's upper right arm.
During an interview on 04/09/24 at 11:02 A.M., the MS said, I help with behaviors. I'm pretty good at deescalating the situation. I can usually calm them down. The MS said on 04/03/24 around 7:20 A.M., the resident got loud and blocked CMT E from moving the medication cart. While assisting, the resident shoved the MS and the MS got a hold of the resident's wrists. The MS said he/she had never done anything like that before.
During an interview on 04/10/24 at 3:59 P.M., CMT E said on 04/03/24 around 7:20 A.M., the resident was having behaviors and blocking the medication cart. The MS stepped in to assist in letting him/her move the cart. The resident then shoved the MS, and the MS turned and grabbed the resident's wrist. The MS usually has a good rapport with the residents and that is the only time he/she had witnessed him/her get a hold of a resident. CMT E told LPN H about the incident afterwards. On 04/04/24 the ADON asked CMT E to write a statement, he/she wrote the statement and sent it by text on 04/04/24 at 01:04 P.M. CMT E said he/she was not interviewed, just asked to write a statement.
During an interview on 04/09/24 at 11:10 A.M., LPN H said on 04/03/24 around 7:20 A.M., he/she was at the nurse's station and heard yelling by the dining room. The resident blocked CMT E from moving the medication cart. There were a lot of people jumbled all around and someone yelled out let him/her go. LPN H said there were too many people around to see anything. The ADON was not there, and they don't have a DON. A staff member called and reported it to the ADON the next morning. If staff sees something that is out of line or questionable, they should intervene and notify the ADON or DON. LPN H did not report the incident to the ADON or Administrator or initiate an investigation.
During an interview on 04/09/24 at 11:30 A.M., Certified Nursing Assistant (CNA) G, said he/she was bringing breakfast trays back to the kitchen on 04/03/24 around 7:20 A.M., and the resident was blocking CMT E from moving the medication cart and yelling. The MS was trying to block the resident and the resident shoved the MS. The MS turned and grabbed the resident's wrists. A kitchen worker was yelling at the MS to stop. CNA G didn't report the incident to anyone.
During an interview on 04/09/24 at 11:39 A.M., the Assistant Dietary Manager (ADM) said on 04/03/24 around 7:20 A.M., the resident was blocking the CMT from moving the medication cart and staff was trying to divert him/her. The MS stepped between the resident and the medication cart. The resident shoved the MS, and the MS turned and grabbed the resident's wrist. The ADM didn't report anything because there were a lot of people and didn't really see anything that needed reported or investigated.
During an interview on 04/09/24 at 1:20 P.M., the ADON said the incident was reported to him/her on 04/04/24 at 10:29 A.M., (over 24 hours after the incident occurred) via a text by LPN F. The ADON reported it to the Administrator. The ADON completed his/her part of the investigation by getting statements and viewing the video. The ADON said he/she saw nothing on the video to make him/her feel like it was abuse or a reportable incident. The ADON said he/she did not interview the resident or staff and did not assess the resident.
During an interview on 04/09/24 at 2:32 P.M., the Administrator said her part of the investigation was the follow-up and she did not interview the resident. An investigation should be started immediately and followed with a determination of abuse or no abuse. The ADON had reviewed the video and informed the administrator it did not show the MS put his/her hands on the resident. It was decided it was not a reportable incident. The Administrator said she honestly believed it did not occur. However, the staff statements showed the MS grabbed the resident's wrists after he/she pushed the MS.
During an interview on 04/09/24 at 2:57 P.M., the ADON said he/she was the only person that reviewed the video and missed the part where the resident was grabbed on the upper arm. The ADON said the text from LPN F did contain a picture of the bruise on the resident's arm. The ADON did not document anything about it in the medical chart and did not make an observation.
During an interview on 04/16/24 at 02:59 P.M., the Medical Director (MD) said he was not aware an abusive situation had occurred between the resident and staff. The MD said he did not think the facility could adequately care for some of the resident's behaviors.
NOTE: At the time of the survey, the violation was determined to be at the immediate and serious jeopardy level J. Based on interview and record review completed during the onsite visit, it was determined the facility had implemented corrective action to address and lower the violation at the time. A revisit will be conducted to determine if the facility is in substantial compliance with participation requirements.
At the time of exit, the severity of the deficiency was lowered to the D level. This statement does not denote that the facility has complied with State law (Section 198.026.1 RSMo.) requiring that prompt remedial action be taken to address Class I violation(s).
Complaint #MO235359
CRITICAL
(J)
Immediate Jeopardy (IJ) - the most serious Medicare violation
Deficiency F0741
(Tag F0741)
Someone could have died · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide a crisis plan for one resident (Resident #91) of 20 sampled...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide a crisis plan for one resident (Resident #91) of 20 sampled residents, as directed from the Pre-admission Screening and Resident Review (PASRR) (a federal requirement to help ensure that individuals who have a mental disorder or intellectual disabilities are not inappropriately placed in nursing homes for long term care). Resident #91, who required supervision due to physical aggression, self-harming behaviors, and mental illness, was observed to have escalating behaviors which resulted in the resident: cutting him/herself with sharpened pencil 01/25/24; laying on top of a closed razor so the staff couldn't confiscate it on 02/16/24; cutting him/herself with a dull piece of broken plastic on 02/25/24; cutting him/herself with a razor on 02/29/24; cutting his/her finger by placing it in an open soda can on 03/27/24; attempting to harm him/herself with a broken piece of a cooler lid on 04/04/24; ingesting hair conditioner on 04/05/24; escaping out of the facility door and running towards the road as a truck drove by the facility on 04/07/24, and cutting him/herself with a screw and a razor on 04/11/24. The facility did not put any interventions into place after each behavior and staff were not aware of or trained on any interventions to intercede in these behaviors. The facility census was 96 residents.
The administrator was notified on 04/12/24 at 9:00 A.M., of an Immediate Jeopardy (IJ) which began on 04/11/24. The IJ was removed on 04/12/24, as confirmed by surveyor onsite verification.
Review of the facility assessment, dated 02/12/23, showed:
- Facility assessment not reviewed annually since 2023;
- No documentation the Quality Assessment and Assurance (QAA) and Quality Assurance Performance Improvement (QAPI) committee reviewed the facility assessment;
- The number of residents with intellectual and/or developmental disability not accurate;
- The behavioral healthcare needs (Including Trauma/PTSD) who have an individualized care plan to be zero and inaccurate;
- The competencies required by the facility did not include behavior health (including PTSD and Trauma History), or meeting the needs of individuals with mental illness/intellectual disability or development disability.
The facility did not provide a policy on Crisis Intervention.
1. Review of Resident #91's Preadmission Screening and Resident Review (PASRR) (a federal program to prevent inappropriate admission and retention of people with mental disabilities in nursing facilities), dated 11/27/23, showed:
- The PASRR Level II indicated the resident's needs can be met in a nursing facility;
- Resident with Post-Traumatic Stress Disorder (PTSD) (a mental health condition triggered by a terrifying event);
- PASRR related disability, serious mental illness, intellectual developmental disability;
- The PASRR Level II indicated the following supports and services are to be provided by the nursing facility, behavioral support services, structured environment, crisis intervention services;
- Behaviors include, impatient, demanding, physically threatening;
- Extensive history of, aggression, self-injurious behaviors, suicide attempts, attention seeking behavior, mood liability, anxiety, depression, impulse control issues, limited insight and judgement, poor decision making skills, and inability to keep self safe;
- The individual needs a provision of services to address the individuals mental health and behavioral needs, obtain Individual Support Plan (ISP), Individualized Treatment Plan (ITP), Behavioral Support Plan (BSP), from Department of Mental Health (DMH) Community Mental Health Center and/or Developmental Disability Regional Office;
- Provision of a structured environment, provide instruction at the individuals level of understanding, environmental supports to prevent elopement, assess and plan for the level of supervision required to prevent harm to self or others, provide individual personal space, provide sensory support, establish consistent routines, provide schedule of daily tasks/activities;
- Crisis intervention services, assess and plan for crisis intervention that provides emotional support, education and safety, it should create clear steps that are taken to support the resident during a behavioral crisis, including who to contact for assistance, how to work together, how to determine when a crisis is over. The plan should also identify a physician and emergency medical services that should be contacted, the facility may also wish to utilize Department of Mental Health Behavioral Health Crisis Hotline;
- Suicide precautions, assault precautions, and elopement precautions;
- The crisis plan is warranted due to the resident has an extensive history of aggression, suicidal ideation, self injurious behaviors and elopements;
- Long term care placement recommended for the resident's safety.
Review of Resident #91's medical record showed:
- admitted on [DATE];
- Diagnoses of PTSD, autistic disorder (a serious developmental disorder that impairs the ability to communicate and interact), borderline personality disorder (a mental disorder characterized by unstable moods, behavior and relationships), oppositional defiant disorder (a disorder marked by defiant and disobedient behavior to authority figures), disruptive mood disorder (a condition in which children or adolescents experience ongoing irritability, anger, and frequent, intense temper outbursts), anxiety, attention deficit hyperactive disorder (a chronic condition including attention difficulty, hyperactivity and impulsiveness).
- Medications prescribed and administered for behavior management;
- No crisis management plan.
Review of Nurse's progress notes, dated 01/25/24 through 04/11/24 showed:
- On 01/25/24, the resident cut him/herself with sharpened pencils;
- On 02/03/24, the resident found with a dull, broken piece of plastic;
- On 02/16/24, the resident noted to be more sad than usual for two days. Resident asked for a razor to shave legs. The nurse was going to go with the resident to supervise but the resident ran to room with the razor. The resident lay on top of a closed razor so the staff couldn't confiscate it;
- On 02/25/24, the resident cut him/herself with a dull piece of broken plastic;
- On 02/29/24, the resident asked if he/she could shave. A Certified Nurse Aide (CNA) was sent to assist the resident with shaving. The resident went into the shower room with a razor and cut him/herself on the arm with a razor. It was witnessed by a CNA, Certified Medication Technician (CMT) and another resident. The CMT obtained the razor and the resident told the CNA he/she did not want to live anymore. Staff spoke with the resident who said if he/she would be sent to the hospital then he/she would say it was an accident. The resident was offered 1:1, but the resident calmed down.
- On 03/12/24, the resident walked down the hall sniffing a marker. Staff requested the marker be handed over to staff so the resident wouldn't [NAME] the marker;
- On 03/13/24, resident #91 initiated an altercation with another resident;
- On 03/14/24, resident #91 interrupted a conversation between a nurse and the other resident involved in the altercation on 03/13/24. Resident #91 became aggressive toward staff, walked down the hall and became aggressive toward the other resident. Due to being the 4th altercation during day shift the resident was sent out to the hospital.
On 03/27/24, the resident put his/her finger in an open soda can and cut his/her finger;
- On 03/29/24, during an Epsom salt foot soak the resident independently removed his/her toe nail from the nail bed of his/her left greater toe. The resident stated the toe nail was loose and was bothering him/her;
- On 04/01/24, the resident rolled out of bed onto the floor hitting his/her head on the floor;
- On 04/03/24, the resident threw dining room chairs against walls in the sitting room;
- On 04/04/24, the resident threw hangers at the Assistant Director of Nursing (ADON), hit CNA in chest and ran to room slamming the door shut and hitting the door repeatedly. Prior to this incident the resident grabbed an ice chest cooler lid with a crack and stated he/she wanted to hurt herself/himself. The resident was sent to the hospital due to wanting to harm self. The resident returned from the hospital. The resident reported he/she turned over in bed and hit his/her head against the bedside table;
- On 04/05/24 the resident wanted to harm him/herself with a broken piece of a cooler lid;
- On 04/05/24 the resident ingested hair conditioner and, after telling staff, moved electric bed into hallway blocking the path to the resident. The resident later told staff he/she had vomited in the toilet but flushed. The resident complained of his/her stomach being upset;
- On 04/07/24 the resident left out of the facility door and ran towards the road as a truck drove by the facility. The resident fought Emergency Medical Services (EMS) staff and sheriff about getting into the ambulance.
- On 04/09/24 the resident had several behaviors. The resident said he/she is not ok;
- On 04/10/24 the resident stated he/she hates feeling like this. Resident asked for an as needed (PRN) medication which was administered. The resident walked into bathroom, given a few minutes for privacy and entered. The resident was tearful saying he/she hates feeling like this. The resident went behind the shower curtain then handed staff a straightened out paperclip. The resident had a superficial scrape to the skin. The resident later ran out of the door into the enclosed courtyard crying that the medication doesn't work;
- On 04/11/24 Resident #91 kicked open a locked supply room closet door. The resident pulled a screw from the wall and wedged self between shelving and wall beginning to scratch self with the screw. The resident said staff shouldn't care about him/her or try to help. The resident injured self with a safety razor obtained from the storage room. The resident refused to allow nurse to apply pressure, but agreed to hold gauze him/herself. The resident was sent out to the hospital.
Review of the resident's care plan, updated 03/22/24, showed:
- Resident #91 has behavior problems (history of manipulation, aggression, aggressive toward other);
- Intervene as necessary to protect the rights and safety of others;
- Approach/speak in a calm manner; divert attention;
- Resident #91 has potential to be physically aggressive;
- When resident becomes agitated, intervene before agitation escalates, guide away from source of distress, engage calmly in conversation;
- If response is aggressive, staff is to walk calmly away and approach later;
- Did not identify the residents triggers;
- Did not address, suicidal ideations, elopements, or self harm with interventions;
- Did not address a crisis plan.
The facility did not put interventions into place after Resident #91's aggressive and self-harming behaviors began to escalate.
During an interview on 04/12/24 at 2:20 P.M., CNA E said the facility can't provide the care that Resident #91 requires. They are not trained to care for someone with those types of behaviors.
During an interview on 04/12/24 at 2:24 P.M., CNA C said Resident #91 needs more care than the facility can provide.
During an interview on 04/12/24 at 2:27 P.M., LPN K said he/she is familiar with Resident #91. Resident #91 doesn't belong at the facility because they can't keep him/her safe and provide the care needed.
During an interview on 04/12/24 at 3:10 P.M., the Assistant Director of Nursing (ADON) and Administrator said the facility can't provide the care needed for Resident #91. They had tried sending the resident to the hospital, but the hospital sends him/her right back, saying the behaviors should be handled at the facility. They have done medication changes and are currently seeking other placement. The staff isn't trained to care for a resident like this and they can't keep Resident #91 safe.
During an interview on 04/16/24 at 2:59 P.M., the Medical Director (MD) said he/she did not think the facility could adequately care for some residents with these behaviors.
NOTE: At the time of the survey, the violation was determined to be at the immediate and serious jeopardy level J. Based on interview and record review completed during the onsite visit, it was determined the facility had implemented corrective action to address and lower the violation at the time. A revisit will be conducted to determine if the facility is in substantial compliance with participation requirements.
At the time of exit, the severity of the deficiency was lowered to the D level. This statement does not denote that the facility has complied with State law (Section 198.026.1 RSMo.) requiring that prompt remedial action be taken to address Class I violation(s).
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0558
(Tag F0558)
Could have caused harm · This affected 1 resident
Based on observation, interview and record review, the facility failed to evaluate and provide an assistive device to adequately meet the needs of one resident (Resident #13) out of three sampled resi...
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Based on observation, interview and record review, the facility failed to evaluate and provide an assistive device to adequately meet the needs of one resident (Resident #13) out of three sampled residents. The facility census was 96.
The facility failed to provide a policy regarding assistive devices.
1. Review of Resident #13's quarterly Minimum Data Set (MDS), a federally mandated assessment to be completed by the facility staff, dated 01/20/24, showed:
- An admission date of 04/28/22;
- Diagnoses of a stroke affecting the left non-dominant side and hemiplegia (paralysis on one side of the body);
- Impairment to one side in the upper and lower extremities;
- Substantial to maximal assistance for all additional activities of daily living;
- Used a wheelchair.
Observations showed:
- On 04/09/24 at 11:59 A.M. and 04/10/24 at 12:07 P.M., the resident sat in a large 20 inch (in.) wheelchair with a thick concave pad on top of the left wheelchair armrest in the dining room. The resident's left arm sat on the concave pad which raised his/her left shoulder to the bottom of his/her left ear lobe;
- On 04/11/24 at 3:05 P.M., the resident sat in a 18 in. wheelchair with a thick concave pad on top of the left wheelchair armrest outside in the smoking area. The resident's left arm sat on the concave pad which raised his/her left shoulder to the bottom of his/her left ear lobe;
- On 04/12/24 at 9:32 A.M. and 04/15/24 at 1:15 P.M., the resident sat in an 18 in. wheelchair with a thick concave pad on top of the left wheelchair armrest in the hallway. The resident's left arm sat on the concave pad which raised his/her left shoulder to the bottom of his/her left ear lobe.
During an interview on 04/12/24 at 9:32 A.M., Resident #13 said keeping his/her arm in that position was uncomfortable and hurt.
During an interview on 4/11/24 at 4:12 P.M., the Assistant Director of Nursing (ADON) said hospice was switching out the resident's wheelchair for a different one.
During an interview on 04/15/24 at 1:27 P.M., Restorative Aide (RA) I said the wheelchair was provided by hospice, so the facility staff was not able to work on it at all. RNA I was unsure if the facility would provide a different one if hospice was unable to get one that worked. He/She said the pad on the armrest raised the resident's left arm too high. The resident used to have one where the left arm sat lower, but it broke and hospice got the one the resident had now.
During an interview on 04/15/24 at 1:55 P.M., the Administrator said hospice was coming again today to evaluate the resident for a wheelchair. If they were unable to provide one that fit the resident, it was ultimately the facility's responsibility to provide one.
During an interview on 04/16/24 at 2:59 P.M., the Medical Director said he/she would expect the resident to have a chair that suited and protected the resident as well as it could.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0578
(Tag F0578)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to consistently document a code status for two residents (Residents #3...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to consistently document a code status for two residents (Residents #37 and #89) out of 20 sampled residents. The facility census was 96.
The facility did not provide a policy regarding a resident's code status.
1. Review of Resident #37's medical record showed:
- An admission date of [DATE];
- A Nurse's Note, dated [DATE], showed the resident admitted to hospice on [DATE];
- The facesheet, dated [DATE], showed a full code (if a person's heart stopped beating and/or they stopped breathing, cardiopulmonary resuscitation (CPR) procedures would be provided) status;
- The Physician's Order Sheet (POS), dated [DATE], showed a full code status;
- A Do Not Resuscitate (DNR - does not want CPR) form signed by the resident and responsible party on [DATE], and signed by the physician on [DATE].
2. Review of Resident 89's medical record showed:
- An admission date of [DATE];
- The revised care plan, dated [DATE], showed a DNR status;
- The POS, dated [DATE], showed a full code status.
During an interview on [DATE] at 1:00 P.M., Resident #89 said he/she wanted to be a full code and the paperwork was signed for a full code. A green tag to indicate he/she was a full code, was placed on his/her door about a month ago. He/She originally requested a DNR status.
During an interview on [DATE] at 1:47 P.M., the Assistant Director of Nursing (ADON) said the resident's room number and name sign had a colored dot that indicated the code status. A green dot meant a full code and a red dot meant a DNR. A resident's code status should be documented consistently throughout the medical record and the indicator dot should match what is in the chart. It was the Director of Nursing's (DON) responsibility to ensure all code status information matched, but the facility didn't have a DON right now.
During an interview on [DATE] at 4:40 P.M., the Minimum Data Set (MDS - a federally mandated assessment instrument completed by the facility staff) Coordinator said he/she would expect a resident's code status to be documented consistently throughout the resident's medical record. Resident #37 had just recently been admitted to hospice and that was the cause of his/her information not matching. It was the MDS Coordinator's responsibility to ensure the care plan was consistent with the code status and was missed.
During an interview on [DATE] at 4:45 P.M., the Administrator said she would expect a resident's code status be documented consistently throughout the resident's medical record and the indicator dot should match what is in the chart.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0582
(Tag F0582)
Could have caused harm · This affected 1 resident
Based on interview and record review, the facility failed to issue a Skilled Nursing Facility Advance Beneficiary Notice (SNF ABN) and failed to have the resident's Notice of Medicare Non-Coverage (NO...
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Based on interview and record review, the facility failed to issue a Skilled Nursing Facility Advance Beneficiary Notice (SNF ABN) and failed to have the resident's Notice of Medicare Non-Coverage (NOMNC) signed by the resident representative for one resident (Resident #33) out of three sampled residents who remained in the facility when benefits were not exhausted. The facility's census was 96.
The facility did not provide a SNF ABN and NOMNC policy.
1. Review of Resident #33's NOMNC showed:
- The resident discharged from skilled services on 02/08/24, with skilled Medicare days remaining;
- The resident remained in the facility;
- The resident's representative provided verbal consent on 02/28/24, and the representative did not sign the NOMNC;
- The facility failed to provide a SNF ABN to the resident and/or the resident representative.
During an interview on 04/16/24 at 1:17 P.M., the Social Services Designee (SSD) said the SNF ABN and NOMNC forms should have been completed timely and signed appropriately. Being new to the SSD role had created a challenge and some forms were not completed.
During an interview on 04/16/24 at 1:20 P.M., the Minimum Data Set (MDS - a federally mandated assessment instrument completed by the facility staff) Coordinator said the SNF ABN and NOMNC forms should have been completed timely and signed appropriately. There have been staff changes that led to confusion with the forms and they did not get completed.
During an interview on 04/16/24 at 1:59 P.M., the Administrator said she would expect the SNF ABN and NOMNC forms to be completed timely and signed appropriately. A change in personnel and management led to the forms not getting done. There was no SSD at the time the forms should have been given.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Report Alleged Abuse
(Tag F0609)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to notify the state survey agency regarding an allegatio...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to notify the state survey agency regarding an allegation of staff to resident abuse when a staff member grabbed one resident (Resident #91) out of 20 sampled residents by the arm and wrist resulting in a bruise to the arm. The facility census was 96.
Review of the facility policy titled, Abuse, undated, showed:
- The facility will ensure each resident is free from abuse;
- Every staff member must immediately report any observed abuse of a resident by another staff member, resident, family member, or visitor;
- The Director of Nursing (DON) will ensure all alleged violations are reported immediately, but not later than 2 hours after the allegation is made if the events that caused the allegation involve abuse;
- Report to the administrator of the facility and to other officials (including State Survey Agency and Adult Protective Services) not later than 24 hours if the event that causes the allegation did not involve abuse.
1. Review of Resident #91's medical record showed:
- admitted on [DATE];
- Diagnoses of post traumatic stress disorder (PTSD - a mental health condition triggered by a terrifying event - either experiencing it or witnessing it; symptoms may include flashbacks, nightmares and severe anxiety, as well as uncontrollable thoughts about the event), autistic disorder (a serious developmental disorder that impairs the ability to communicate and interact), borderline personality disorder (a mental disorder characterized by unstable moods, behavior and relationships), oppositional defiant disorder (a disorder marked by defiant and disobedient behavior to authority figures), disruptive mood disorder (a condition in which children or adolescents experience ongoing irritability, anger, and frequent, intense temper outbursts), anxiety, and attention deficit hyperactive disorder (ADHD - a chronic condition including attention difficulty, hyperactivity and impulsiveness);
- A nurses note created on 04/04/24 at 10:09 P.M., (regarding the 04/03/24 incident), showed this nurse was at the B Hall nurse's station when he/she heard yelling near the dining area. As he/she walked toward the dining area, the resident was observed blocking the path of the medication cart and yelling at Certified Medication Technician (CMT) E;
- No additional documentation related to the incident on 04/03/24;
- Skin evaluation completed on 04/10/24 at 2:26 P.M., showed bruising noted to the back of the right arm, yellow to green in color, three centimeter (cm) x four cm.
Review of the Administrative Investigation Form, completed on 04/04/24 at 10:30 A.M., showed:
- On 04/04/24, the Assistant Director of Nursing (ADON) notified the Administrator she had been notified by Licensed Practical Nurse (LPN) F that Resident #91 had made an allegation the Maintenance Supervisor (MS) had grabbed him/her by the arm, on 04/03/24 around 07:30 A.M.;
- The ADON was instructed to watch the camera system, gather statements and have a full body assessment of the resident completed;
- The ADON reported to the Administrator that she watched the camera and there was no indication the MS grabbed the resident;
- No report made to the state agency.
During an interview on 04/09/24 at 9:50 A.M., the resident said:
- Last week, the resident was very upset and stood in the way of CMT E moving the medication cart;
- The MS grabbed the resident by the arms and left a bruise;
- He/she reported the incident to LPN F the next morning;
- LPN F took a picture of the bruise on 04/04/24, the day after the incident occurred on 04/03/24;
- He/she didn't know if LPN F forgot to report it as he/she had not heard anything.
Observation on 04/09/24 at 9:50 A.M., showed a large bruise on the back of the resident's right upper arm.
During an interview on 04/09/24 at 1:20 P.M., the ADON said the incident was reported to her on 04/04/24 at 10:29 A.M., by text from LPN F. The ADON then reported it to the Administrator. The ADON said she completed the investigation, got staff statements, viewed the video, and nothing was seen to make her feel like it was abuse or a reportable incident. The ADON said she did not interview the staff or resident, or complete a skin assessment. The ADON did not report it to the state agency.
During an interview on 04/09/24 at 2:57 P.M., the ADON said she did receive a text containing a picture of a bruise from LPN F when the incident was reported on 04/04/24.
During an interview on 04/09/24 at 2:32 P.M., the Administrator said the ADON reported the incident to her on 04/04/24 at 10:30 A.M., by text. She he would expect an investigation to begin immediately, be followed with a determination if the incident was abuse, and her part would be the follow-up. She did not view the video, the ADON reported to her that it did not show the MS put his/her hands on the resident but staff interviews showed the MS grabbed the resident by the wrists after being pushed. She honestly believed it didn't happen and it was decided it was not a reportable incident. She said the incident should have been reported to the state agency.
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 interview and record review, the facility failed to notify a representative of the office of the Missouri State Long-Te...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to notify a representative of the office of the Missouri State Long-Term Care Ombudsman (an advocate for residents in a long-term care facility) and the resident and/or the resident's representative in writing of a facility-initiated transfer when three residents (Residents #78, #91 and #97) out of seven sampled residents transferred to the hospital. The facility census was 96.
The facility did not provide a facility-initiated transfer policy.
1. Review of Resident #78's medical record showed:
- Resident transferred to the hospital for medical evaluation on 01/13/24, and readmitted to the facility on [DATE];
- No documentation of the written notifications to the resident and/or the resident's representative of the resident's transfer to the hospital.
2. Review of Resident #91's medical record showed:
- Resident transferred to the hospital for medical evaluation on 03/01/24, and readmitted to the facility on [DATE];
- No documentation of the written notifications to the resident and/or the resident's representative of the resident's transfer to the hospital;
- No documentation of notification to the Ombudsman's Office for the transfer.
3. Review of Resident #97's medical record showed:
- Resident transferred to the hospital for medical evaluation and treatment on 01/30/24, and returned to the facility on [DATE]; 02/25/24, and returned on 02/26/24; 03/01/24, and returned on 03/02/24; and on 03/07/24, and did not return;
- No documentation of the written notifications to the resident and/or the resident's representative of the resident's transfers to the hospital on [DATE], 03/01/24, and 03/07/24;
- Transfer/Discharge Physician and Guardian Notification form, dated 2/25/24, showed the contact method of the medical director not selected, the guardian was contacted by a message left, and signed by the nurse;
- No documentation of the notification to the Ombudsman's Office for the transfers on 02/25/24, 03/01/24, and 03/07/24.
During an interview on 04/15/24 at 4:15 P.M., the Social Service Designee (SSD), said the nurse was supposed to fill out the transfer/discharge and bed hold paper, and fax it to the guardians. He/She did not follow up on them and did not mail them.
During an interview on 04/15/24 at 4:15 P.M., the Minimum Data Set (MDS - a federally mandated assessment instrument completed by the facility staff) Coordinator said it previously had been the Director of Nursing (DON) who would follow up, but they no longer had a DON. He/She emailed the transfer/discharge and bed holds to the guardians, but if the guardian was a family member, they probably didn't have an email address and they didn't get it mailed.
During an interview on 04/15/24 at 5:21 P.M., Licensed Practical Nurse (LPN) A said the nurses did the transfer/discharge and bed hold notice. After it was completed, they faxed it to the guardian. The SSD would be the one to follow up on the form since it was turned into him/her.
During an interview on 04/16/24 at 11:51 A.M., LPN A said the transfer and discharge checklists were completed by the nursing staff and sent on to the DON and SSD. Notifications should be sent by the SSD for the Ombudsman, the resident, and the guardian.
During an interview on 4/16/24 at 1:15 P.M., the SSD said nursing sent the checklist for bed holds and transfer/discharge notices when residents were sent out of the facility. Transfer and discharge notices should be sent when a resident transferred out to the hospital.
During an interview on 04/16/24 at 2:00 P.M., the Administrator said she would expect transfer/discharge forms to be issued and signed when a resident transferred out to the hospital.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0625
(Tag F0625)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide written notification of their bed-hold policy to residents ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide written notification of their bed-hold policy to residents and/or their representatives at the time of transfer for three residents (Resident #78, #91, and #97) of seven sampled residents. The facility census was 96.
1. Review of Resident #78's medical record showed:
- admission date of 12/12/22;
- Resident transferred to the hospital on [DATE], and readmitted to the facility on [DATE];
- No written documentation of the notification for the bed hold policy provided to the resident and/or the resident's responsible party.
2. Review of Resident #91's medical record showed:
- admission date of 11/29/23;
- Resident transferred to the hospital on [DATE], and readmitted to the facility on [DATE];
- No written documentation of the notification for the bed hold policy provided to the resident and/or the resident's responsible party.
3. Review of Resident #97's medical record showed:
- admission date of 11/15/23;
- Resident transferred to the hospital on [DATE], and returned to the facility on [DATE];
- Resident transferred to the hospital on [DATE], and returned to the facility on [DATE];
- Resident transferred to the hospital on [DATE], and did not return to the facility;
- No documentation of the notification for the bed hold policy provided to the resident and/or the resident's representative for transfers on 01/30/24, 03/01/24, and 03/07/24.
During an interview on 04/15/24 at 4:15 P.M., the Social Service Designee (SSD) said the nurse was supposed to fill out the bed hold paperwork and fax it to the guardians. The SSD got the paperwork from the nurses and filed them. He/She did not follow up on the notifications and did not mail them out.
During an interview on 04/15/24 at 4:15 P.M., the Minimum Data Set (MDS - a federally mandated assessment instrument completed by the facility staff) Coordinator said it previously had been the Director of Nursing (DON) who followed up on the bed holds, but they no longer had a DON. He/She emailed the transfer/discharge and bed hold paperwork to the guardians.
During an interview on 04/15/24 at 5:21 P.M., Licensed Practical Nurse (LPN) A said the nurse was responsible for the transfer/discharge and bed hold notices.
During an interview on 04/16/24 at 2:00 P.M., the Administrator said she would expect the bed hold notification to be issued and signed when a resident transferred to the hospital.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
ADL Care
(Tag F0677)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure all residents received assistance with activit...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure all residents received assistance with activities of daily living (ADLs - dressing, grooming, bathing, eating, and toileting) when staff failed to provide one resident (Resident #68) out of three sampled residents assistance with showers and shaving. The facility census was 96.
The facility did not provide a policy regarding ADLs or showers.
1. Review of Resident #68's medical record showed:
- admitted on [DATE];
- Diagnoses of Alzheimer's disease (progressive mental deterioration) with late onset dementia (a disorder marked by memory loss, personality changes, and impaired reasoning that interferes with daily functioning) with other behavioral disturbance, Parkinson's disease (a disease of the central nervous system that affects movement, often including tremors), major depressive disorder (long-term loss of pleasure or interest in life), shortness of breath, history of falling, anxiety disorder (persistent worry and fear about everyday situations), and other symptoms and signs involving cognitive functions and awareness.
Review of the resident's quarterly Minimum Data Set (MDS - a federally mandated assessment instrument completed by the facility staff), dated 01/30/24, showed:
- Severe cognitive impairment;
- Substantial/maximal assistance required for toileting, hygiene, shower/bathe self, lower body dressing, and personal hygiene;
- Partial/moderate assistance required for upper body dressing;
- Supervision/touching assistance for toilet transfer, and tub/shower transfers;
- Always incontinent of bowel and bladder.
Review of the resident's care plan, dated 02/04/24, showed ADLs were not addressed.
Review of the resident's shower schedule showed the resident scheduled for showers twice a week on Wednesdays and Saturdays.
Review of the resident's shower sheets, dated 02/07/24 through 04/10/24, showed:
- The resident did not receive a shower on 02/10/24, 02/14/24, and 02/24/24, with a total of three out of seven missed opportunities for a shower. The resident was not shaved on 02/07/24, 02/10/24, 02/14/24, 02/17/24, 02/21/24, 02/24/24, and 02/28/24, with a total of seven out of seven missed opportunities to shave the resident's face;
- The resident did not receive a shower on 03/09/24, 03/13/24, 03/20/24, 03/27/24, and 03/30/24, with a total of five out of nine missed opportunities for a shower. The resident was not shaved on 03/02/24, 03/06/24, 03/09/24, 03/13/24, 03/16/24, 03/20/24, 03/27/24, and 03/30/24, with a total of eight out of nine missed opportunities to shave the resident's face;
- The resident did not receive a shower on 04/03/24 and 04/06/24, with a total of two out of three missed opportunities for a shower. The resident was not shaved on 04/04/24, 04/06/24, and 04/10/24, with a total of three out of three missed opportunities to shave the resident's face;
- The resident did not receive a shower for nine days between 02/07/24 and 02/16/24; did not receive a shower for eight days between 02/21/24 and 03/02/24; did not receive a shower for nine days between 03/06/24 and 03/16/24; and did not receive a shower for 17 days between 03/23/24 and 04/10/24.
Observations and an interview of the resident showed:
- On 04/09/24 at 9:31 A.M., the resident lay in bed with an unshaven face;
- On 04/09/24 at 10:45 A.M., the resident lay in bed with hair disheveled and an unshaven face;
- On 04/10/24 at 12:38 P.M., the resident sat at a table in the dining room with uncombed hair and an unshaven face;
- On 04/12/24 at 10:55 A.M., the resident sat on the side of the bed with uncombed hair and an unshaven face;
- On 04/15/24 at 2:16 P.M., the resident sat in his/her wheelchair with disheveled hair and an unshaven face.
During an interview on 04/09/24 at 10:45 A.M., the resident said he/she showered as often as he/she could.
During an interview on 04/15/24 at 2:00 P.M., Certified Nursing Assistant (CNA) D said the resident needed total help with showers and was supposed to get a shower at least two to three times a week.
During an interview on 04/16/24 at 2:40 P.M., the MDS Coordinator said residents should have a shower at least twice a week. Residents were scheduled for showers two or three times a week, and some daily, depending on the resident's need. Shower schedules were at the nurse's station and in the CNA's plan of care. Restorative therapy set up the shower schedule.
During a telephone interview on 04/25/24 at 11:41 A.M., the Administrator said residents should have a shower three times a week. She said shaving was up to the resident if they were able to make the decision, or with every shower if the resident was unable to make the decision.
During a telephone interview on 04/25/24 at 11:50 A.M., the Assistant Director of Nursing (ADON) said depending on the resident's needs, showers should be given two to three times a week, with a minimum of two showers a week for each resident. Shaving was at the resident's request.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Incontinence Care
(Tag F0690)
Could have caused harm · This affected 1 resident
Based on observation, interview and record review, the facility failed to ensure a suprapubic catheter (a tube inserted into the bladder, through an opening in the abdominal wall, to drain urine) was ...
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Based on observation, interview and record review, the facility failed to ensure a suprapubic catheter (a tube inserted into the bladder, through an opening in the abdominal wall, to drain urine) was changed in a timely manner per physician's orders, failed to ensure the urinary drainage bag was kept off the floor, and failed to provide suprapubic catheter care as ordered and when the dressing was soiled from fecal material from a leaking colostomy for one resident (Resident #25) out of three sampled residents. The facility census was 96.
The facility did not provide a suprapubic catheter policy.
Facility policy titled, Urinary Catheter Care, undated showed:
- Nursing assistants must do catheter and perineal care with a.m. and p.m. care, and after each of the resident's bowel movements;
- Always wash your hands before and after handling the catheter, tube or bag, and wear gloves;
- Clean the area where the catheter is inserted by wiping away from the insertion site, to prevent germs from being moved from the anus to the urethra;
- Wash the catheter to remove any blood or other materials from the catheter, wiping downwards;
- Keep the bag below the level of the resident's bladder at all times;
- Use a catheter bag to cover to protect the resident's dignity.
1. Review of Resident #25's medical record showed:
- admission date of 01/16/24;
- Diagnosis of multiple sclerosis (MS - a disease of the central nervous system resulting in muscle weakness and loss of coordination).
Review of the resident's Physician Order Sheet (POS), dated April 2024, showed:
- An order, dated 01/25/24, to change the suprapubic catheter (surgically created connection between the urinary bladder and the skin through the abdomen used to drain urine from the bladder) with a 22 French (catheter scale measurement) Foley catheter (an indwelling catheter) monthly on the first day of the month and as needed related to MS;
- An order, dated 01/17/24, for suprapubic catheter care every shift and as needed;
- An order, dated 01/26/24, to cleanse the suprapubic catheter site with wound cleanser, apply bacitracin (an antibiotic ointment) over the counter, cover with a split sponge, and secure with tape every day shift.
Review of the resident's Treatment Administration Record (TAR), dated April 2024, showed:
- An order, dated 01/17/24, for suprapubic catheter care every shift and as needed;
- An order, dated 01/25/24, to change the suprapubic catheter with a 22 French Foley catheter monthly on the first day of the month and as needed related to MS (due on 04/01/24). On 04/01/24, initialed and coded by staff to see the progress note;
- The suprapubic catheter changed on 04/12/24, 11 days late;
- For 04/01/24 through 04/16/24, no documentation of suprapubic catheter care provided on 04/01/24, 04/06/24, 04/14/24, and 04/16/24, with four out of 16 opportunities missed;
- No progress note dated 04/01/24 related to the catheter in the chart.
Observation on 04/12/24 at 7:30 A.M., showed:
- The resident lay in bed with the catheter drainage bag hooked to the bed frame and touching the floor and not covered with a dignity bag;
- Restorative Aide (RA) I, Certified Nursing Assistant (CNA) D and Licensed Practical Nurse (LPN) K provided care for a leaking colostomy (a surgical opening for the large intestine through the abdomen) that had soaked the suprapubic catheter dressing;
- CNA E did not cleanse the suprapubic catheter from the insertion point out;
- LPN K did not apply a new suprapubic catheter dressing.
During an interview on 04/09/24 at 9:18 A.M., Resident #25 said staff failed to change the catheter on the first of April as it was ordered. A nurse told the resident that the facility didn't have a 22 French Foley catheter to change it with. The facility didn't provide catheter care daily.
Observation on 04/11/24 at 4:30 P.M., of the supply storage closet showed one 22 French urinary catheter in a box of different sized catheters.
During an interview on 04/11/24 at 4:35 P.M., the Assistant Director of Nursing (ADON) and the Administrator said they expected catheters to be changed and cared for per orders. If a medically needed item is not in stock and not obtainable, then the resident could have been sent out. Resident #25 was very competent about his/her required care. The ADON and Administrator were not aware of the catheter not being changed. Any soiled dressing should be reapplied once removed and the area cleansed. Catheters should not touch the floor.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0700
(Tag F0700)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to appropriately assess the use of bed rails, review the ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to appropriately assess the use of bed rails, review the risks and benefits of bed rails with the resident or resident representative and obtain informed consent prior to using bed rails, and appropriately plan care, for two residents (Resident #3 and #13) out of two sampled residents and one additional resident (Resident #20) outside of the sample. The facility census was 96.
Review of the Federal Drug Administration (FDA) documents entitled, Hospital Bed System Dimensional and Assessment Guidance to Reduce Entrapment, dated [DATE], showed 413 people died as a result of entrapment events in the United States. Further review revealed those among the most vulnerable for these entrapment type events are elderly patients and residents, especially those who are frail, confused, restless, or who have uncontrolled body movement.
Review of the FDA document entitled, Practice Hospital Bed Safety, dated February 2013, showed seven different potential zones of entrapment. The guidance characterizes the head, neck, and chest as key body parts that are at risk for entrapment.
Review of the FDA document entitled, Guide to Bed Safety Rails in Hospitals, Nursing Homes and Home Health Care: The Facts, showed the potential risks of bed rails may include:
- Strangling, suffocating, bodily injury or death when patients or part of their body are caught between rails or between the bed rails and mattress;
- More serious injuries from falls when patients climb over rails;
- Skin bruising, cuts, and scrapes;
- Inducing agitated behavior when bed rails are used as a restraint;
- Feeling isolated or unnecessarily restricted;
- Preventing patients, who are able to get out of bed, from performing routine activities such as going to the bathroom or retrieving something from a closet.
1. Review of Resident #3's medical record showed:
- admitted on [DATE];
- Diagnoses of cerebral palsy (a congenital disorder of movement, muscle tone or posture) and dementia (a condition characterized by progressive or persistent loss of intellectual functioning, especially with impairment of memory and other mental function);
- No documentation of an informed consent signed by the resident and/or representative explaining the risks and benefits.
Review of the resident's significant change Minimum Data Set (MDS), a federally mandated assessment to be completed by the facility staff, dated [DATE], showed:
- Severe cognitive impairment;
- Impairment to both sides of the upper and lower extremities;
- Dependent for bed mobility;
- Bed rails not used.
Review of the resident's Bed Safety Assessment, dated [DATE], showed bed rails not required.
Observations of the resident showed:
- On [DATE] at 04:16 P.M., [DATE] at 9:31 A.M., and 1:12 P.M., the resident lay in a low bed with a fall mat in the floor and the upper 1/2 bed rails in the raised position on the right and left sides of the bed;
- On [DATE] at 2:51 P.M., [DATE] at 9:12 P.M., [DATE] at 9:42 A.M., and [DATE] at 1:15 P.M., the resident lay in a low bed with a fall mat in the floor and the upper right 1/2 bed rail in the raised position on the left side of the bed against the wall.
Review of the resident's care plan, dated [DATE], showed it did not address the use of bed rails.
2. Review of Resident #13's medical record showed:
- admitted on [DATE];
- Diagnoses of stroke affecting the left non-dominant side and hemiplegia (paralysis on one side of the body);
- No documentation of an informed consent signed by the resident and/or representative explaining the risks and benefits.
Review of the resident's quarterly MDS, dated [DATE], showed:
- Severe cognitive impairment;
- Impairment to the left upper and both sides of the lower extremities;
- Substantial to maximal (helper does more than half) assistance for all activities of daily living (ADL's);
- Bed rails not used.
Review of the resident's Bed Safety Assessment, dated [DATE] showed bed rails not required at this time.
Review of the resident's Nurses Notes, dated [DATE] at 11:07 P.M., showed the resident sat on the floor with left arm twisted behind him/her and stuck between the bed and the bed rail. The resident complained of pain to his/her left shoulder. The resident was assisted to untangle his/her arm from between the bed and the bed rail and sat on the bed with assist of two staff. The resident said he/she was trying to get up to change clothes. The resident said he/she did not fall and sat on the floor because he/she could not get his/her arm out.
Review of the resident's care plan, dated [DATE], showed it did not address the use of bed rails.
Observations of the resident showed:
- On [DATE] at 4:19 P.M., and [DATE] at 2:57 P.M., the resident lay in a low bed with the upper 1/4 bed rails in the raised position on both sides of the bed;
- On [DATE] at 9:27 A.M., the resident sat on the bedside with both upper 1/4 bed rails in the raised position;
3. Review of Resident #20's medical record showed:
- admitted on [DATE];
- Diagnosis of Huntington's disease (a rare inherited disease causing progressive breakdown of brain nerve cells, having an impact on functional abilities, usually resulting in movement, cognitive and psychiatric disorders);
- No documentation of an informed consent signed by the resident and/or representative explaining the risks and benefits.
Review of the resident's significant change MDS, dated [DATE], showed:
- Severe cognitive impairment;
- Impairment to both sides of the upper and lower extremities;
- Dependent on bed mobility;
- Bed rails times two used daily.
Review of the resident's Bed Safety Assessment, dated [DATE], showed:
- Bed rail times one was used to keep the resident from falling out of bed and helped with positioning;
- Potential safety issues of the bars within the bed rails were not closely spaced to prevent entrapment.
Review of the resident's care plan, dated [DATE], showed:
- The resident with a bedrail to help with positioning and safety;
- No documentation of additional interventions.
Observations of the resident showed:
- On [DATE] at 9:34 A.M., the resident lay in bed with both upper 1/2 bed rails in the upright position on both sides of the bed. The resident's left lower leg crossed over the right leg with his/her left foot between the inside bars of the right upper 1/2 bed rail. The resident unable to remove his/her foot from the right upper 1/2 bed rail in the raised position. Certified Nursing Assistant (CNA) L entered the resident's room and removed the resident's foot out of the raised 1/2 bed rail;
- On [DATE] at 1:12 P.M., [DATE] at 2:54 P.M., and [DATE] at 1:15 P.M., the resident lay in a low bed with a fall mat in the floor and the left upper 1/2 bed rail in the raised position on the wall side of bed;
- On [DATE] at 3:10 P.M., the resident sat in a wheelchair with the left upper 1/2 bed rail in the raised position on the wall side of the bed.
During an interview on [DATE] at 1:10 P.M., the Administrator and the MDS Coordinator said the facility had no residents with bed rails in use.
During an interview on [DATE] at 1:10 P.M., the Assistant Director of Nursing (ADON) said he/she was not aware of any residents with bed rails.
During an interview on [DATE] at 9:47 A.M., the MDS Coordinator said he/she thought hospice staff had brought new beds in and was unaware there were bed rails on them.
During an interview on [DATE] at 11:02 A.M., the Administrator said she would expect bed rail assessments and consents with risks and benefits to be accurately completed. The bed rails should also be addressed on the care plan if they were used.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0742
(Tag F0742)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide the necessary behavioral health care and services to attain...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide the necessary behavioral health care and services to attain or maintain the highest practicable physical, mental and psychosocial well-being in accordance of the required provision of services to address the individuals mental health and behavioral needs, for one resident (Resident #91) from a sample of 20 residents. The facility census was 96.
The facility did not provide a policy regarding behaviors.
Review of Resident #91's Preadmission Screening and Resident Review (PASRR - a federal requirement to help ensure that individuals are not inappropriately placed in nursing homes), dated 11/27/23, showed:
- The resident's needs can be met in a nursing facility;
- Resident with post traumatic stress disorder (PTSD - a mental health condition triggered by a terrifying event);
- Disabilities of serious mental illness and intellectual developmental disability (a group of disorders characterized by a limited mental capacity and difficulty with adaptive behaviors);
- Supports and services to be provided by the nursing facility: behavioral support services, structured environment, and crisis intervention services;
- Behaviors of impatience, demanding, and physically threatening;
- Extensive history of aggression, self-injurious behaviors, suicide attempts, attention seeking behaviors, mood liability (rapid, often exaggerated changes in mood, where strong emotions or feelings (uncontrollable laughing or crying, or heightened irritability or temper) occur), anxiety, depression, impulse control issues, limited insight and judgement, poor decision making skills, and inability to keep self safe;
- Requires a provision of services to address the individuals mental health and behavioral needs, obtain an Individual Support Plan (ISP), and Individualized Treatment Plan (ITP), a Behavioral Support Plan (BSP) from the Department of Mental Health (DMH) Community Mental Health Center and/or the Developmental Disability Regional Office;
- Provision of a structured environment, provide instruction at the individual's level of understanding, environmental supports to prevent elopement, assess and plan for the level of supervision required to prevent harm to self or others, provide individual personal space, provide sensory support, establish consistent routines, and provide a schedule of daily tasks/activities;
- Crisis intervention services to assess and plan for crisis intervention that provides emotional support, education and safety. It should create clear steps that are taken to support the resident during a behavioral crisis, including who to contact for assistance, how to work together, and how to determine when a crisis is over. The plan should also identify a physician and emergency medical services that should be contacted. The facility may also wish to utilize DMH Behavioral Health Crisis Hotline;
- Provide suicide precautions, assault precautions, and elopement precautions;
- The crisis plan is warranted due to the resident has an extensive history of aggression, suicidal ideation, self injurious behaviors and elopements;
- Long term care placement recommended for the resident's safety.
Review of the resident's medical record showed:
- admitted on [DATE];
- Diagnoses of PTSD, autistic disorder (a developmental condition causing an inability to relate to everyday life and adjust socially), borderline personality disorder (a mental illness that severely impacts a person's ability to regulate their emotions), oppositional defiant disorder (a disorder marked by defiant and disobedient behavior to authority figures), disruptive mood disorder (a condition in which children or adolescents experience ongoing irritability, anger, and frequent, intense temper outbursts), anxiety, attention and deficit hyperactivity disorder (a chronic condition including attention difficulty, hyperactivity and impulsiveness).
Review of the resident's Nurse's Progress Notes, dated 01/25/24 through 04/11/24, showed:
- On 01/25/24, the resident cut him/herself with sharpened pencils;
- On 02/03/24, the resident found with a dull, broken piece of plastic;
- On 02/16/24, the resident more sad than usual for two days. Resident asked for a razor to shave legs. The nurse was going to go with resident to supervise, but the resident ran to the room with the razor. The resident lay on top of a closed razor so the staff couldn't confiscate it;
- On 02/25/24, the resident cut him/herself with a dull piece of broken plastic;
- On 02/29/24, the resident asked if he/she could shave. A Certified Nurse Aide (CNA) was sent to assist the resident with shaving. The resident went into the shower room with a razor. The resident cut him/herself on the arm with a razor which was witnessed by a CNA, a Certified Medication Technician (CMT) and another resident. The CMT obtained the razor and the resident told the CNA he/she did not want to live anymore. The resident said if he/she would be sent to the hospital, then he/she would say it was an accident. Resident offered one-to-one (1:1) care, but the resident calmed down. This resident threw shoes at another resident who witnessed him/her using the razor. Resident removed from the other resident's room, placed on 1:1 and an order was obtained to send the resident out to the hospital;
- On 03/13/24, the resident initiated an altercation with another resident;
- On 03/14/24, the resident interrupted a conversation between a nurse and the other resident involved in the altercation on 03/13/24. Resident #91 became aggressive toward the staff, walked down the hall and became aggressive toward the other resident. Due to being the fourth altercation during the day shift, the resident was sent out to the hospital;
- On 03/27/24, the resident put his/her finger in an open soda can and cut his/her finger;
- On 04/03/24, the resident threw dining room chairs against the walls in the sitting room;
- On 04/04/24, the resident threw hangers at the Assistant Director of Nursing (ADON) and hit a CNA in the chest. The resident ran to his/her room, slammed the door shut and hit the door repeatedly. Prior to this incident, the resident grabbed an ice chest cooler lid with a crack in it and said he/she wanted to hurt him/herself. The resident was sent to the hospital. The resident returned from the hospital;
- On 04/05/24, the resident wanted to harm him/herself with a broken piece of a cooler lid;
- On 04/05/24, the resident ingested hair conditioner, told staff, and moved an electric bed into the hallway blocking the path to the resident. The resident told staff he/she had vomited in the toilet and flushed it. The resident complained of an upset stomach;
- On 04/07/24 the resident left out of the facility door and ran towards the road as a truck drove by the facility. The resident fought Emergency Medical Services (EMS) staff and the sheriff about getting into the ambulance, but eventually got into the ambulance;
- On 04/09/24, the resident had several behaviors today and said he/she was not okay;
- On 04/10/24, the resident said he/she hated feeling like this. The resident asked for an as needed (PRN) medication and it was administered. The resident walked into the bathroom and a few minutes later, staff entered the bathroom. The resident was tearful and said he/she hated feeling like this. The resident went behind the shower curtain and scratched at his/her arm with a straightened out paper clip which he/she gave the staff. The resident had a superficial scrape to the skin. The resident later ran out of the door into the enclosed courtyard crying that the medication didn't work;
- On 04/11/24, the resident kicked open a locked supply room closet door, pulled a screw from the wall, wedged him/her self between shelving and the wall, and began to scratch him/herself with the screw. The resident said staff shouldn't care about him/her or try to help. The resident injured him/herself with a safety razor obtained from the storage room. The resident refused to allow the nurse to apply pressure, but agreed to hold gauze him/herself over the wound. The resident was sent out to the hospital.
Review of the resident's care plan, updated 03/22/24, showed:
- Behavior problems (history of manipulation, aggression, aggressive toward other);
- Intervene as necessary to protect the rights and safety of others;
- Approach/speak in a calm manner and divert attention;
- Potential to be physically aggressive;
- When agitated, intervene before agitation escalates, guide away from source of the distress, and engage calmly in conversation;
- If resident's response was aggressive, staff to walk calmly away and approach later;
- Did not identify the resident's specific triggers to avoid that would cause increased anxiety and behaviors;
- Did not address suicidal ideations, elopements, or self-harm behaviors with interventions;
- Did not address a crisis plan.
The facility failed to provide the resident with a crisis plan with interventions, an IPS, an ITP, a BSP, a plan for the level of supervision required to prevent harm to self or others, suicide precautions, assault precautions, and elopement precautions per the resident's PASRR.
During an interview on 04/12/24 at 3:10 P.M., the ADON and the Administrator said the facility can't provide the care needed for the resident. They had tried sending the resident to the hospital, but the hospital sent the resident right back and said the behaviors should be handled at the facility. They had done medication changes and were currently seeking another placement. The staff wasn't trained to care for the resident and they couldn't keep the resident safe.
During an interview on 04/15/24 at 1:30 P.M., the ADON said they provided in-services with staff once a month, but did not know what the specific training for the behavioral residents was, or when it had last been done. She was in charge of the training until a new DON could be hired.
During an interview on 04/16/24 at 2:59 P.M., the Medical Director (MD) said he/she did not think the facility could adequately care for residents with this kind of behavior.
During an interview on 04/16/24 at 10:10 P.M., the Administrator said she did not feel
the facility could provide the behavioral needs of the resident. The facility did not have the staff to do 1:1 care, as it would take away care from the other residents.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Medication Errors
(Tag F0758)
Could have caused harm · This affected 1 resident
Based on interview and record review, the facility failed to limit the use of an as needed (PRN) order for psychotropic (medications that affect how the brain works and causes changes in mood, awarene...
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Based on interview and record review, the facility failed to limit the use of an as needed (PRN) order for psychotropic (medications that affect how the brain works and causes changes in mood, awareness, thoughts, feelings, or behaviors) medication to 14 days for three residents (Resident #38, #59, and #92) and failed to ensure one resident (Resident #92) was free from an unnecessary antipsychotic (a medication to treat a mental disorder characterized by a disconnection from reality) medication out of seven sampled residents. The facility also failed to ensure an appropriate diagnosis for the use of a psychotropic medication and to attempt a gradual dose reduction (GDR) for one resident (Resident #51) outside the sample. The facility census was 96.
The facility did not provide policies for the limited use of PRN medications, unnecessary antipsychotic medication use, appropriate diagnosis, use of psychotropic medication, and GDRs.
1. Review of Resident #38's April 2024 Physician's Order Sheet (POS) showed:
- Diagnoses of schizoaffective disorder (a long term mental disorder that affects a person's ability to think, feel, or behave clearly, sometimes including delusions or hallucinations), dementia (a disorder marked by memory loss, personality changes, and impaired reasoning that interferes with daily functioning), major depressive disorder (MDD - long-term loss of pleasure or interest in life), obsessive-compulsive personality disorder (OCD - characterized by unreasonable thoughts and fears (obsessions) that lead to compulsive behaviors);
- An order for Haldol (an antipsychotic medication) 5 milligram per milliliter (mg/ml), inject 1 ml intramuscularly (IM) every six hours as needed for agitation, dated 07/12/23, and no stop date;
- No 14 day stop date order for the Haldol PRN order.
2. Review of Resident #51's April 2024 POS showed:
- admission date of 9/8/2023;
- Diagnoses of anxiety disorder (persistent worry and fear about everyday life), MDD, and bipolar disorder (mental illness that causes unusual shifts in a person's mood, energy, activity levels and concentration);
- An order for nortriptyline (an antidepressant medication) 10 mg by mouth in the evening for nerve pain, dated 9/12/23;
- An order for duloxetine (an antidepressant medication) 60 mg by mouth twice daily for MDD, dated 9/8/23;
- An order for olanzapine (an antipsychotic medication) 5 mg by mouth twice daily for bipolar disorder, dated 2/12/24;
- An order for quetiapine (an antipsychotic medication) 50 mg by mouth at bedtime for bipolar disorder, dated 9/8/23;
- An order for quetiapine 25 mg by mouth in the afternoon for anxiety, dated 2/1/24;
- No documentation of an appropriate diagnosis for the quetiapine 25 mg dose;
- No attempt by the physician for a GDR of the nortriptyline, duloxetine, and quetiapine 50 mg medications.
3. Review of Resident #59's April 2024 POS showed:
- Diagnoses of encephalopathy (any brain disease that alters brain function or structure), post traumatic stress disorder (PTSD - a mental health condition triggered by a terrifying event), autistic disorder (a developmental condition causing an inability to relate to everyday life and adjust socially), anxiety, schizoaffective disorder (a condition characterized by abnormal thought processes and deregulated emotions) bipolar type;
- An order for lorazepam (an antianxiety medication) 2 mg/ml, give 0.5 ml by mouth every 12 hours PRN for anxiety, dated 1/12/24, and no stop date;
- No 14 day stop date order for the lorazepam PRN order.
4. Review of Resident #92's April 2024 POS showed:
- Diagnoses of alcohol dependence with alcohol-induced dementia (a disorder marked by memory loss, personality changes, and impaired reasoning that interferes with daily functioning), dementia with other behavioral disturbance, insomnia (difficulty sleeping), and anxiety;
- An order for lorazepam 1 milligram (mg) by mouth every eight hours PRN for anxiety, dated 02/02/24, with no stop date;
- An order for Risperdal (an antipsychotic medication) 1 mg by mouth three times daily as needed for agitation related to dementia, severe, with other behavioral disturbance, dated 02/02/24, with no stop date;
- An order for olanzapine (an antipsychotic medication) intramuscularly (IM) 10 mg one time only for aggression, anxiety for one day, dated 04/14/24;
- No 14 day stop date order for the lorazepam and the Risperdal PRN orders.
Review of the resident's nurse's note, dated 04/14/24, showed:
- Episodes of aggressive behavior throughout the shift, directed towards staff;
- Wandered into other resident rooms and not easily redirected;
- Pushed and punched staff to get back into another resident's room;
- Grabbed a nurse's wrists and pulled the nurse down the hall;
- Assaulted staff with closed fists when redirected from entering other resident rooms;
- Another nurse obtained an order for a PRN olanzapine injection;
- When the nurse stepped in between the staff and the resident, the resident grabbed the nurse and walked to his/her room and said he/she wanted to go to bed;
- Once in the room, the resident yelled at staff and grabbed the nurse's wrists;
- A second nurse gave the resident an injection, olanzapine;
- The resident punched one nurse and Certified Nurse Aide (CNA).
Review of the resident's April 2024 MAR showed:
- Lorazepam 1 mg by mouth every eight hours as needed for anxiety, dated 02/02/24, and not administered on 04/14/24;
- Risperdal 1 mg by mouth three times a day as needed for agitation, dated 02/02/24, and not administered on 04/14/24;
- Olanzapine IM 10 mg one time only for aggression, anxiety, start date of 04/14/24 and end date of 04/14/24, administered on 04/14/24;
- No PRN medications attempted prior to obtaining the order for the olanzapine IM injection.
Review of the resident's care plan, dated 02/14/24, showed the resident received psychotropic (a medication that affects how the brain works) medications without an appropriate diagnosis.
During an interview on 04/15/24 at 10:20 A.M., the Assistant Director of Nursing (ADON) said a PRN antipsychotic should only be ordered for 14 days at a time. The medication should then be stopped at the 14th day, or a new order should be obtained from the physician on the 14th day. An appropriate diagnosis should be included and GDRs should be completed in a timely manner.
During an interview on 04/16/24 at 10:30 A.M., the Administrator said staff should try deescalating residents and administer the PRN medications prior to calling for an antipsychotic medication IM one time order. If a resident was starting to have behaviors, then PRNs should be administered before a big event occurred requiring an actual one time injection of usually stronger medications.
During an interview on 04/16/24 at 1:30 P.M., the Administrator said PRN antipsychotic medications should only be ordered for 14 days at a time. All medication should have an approved diagnosis and GDRs should be completed.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0909
(Tag F0909)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility staff failed to conduct regular inspections of all bed frames, ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility staff failed to conduct regular inspections of all bed frames, mattresses and side rails as part of a regular maintenance program for three residents (Residents #3, #13, and #20) out of 20 sampled residents. The facility census was 96.
Review of the Federal Drug Administration (FDA) documents entitled, Hospital Bed System Dimensional and Assessment Guidance to Reduce Entrapment, dated [DATE], showed 413 people died as a result of entrapment events in the United States. Further review revealed those among the most vulnerable for these entrapment type events are elderly patients and residents, especially those who are frail, confused, restless, or who have uncontrolled body movement.
Review of the FDA document entitled, Practice Hospital Bed Safety, dated February 2013, showed different potential zones of entrapment. The guidance characterizes the head, neck, and chest as key body parts that are at risk for entrapment.
1. Review of Resident #3's medical record showed:
- admitted on [DATE];
- No documentation of a maintenance assessment for side rails.
Observations of the resident showed:
- On [DATE] at 04:16 P.M., [DATE] at 9:31 A.M. and 1:12 P.M., the resident lay in a low bed with a fall mat on the floor and upper 1/2 bed rails in raised position on right and left sides of the bed;
- On [DATE] at 2:51 P.M., [DATE] at 9:12 P.M., [DATE] at 9:42 A.M., and [DATE] at 1:15 P.M., the resident lay in a low bed with a fall mat on the floor and the upper right 1/2 bed rail in raised position on the left side of the bed against the wall.
2. Review of Resident #13's medical record showed:
- admitted on [DATE];
- No documentation of a maintenance assessment for side rails.
Observations of the resident showed:
- On [DATE] at 4:19 P.M., and [DATE] at 2:57 P.M., the resident lay in a low bed with upper 1/4 bed rails in raised position on upper both sides of the bed;
- On [DATE] at 9:27 A.M., the resident sat on the bedside, with the left upper 1/4 bed rail in the raised position to the left side of resident, upper 1/4 bed rail in raised position on the right side of the bed;
- On [DATE] at 01:12 P.M., [DATE] at 03:10 P.M., [DATE] at 09:35 P.M., and [DATE] at 01:15 A.M., the resident sat in a wheelchair in hall, upper 1/4 bed rails in raised position on right and left sides of the bed.
3. Review of Resident #20's medical record showed:
- admitted on [DATE];
- No documentation of maintenance assessment for side rails.
Observations of the resident showed:
- On [DATE] at 9:34 A.M., the resident lay in bed with the left lower leg crossed over the right leg with his/her left foot between the inside bars of the upper raised 1/2 bed rail on the right side of the bed, upper 1/2 bed rails in raised position on both right and left sides of the bed;
- Resident unable to remove his/her foot from the upper 1/2 bed rail in raised position on right side of the bed. Certified Nursing Assistant (CNA) L entered the resident's room and moved his/her foot out of the raised 1/2 bed rail;
- On [DATE] at 1:12 P.M., [DATE] at 2:54 P.M., and [DATE] at 1:15 P.M., the resident lay in a low bed with a fall mat in the floor and left upper 1/2 bed rail up in raised position on the wall side of bed;
- On [DATE] at 3:10 P.M., the resident sat in a wheelchair, left upper 1/2 bed rail up in raised position on the wall side of bed.
During an interview on [DATE] at 09:47 A.M., the Minimum Data Set (MDS - a federally mandated assessment completed by the facility) Coordinator said he/she thought hospice brought new beds. He/She was unaware there were side rails and they have been removed.
During an interview on [DATE] at 11:02 A.M., the Administrator said there were no assessments/inspections completed on the bed rails, and no documentation that she is aware of.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Resident Rights
(Tag F0550)
Could have caused harm · This affected multiple residents
Based on observation and interview, the facility failed to protect residents' right to privacy by not ensuring other residents did not enter the shower room during showers. This affected three residen...
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Based on observation and interview, the facility failed to protect residents' right to privacy by not ensuring other residents did not enter the shower room during showers. This affected three residents (Residents #57, #64, and #51) out of 20 sampled residents and five additional residents (Residents #8, #21, #29, #79, and #85). The facility census was 96.
The facility did not provide a policy regarding protection of privacy during bathing.
Observation on 04/09/24 at 11:00 A.M., of the women's shower room showed:
- The toilet located in the front of the room and to the left of the door with a curtain;
- The shower in the back of the room to the right and facing the door with a curtain.
Observation on 04/15/24 at 2:09 P.M., showed:
- Resident #85 entered the shower room a few minutes prior;
- The running water from the shower could be heard outside the door;
- Without knocking, Resident #21 entered the shower room;
- A Certified Nurse Assistant (CNA) cracked open the shower room door and said Resident #85 was showering and Resident #21 was using the toilet.
During an interview on 04/09/24 at 9:31 A.M., Resident #8 said his/her only concern was the lack of privacy during a shower. Other residents just walked right in and used the toilet while he/she was in the shower.
During an interview on 04/09/24 at 8:49 A.M., Resident #29 said he/she did not think it was right that other people came in the bathroom and used the toilet while he/she was in the shower.
During an interview on 04/09/24 at 9:35 A.M., Resident #79 said he/she really didn't like people coming in when he/she was in the shower. They didn't knock, came in, and used the toilet.
During an interview on 04/11/24 at 4:32 P.M., Resident #64 said he/she required assistance with showers. Every time he/she took a shower, another resident always walked in and usually used the toilet. That bothered him/her. He/She preferred people not walk in during his/her shower. The shower rooms were not private like they should be.
During an interview on 04/11/24 at 4:39 P.M., Resident #51 said he/she showered independently. The resident said every time the resident showered, another resident always walked in, without knocking. Then that resident usually used the toilet.
During an interview on 04/15/24 at 12:50 P.M., Resident #57 said he/she showered without assistance. He/She said someone always walked in while he/she was in the shower without knocking. There were curtains around the shower and the toilet. Other residents always opened the curtain during his/her shower.
During an interview on 04/15/24 at 1:15 P.M., CNA B said he/she had been in the shower room a few times assisting residents with a shower and another resident just walked in. He/She called out that someone was in there, but the other residents just walked on in, most of the time to use the toilet. The residents had shared restrooms, but some just wanted to use the toilet in the shower room.
During an interview on 04/15/24 at 1:22 P.M., CNA C said some residents knocked and some just walked on in. He/She tried to stop them, but most of the time they just came in and used the toilet.
During an interview on 04/11/24 at 2:58 P.M., the Assistant Director of Nursing (ADON) said he/she was unaware of any concerns with privacy during showering. It hadn't been mentioned.
During an interview on 04/11/24 at 2:59 P.M., the Administrator said she had not heard of concerns regarding residents walking in on each other in the shower room. They would have to come up with a plan to fix it.
CONCERN
(E)
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, interview, and record review, the facility failed to provide a safe, clean, and comfortable homelike environment. The facility census was 96.
The facility did not provide a maint...
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Based on observation, interview, and record review, the facility failed to provide a safe, clean, and comfortable homelike environment. The facility census was 96.
The facility did not provide a maintenance policy.
Review of the facility's Maintenance Request Log, dated 02/05/24, showed:
-No request made or completed after 02/05/24;
-No maintenance request made regarding a musty odor.
1. Observations on 04/09/24 at 9:30 A.M. and 1:43 P.M., 04/12/22 at 11:10 A.M., and 04/16/22 at 12:10 P.M., showed A and B Halls with a strong, unidentifiable musty odor.
2. Observations on 04/12/24 at 9:30 A.M., 9:43 A.M. and 9:55 A.M., showed:
- Room A11 with grime and debris beneath four resident beds, a fan with excessive dust buildup, missing light fixture cover, and the door with a damaged surface near the door handle area;
- Room A13 with missing drawer front on the wooden clothing cabinet;
- Room A14 with grime and debris beneath two resident beds;
- Room A17 with a missing drawer front on two wooden clothing cabinets;
- [NAME] A Hall men's shower room with a hole in the wall about 1 foot (ft) by 1ft and
the shower stall floor with a damaged coated surface;
- East A Hall men's shower room stall floor with separated caulking bead in the corner where the wall and floor meet.
During an interview on 04/12/24 at 9:30 A.M., the resident in room A11 said he/she had not seen staff clean his/her room. Cleaning was mainly done in the halls.
During an interview on 04/12/24 at 9:40 A.M., the resident in room A14 said he/she cleaned under his/her own bed, but staff came in and tidied up the room sometimes.
During an interview on 04/12/24 at 9:43 A.M., the resident in room A17 said there was a missing drawer face on his/her cabinet, and it needed to be fixed.
During an interview on 04/12/24 at 9:32 A.M., Certified Nurse Aide (CNA) L said he/she cleaned the male resident rooms every two hours while on shift but did not clean under the beds. The housekeepers should do that.
3. Observation on 04/16/24 at 12:26 P.M., of the A and B Hall dining room showed a missing wooden cabinet door and drawer front behind the steam table.
4. Observation on 04/16/24 at 12:14 P.M., of the A Hall nurses' office showed a four ft piece of missing vinyl baseboard with a black substance below the window.
During an interview on 04/12/24 at 11:10 A.M., the Housekeeping Supervisor said housekeepers were expected to report damage and work order forms were kept up in the front office. There were problems with mice and roaches in the facility. They were worse if the areas were not kept clean. Residents were known to put food in the drawers also, so rooms were expected to be checked daily as well as the halls. There was an odor in the halls due to the residents throwing their dirty clothes and briefs in the closets sometimes.
During an interview on 04/12/24 at 11:15 A.M., Housekeeper J said maintenance should be notified if there were problems in the resident rooms or other parts of the facility. He/she told maintenance directly or filled out paperwork when damage was noticed in resident rooms.
During an interview on 04/12/24 at 4:30 P.M., the Interim Maintenance Director said there was a process in place for staff to turn in maintenance requests. They were placed in the maintenance door and turned into the office up front. There was no logbook available because the past Maintenance Director took care of that. Maintenance should repair walls because they should be free of damage. Doors and furniture should be in good repair.
During an interview on 04/16/24 at 11:51 A.M., Licensed Practical Nurse (LPN) A said damage was usually reported to maintenance verbally. There were also work order forms to fill out and issues were addressed. The facility should not smell bad and be kept in good repair.
During an interview on 04/16/24 at 1:59 P.M., the Administrator said problems were to be reported by staff using maintenance request forms. The Interim Maintenance Director would address and fix the problems. Corporate also had a maintenance log kept in a file folder. There should not be a body odor or other smells throughout the halls of the facility. Better cleaning methods could be put in place. The building and furniture should be kept in good repair.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Comprehensive Care Plan
(Tag F0656)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to develop and implement an individualized comprehensive ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to develop and implement an individualized comprehensive care plan with specific interventions for six residents (Residents #3, #13, #57,#59, #61, and #68) out of 20 sampled residents and one resident (Resident #20) outside of the sample. The facility's census was 96.
The facility did not provide a care plan policy.
Review of the facility's policy titled, Smoking, undated, showed:
- The supervising staff member will notify the unit nurse when a resident's ability to smoke safely is in question;
- On admission, the unit nurse will ascertain the resident's wishes about smoking and respect the resident's decision;
- Assess the resident's ability to smoke safely by completing a smoking assessment that includes an evaluation of the resident's safety awareness, judgement, cognitive ability, and manual dexterity;
- Instruct staff members to notify the unit nurse immediately if it is suspected the resident has violated the facility smoking policy or if the resident's clothing or skin has signs of cigarette burns;
- The Minimum Data Set (MDS - a federally mandated assessment instrument completed by the facility staff) Nurse will evaluate each resident who smokes for smoking safety with every MDS assessment, and document the resident's need for supervision in the care plan, and update with any change in the resident's capabilities and needs.
1. Review of Resident #3's medical record showed:
- admitted on [DATE];
- Diagnoses of cerebral palsy (a congenital disorder of movement, muscle tone or posture) and dementia (a condition characterized by progressive or persistent loss of intellectual functioning, especially with impairment of memory and other mental function).
Review of the resident's significant change MDS, dated [DATE], showed:
- Severe cognitive impairment;
- Impairment to both sides of the upper and lower extremities;
- Dependent for bed mobility;
- Bed rails not used.
Observations of the resident showed:
- On 04/09/24 at 04:16 P.M., 04/10/24 at 9:31 A.M., and 1:12 P.M., the resident lay in a low bed with a fall mat in the floor and the upper 1/2 bed rails in the raised position on both sides of the bed;
- On 04/10/24 at 2:51 P.M., 04/11/24 at 9:12 P.M., 04/12/24 at 9:42 A.M., and 04/15/24 at 1:15 P.M., the resident lay in a low bed with a fall mat in the floor and the upper right 1/2 bed rail in the raised position on the left side of the bed against the wall.
Review of the resident's care plan, dated 01/03/24, showed it did not address the use of bed rails.
2. Review of Resident #13's medical record showed:
- admitted on [DATE];
- Diagnoses of stroke affecting the left non-dominant side and hemiplegia (paralysis on one side of the body).
Review of the resident's quarterly MDS, dated [DATE], showed:
- Severe cognitive impairment;
- Impairment to the left upper and both sides of lower extremities;
- Dependent for putting on and removing foot wear;
- Substantial to maximal (helper does more than half) assistance for all additional activities of daily living;
- Bed rails not used.
Observations of the resident showed:
- On 04/09/24 at 4:19 P.M., and 04/10/24 at 2:57 P.M., the resident lay in a low bed with the upper 1/4 bed rails in the raised position on both sides of the bed;
- On 04/10/24 at 9:27 A.M., the resident sat on the bedside, with the left upper 1/4 bed rail in the raised position to the left side of the resident and the upper 1/4 bed rail in the raised position on the right side of the bed.
Review of the resident's care plan, dated 04/14/24, showed it did not address the use of bed rails.
3. Review of Resident #20's medical record showed:
- admitted on [DATE];
- Diagnosis of Huntington's Disease (a rare inherited disease causing progressive breakdown of brain nerve cells, having an impact on functional abilities, usually resulting in movement, cognitive and psychiatric disorders).
Review of the resident's significant change MDS, dated [DATE], showed:
- Severe cognitive impairment;
- Impairment to both sides in the upper and lower extremities;
- Dependent on bed mobility;
- Bed rails times two used daily.
Observations of the resident showed on 04/10/24 at 1:12 P.M., and 2:54 P.M., and 04/15/24 at 1:15 P.M., the resident lay in a low bed with a fall mat in the floor and the left upper 1/2 bed rail in the raised position on the wall side of the bed;
Review of the resident's care plan, dated 01/15/24, showed:
- The resident with a bed rail to help with positioning and safety;
- Did not address additional interventions.
4. Review of Resident #57's medical record showed:
- admission date of 5/19/23;
- Diagnoses of delusional disorders (a mental health condition which a person can't tell what's reality and imagined), major depressive disorder (MDD - persistently low mood), anxiety disorder, post traumatic stress disorder (PTSD - a disorder that occurs if a traumatic event has been witnessed or experienced), bipolar disorder (mental illness that causes unusual shifts in mood), and vascular dementia (impaired thought processes caused by impaired blood flow to the brain).
Review of the resident's quarterly MDS, dated [DATE], showed a diagnosis of PTSD.
Review of the resident's care plan, dated 3/11/24, showed it did not address the identification of the resident's triggers and specific interventions related to the PTSD diagnosis.
5. Review of Resident #59's medical record showed:
- admission date of 11/1/23;
- Diagnoses of encephalopathy (condition that causes brain dysfunction), PTSD, autistic disorder (developmental disability that caused by differences in the brain), impulse disorder (inability to control impulses and behaviors), personality disorder (behavior that deviates from accepted behavior), muscle weakness, and difficulty walking;
- No smoking assessment completed.
Review of the resident's significant change MDS, dated , 10/24/23, showed the resident used tobacco.
Review of the resident's quarterly MDS, dated , 2/4/24, showed:
- Diagnosis of PTSD;
- Cognitively impaired.
Review of the resident's Progress Notes, dated 2/6/24-3/28/24, showed the resident had falls on
2/6/24, 2/16/24, 3/4/24, and 3/28/24.
Review of the resident's care plan, dated 2/2/24, showed:
- Did not address the identification of the resident's triggers and specific interventions related to the PTSD diagnosis;
- Did not address the tobacco use or the need for any protective devices while smoking;
- Did not address the resident's fall risks or interventions for falls.
6. Review of Resident #61's medical record showed:
- admitted on [DATE];
- Diagnoses of diabetes mellitus (DM - a condition that affects the way the body processes blood sugar), congestive heart failure (CHF - an inability of the heart to pump sufficient blood flow to meet the body's needs), lumbago with sciatica (low back pain that shoots down the legs, sometimes even going all the way to the toes), neuropathy (a disease of the nerves causing tingling, burning or loss of sensation), suicidal ideations, generalized osteoarthritis (a type of arthritis marked by cartilage deterioration of joints and vertebrae), psychotic disorder with hallucinations, spinal stenosis(the narrowing of one or more spaces within the spinal canal), unsteadiness on feet, and shortness of breath.
Review of the resident's Smoking Safety Evaluation, dated 02/20/23, showed:
- Used tobacco;
- Supervision required for all residents during designated smoking times;
- Balance problems while sitting or standing.
Review of the resident's admission MDS, dated [DATE], showed:
- Moderately cognitively impaired;
- Used tobacco.
Review of the resident's care plan, dated 03/19/24, showed:
- Did not address the resident used tobacco;
- Did not address the resident's smoking safety;
- Did not address any specific smoking interventions.
Observations of the resident, showed on 04/10/24 at 1:40 P.M., 04/12/24 at 8:33 A.M. and 10:30 A.M., and on 04/15/24 at 1:30 P.M. and 1:42 P.M., the resident smoking outside in smoking area, without smoking apron, staff member present.
Observations of the resident showed:
- On 04/10/24 at 1:40 P.M., the resident sat on a rollator walker outside smoking a cigarette, and ash from the cigarette fell on resident's right pant leg, with staff member present.
- On 04/12/24 at 8:33 A.M., the resident sat outside on the seat of the rollator walker smoking, tapped 1/2-inch ash off the cigarette with his/her finger, and ash fell down the right side of resident's jacket onto the right knee of his/her pants. The resident's jacket was noted to have 6 burn holes to the bottom right area, the resident held the cigarette in his/her right hand with first two fingers. There were 3 burn holes noted on the left wrist area of the left jacket arm. There was no protective apron in place. The resident rested his/her upper arms on the handle of the rollator, with his/her hands close together;
- On 04/15/24 at 1:30 P. M., the resident was outside in the smoking area sitting on the rollator, smoking a cigarette, the resident's bilateral upper extremities on the handles of the rollator. The resident flicked the cigarette and ash blew back on the resident's leg and clothing.
- On 04/15/24 at 1:42 P.M., the resident smoked a cigarette down to the butt, tapped the lit end of the butt with a fingertip when finished, and continued to smoke. The resident sat on the seat of the rollator with his/her back to the smoke aide at this time.
7. Review of Resident #68's medical record showed:
- admission date of 02/04/24;
- Diagnoses of Alzheimer's disease (progressive mental deterioration), dementia (a disorder marked by memory loss, personality changes, and impaired reasoning that interferes with daily functioning), CHF, peripheral vascular disease (PVD - a condition that causes partial or complete obstruction of blood flow), Parkinsonism (brain conditions that cause slowed movements, stiffness and tremors), MDD, shortness of breath, hypersomnia (a condition in which you feel extreme daytime sleepiness despite getting sleep that should be adequate, or more than adequate), disorientation, other symptoms and signs involving cognitive functions and awareness, hypertension (high blood pressure), anxiety disorder, dysphagia (difficulty swallowing), straining to urinate, and history of falling.
Review of the resident's quarterly MDS, dated [DATE], showed:
- Severe cognitive impairment;
- Substantial/Maximal assistance for toileting, hygiene, shower/bathe self, lower body dressing, putting on/taking off footwear, and personal hygiene;
- Partial/moderate assistance for upper body dressing;
- Supervision or touching assistance for toilet transfer and tub/shower transfer;
- Always incontinent of bowel and bladder.
Review of the resident's care plan, dated 02/04/24, showed:
- Did not address Activities of Daily Living (ADL's);
- Did not address incontinence of bowel and bladder.
During an interview on 04/15/24 at 11:02 A.M., the Administrator said she would expect bed rails to be addressed on the care plans.
During a phone interview on 04/25/24 at 11:41 A.M., the Administrator said a resident's need for assistance with ADL's should be addressed on their care plan. She said smoking should also be addressed on the care plan.
During a phone interview on 04/25/24 at 11:50 A.M., the Assistant Director of Nursing (ADON) said ADL's, such as toileting, dressing, bathing, feeding, transfer assistance, behaviors, and sometimes input and output of bowel and bladder should be addressed on the care plan. Smoking should also be addressed on the care plan.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0658
(Tag F0658)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to follow physician's orders for three residents (Reside...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to follow physician's orders for three residents (Residents #37, #89 and #91) out of 20 sampled residents, and three residents (Resident #40, #43, and #50) outside of the sample. The facility census was 96.
The facility did not provide a policy regarding following physician orders, medication administration or transporting residents.
1. Review of Resident #37's medical record showed:
- Date of admission [DATE];
- Diagnoses of altered mental status, Alzheimer's (progressive mental deterioration) disease, schizoaffective (a condition characterized by abnormal thought processes and deregulated emotions) disorder, bipolar (a mental disorder that causes unusual shifts in mood) disorder, and generalized anxiety disorder (GAD - persistent worry and fear about everyday situations);
- April 2024 Physician Order Sheet (POS) showed an order for Invega Sustenna (an antipsychotic medication) intramuscular (IM) suspension 234 milligram (mg)/1.5 milliliter (ml) IM every 28 days related to schizophrenia, dated 01/13/23. (next due date 04/16/24);
- March 2024 Medication Administration Record (MAR) showed the Invega due and administered on 03/19/24;
- April 2024 MAR showed the Invega due date and not administered on 04/16/24.
2. Review of Resident #40's medical record showed:
- admission date of 11/15/21;
- Diagnoses of schizoaffective disorder, GAD, unspecified psychosis (a mental disorder with a severe loss of contact with reality), and impulse disorder (a group of behavioral conditions that make it difficult to control your actions or reactions);
- April 2024 POS showed an order for Invega Sustenna Suspension 234 mg/1.5 ml, IM every 28 days, related to schizoaffective disorder, dated 12/21/23;
- March 2024 MAR showed Invega due and administered on 03/14/24;
- April 2024 MAR showed Invega due and not administered on 04/11/24.
3. Review of Resident #43's medical record showed:
- admission date of 10/07/15;
- Diagnoses of autistic (a developmental condition causing an inability to relate to everyday life and adjust socially) disorder, bipolar disorder, psychotic disorder (severe mental disorder that causes abnormal thinking and perceptions) with hallucinations (where you hear, see, smell, taste or feel things that appear to be real but only exist in your mind), mood (a mental health problem that primarily affects a person's emotional state) disorder due to known physiological condition, and severe intellectual disability (a term used when there are limits to a person's ability to learn at an expected level and function in daily life);
- April 2024 POS showed an order for medroxyprogesterone acetate (a hormone used in males to treat hypersexual behavior or deviant sexual behavior) suspension 150 mg/ml IM every 28 days related to mood disorder due to known physiological condition, dated 02/18/23;
- March 2024 MAR showed medroxyprogesterone due and administered on 03/16/24;
- April 2024 MAR showed medroxyprogesterone due and not administered on 04/13/24.
During an interview on 04/15/24 at 12:00 P.M., Licensed Practical Nurse (LPN) A said the medroxyprogesterone injection wasn't given on 04/13/24, as ordered for Resident #43 because it had to be ordered from the pharmacy. Resident #40's Invega injection was due on 04/11/24, but it wasn't in the building according to the MAR so it was not administered. When LPN A entered the facility today, injection medications were not given when they were due, they still sat in the medication cart. Since they were still in the cart and not administered to the residents, he/she changed the administration due dates on the MARs.
During an interview on 4/15/24 at 1:30 P M., the Administrator and Assistant Director of Nursing (ADON) said if a medication injection was missed, the physician should be notified, it should be documented why the medication wasn't given, and a counsel form with the employee should be completed if needed. Medication administration dates could be changed with physician communication and orders to ensure it was within the timeframe.
4. Review of Resident #50's medical record showed:
- admission date of 08/17/20;
- Diagnoses of schizoaffective disorder, oppositional defiant (a type of disruptive behavior disorder) disorder, GAD, attention-deficit hyperactivity disorder (ADHD - behaviors marked by an ongoing pattern of inattention and/or hyperactivity-impulsivity that interferes with functioning or development), mild intellectual disabilities, and intermittent explosive disorder (repeated, sudden bouts of impulsive, aggressive, violent behavior or angry verbal outbursts);
- April 2024 POS showed an order for Haldol Decanoate solution 100 mg/ml IM 100 mg every 21 days related to schizoaffective disorder and bipolar disorder, dated 03/05/24;
- March 2024 MAR showed Haldol administered on 03/25/24;
- April 2024 MAR showed Haldol due and not administered on 04/15/24.
Observation on 04/15/24 at 11:50 A.M., showed Haldol for Resident #50 not in the facility.
5. Review of Resident #91's medical record showed:
- admitted on [DATE];
- Diagnoses of PTSD, autistic disorder, borderline personality disorder (a mental disorder characterized by unstable moods, behavior and relationships), oppositional defiant disorder, disruptive mood disorder (a condition in which children or adolescents experience ongoing irritability, anger, and frequent, intense temper outbursts), anxiety, and ADHD.
Review of the resident's Behavioral Health Hospitalization discharge instructions, dated [DATE], showed:
- An order to change Effexor XR 225 mg every morning for anxiety to Effexor ER 75 mg one capsule once a day in the morning;
- An order to stop prazosin 1 mg capsule every morning for flash backs and anxiety.
Review of the resident's March and April 2024 POS showed:
- An order for Effexor (an antidepressant used to treat depression, and anxiety) extended release (ER) 225 mg every morning for anxiety, dated 02/15/23;
- An order for prazosin (a blood pressure medication also used to treat symptoms of PTSD and associated nightmares) 1 mg capsule every morning for flash backs and anxiety, dated 02/25/24.
- An order for Effexor XR 75 mg once a day in the morning, dated 03/07/24;
- An order for the prazosin 1 mg every morning for flash backs and anxiety discontinued, dated 03/07/24.
Review of the resident's March and April 2024 MAR showed:
- No documentation of an order for Effexor XR 75 mg once a day in the morning, dated 03/07/24;
- Effexor ER 225 mg every morning incorrectly administered for 40 doses for 03/08/24 - 04/16/24;
- No documentation of an order for the prazosin 1 mg every morning discontinued, dated 03/07/24;
- Prazosin 1 mg every morning incorrectly administered for 40 doses for 03/08/24 - 04/16/24.
During an interview on 04/16/24 at 11:05 A.M., the Administrator said she would expect the most current medication orders to be clarified with the physician and be followed.
During an interview on 04/16/24 at 12:04 A.M., the Minimum Data Set (MDS - a federally mandated assessment instrument completed by the facility staff) Coordinator said nursing should go through all new orders and update with the changes. It was nursing's responsibility.
During an interview on 04/16/24 at 12:44 P.M., the Psychiatric Nurse Practitioner said facility staff may have notified him/her about the medication changes on the discharge instructions, he/she was unsure. He/She would expect to be notified and should address any changes.
6. Review of Resident #89's medical record showed:
- admission date of 10/04/23;
- Diagnosis of chronic obstructive pulmonary disease (COPD - a condition that constricts the airways);
- A Physician's Referral Order for a new patient appointment for a visit and an initial evaluation related to shortness of breath and possible diastolic heart disease (a condition in which your heart's main pumping chamber becomes stiff and unable to fill properly), dated 02/01/24.
During an interview on 04/15/24 at 3:39 P.M., Resident #89 said he/she did not get taken to an appointment with the Cardiologist, (a physician who specializes in the study and treatment of heart diseases and heart abnormalities). The appointment had been scheduled for two months, for the date of 04/15/24.
During an interview on 04/15/24 at 4:20 P.M., the Central Supply and Transport Assistant said the transportation scheduler failed to get a confirmation number when originally making the appointment with Medicaid transport for Resident #89. The appointment was missed today due to the mistake. The transportation scheduler made a call today to the physician to try and reschedule a new appointment.
During an interview on 04/16/24 at 10:15 A.M., the Transportation Scheduler said Resident #89 had missed an appointment yesterday that should have been scheduled with Medicaid transport and a confirmation number was not received from Medicaid transport. A new appointment has now been scheduled for the resident on 05/16/24 at 11:30 A.M.
During an interview on 04/16/24 at 11:51 A.M., Licensed Practical Nurse (LPN) A said residents had missed appointments before. The appointment was made with the Cardiologist for Resident #89 and there was no confirmation number received from Medicaid transport so the resident missed the appointment. The appointment was rescheduled for 05/16/24.
During an interview on 04/16/24 at 1:01 P.M., the MDS Coordinator said Resident #89 had an appointment for a Cardiologist that was missed yesterday. The appointment was his/her first scheduled appointment when the referral was made, but it was missed due to an error during transporter set up. A confirmation number for the appointment should have been given but wasn't received. The resident should have been picked up for the appointment but with no confirmation number, Medicaid transport did not know the resident needed to be picked up from the facility.
During an interview on 04/16/24 at 1:59 P.M., the Administrator said Resident #89 should have been taken to an appointment with the Cardiologist yesterday but wasn't. The transporter said he/she had scheduled Medicaid transport for the resident but was not able to provide the confirmation number. Medicaid transport was contacted but they did not have a confirmation number and didn't know to pick up the resident.
During an interview on 04/16/24 at 2:59 P.M., the Medical Director said if the residents had orders for specialty appointments, the appointments should be scheduled and the residents should be transported to the appointments.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Quality of Care
(Tag F0684)
Could have caused harm · This affected multiple residents
Based on interview and record review, the facility failed to ensure four residents (Resident #3, #13, #20, and #37) out of four sampled residents receiving hospice (palliative care for the terminally ...
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Based on interview and record review, the facility failed to ensure four residents (Resident #3, #13, #20, and #37) out of four sampled residents receiving hospice (palliative care for the terminally ill with a life expectancy of six months or less) services had a complete hospice coordinated plan of care. The facility failed to ensure one resident (Resident #37) had any hospice care documentation. The facility census was 96.
The facility did not provide a hospice policy.
1. Review of Resident #3's medical record showed:
- admitted to hospice on 03/20/24;
- No facility staff signatures for the coordinated plan of care.
2. Review of Resident #13's medical record showed:
- admitted to hospice on 06/07/22;
- No facility staff signatures for the coordinated plan of care.
3. Review of Resident #20's medical record showed:
- admitted to hospice on 01/13/23;
- No facility staff signatures for the coordinated plan of care.
4. Review of Resident #37's medical record showed:
- An order for hospice to evaluate and treat, dated 03/15/24;
- Nurse's note, dated 03/21/24, the resident admitted to hospice on 03/20/24;
- Nurses notes, dated 3/30/24, 3/31/24, and 4/1/24, the resident continued on hospice services.
Review of the facility's hospice binder showed:
- No documentation of the resident's hospice information;
- The facility failed to document the resident's hospice admission date, hospice orders, the name of the hospice nurse and the specific days of the hospice nurse visits, the name of the hospice aide and the specific days of the hospice aide visits, the medical supplies provided by the hospice, and the durable medical equipment (DME) (equipment that helps complete daily activities) provided by the hospice;
- The facility failed to provide a coordinated plan of care.
Review of the resident's care plan dated 04/04/24, showed the resident had a terminal prognosis and was now on hospice related to chronic obstructive pulmonary disease (COPD - a chronic inflammatory lung disease that causes obstructed airflow from the lungs), chronic kidney disease, Alzheimer's (progressive mental deterioration) dementia (a disorder marked by memory loss, personality changes, and impaired reasoning that interferes with daily functioning), and weight loss.
During an interview on 04/15/24 at 2:00 P.M., the Assistant Director of Nursing (ADON) said she was told by the hospice company there was another hospice binder. She had never seen a third binder and could not find anything on Resident #37. There should be a coordinated plan of care between the hospice and the facility. The coordinated plan of care should be signed by both the hospice and facility staff.
During an interview on 04/16/24 at 1:00 P.M., the Administrator said there should be a coordinated plan of care signed by both hospice and facility staff. The ADON had looked through everything for any hospice information for Resident #37 and couldn't find anything in the building.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Accident Prevention
(Tag F0689)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure the environment remained free of accident haza...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure the environment remained free of accident hazards by not appropriately assessing four residents (Resident #13, #59, #61 and #89) of four sampled residents who were identified as residents who smoke, to ensure they were able to smoke safely. The facility census was 96.
Review of the facility's policy titled, Smoking, undated, showed:
- The supervising staff member will notify the unit nurse when a resident's ability to smoke safely is in question;
- On admission, the unit nurse will ascertain the resident's wishes about smoking and respect the resident's decision;
- Assess the resident's ability to smoke safely by completing a smoking assessment that includes an evaluation of the resident's safety awareness, judgement, cognitive ability, and manual dexterity;
- Instruct staff members to notify the unit nurse immediately if it is suspected the resident has violated the facility smoking policy or if the resident's clothing or skin has signs of cigarette burns;
- The Minimum Data Set (MDS - a federally mandated assessment instrument completed by the facility staff) Nurse will evaluate each resident who smokes for smoking safety with every MDS assessment, and document the resident's need for supervision in the care plan, and update with any change in the resident's capabilities and needs.
1. Review of Resident #13's medical records showed:
- admitted on [DATE];
- Diagnoses of a stroke affecting the left non-dominant side and hemiplegia (paralysis on one side of the body);
- No documentation of a smoking assessment since 10/10/22.
Review of the resident's Smoking Assessment, dated 10/10/22, showed:
- Unable to light a cigarette safely;
- Unable to hold a cigarette safely;
- Unable to extinguish a cigarette safely;
- Unable to use an ashtray to extinguish a cigarette.
Review of the resident's care plan, dated 04/14/24, showed the resident required a smoking apron while smoking due to safety, and he/she refused to wear it. It should be offered with each smoke break.
Observations of the resident showed:
- On 04/10/24 at 6:25 P.M., the resident smoked with six additional residents and two staff present. Resident #13 held a cigarette in the right hand to smoke and did not wear a smoking apron. The resident had a small pile of ashes on his/her pants to the right side of his/her lap;
- On 4/11/24 at 10:17 A.M., the resident smoked with nine additional residents and Smoke Aide (SA) O. SA O stood close to the resident. The resident did not wear a smoking apron, held the cigarette in his/her right hand and pushed the cigarette against the wheelchair frame to knock ashes off. When the resident knocked the ashes off, a pile fell into the wheelchair seat. The resident pushed the hot ash off and it fell to the ground in two piles. SA O relit the cigarette;
- On 04/11/24 at 3:02 P.M., SA O passed cigarettes out to the residents that smoked and lit them. Resident #13 did not wear a smoking apron and one was not offered or encouraged. The resident sat in his/her wheelchair with a lit cigarette in his/her right hand and pushed the cigarette on the wheelchair frame to drop the ashes. Toward the end of the cigarette, the resident sat with his right foot resting on his/her left knee with the resident's right hand resting on the right heel area. The fire end of the cigarette touched the resident's sock heel and a pencil size tan/brown scorched area showed on the sock heel;
- On 04/15/24 at 1:15 P.M., the resident smoked, did not wear a smoking apron, and Certified Nurse Assistant (CNA) B present.
During an interview on 04/11/24 at 1:43 P.M., SA O said there were no residents that required a smoking apron. Resident #13 could probably use one, but he/she wasn't even sure if the facility had one, so he/she didn't offer it to the resident.
During an interview on 04/11/24 an 1:44 P.M., CNA B said he/she was unaware of any residents that required a smoking apron.
During an interview on 04/10/24 at 5:08 P.M., the MDS Coordinator said smoking assessments should be completed by a floor nurse on admission and quarterly. Resident #13 did require a smoking apron but it was refused. It should be offered and encouraged for the resident to use.
2. Review of Resident #59's medical record showed:
- admission date of 11/01/23;
- Diagnoses of encephalopathy (condition that causes brain dysfunction), post traumatic stress disorder (PTSD - disorder that occurs if a traumatic event has been witnessed or experienced), autistic (developmental disability that caused by differences in the brain) disorder, impulse (inability to control impulses and behaviors) disorder, personality disorder (behavior that deviates from accepted behavior), muscle weakness (decrease in muscle strength), and difficulty walking;
- No documentation of a smoking assessment.
Review of the resident's significant change MDS, dated , 10/24/23, showed the resident used tobacco.
Review of the resident's quarterly MDS, dated , 02/04/24, showed:
- Cognitively impaired;
- Supervision with ADLs;
Review of the resident's care plan, dated, 02/02/24, showed:
- Did not address the resident used tobacco;
- Did not address the smoking safety or supervision during smoking;
- Did not address specific interventions during smoking.
Observations of the resident showed:
- On 04/11/24 at 10:36 A.M., the resident smoked outside with no smoking apron and supervised by SA O. SA O lit the resident's cigarette and the resident held the cigarette in his/her right hand with 2 inches (in.) of ashes hanging off the cigarette. The resident had ashes on his/her sweatshirt and wheelchair seat;
- On 04/11/24 at 1:34 P.M., the resident smoked outside with no smoking apron and supervised by SA O. SA O lit the resident's cigarette and the resident held the cigarette in his/her right hand with 3 in. of ashes hanging off the cigarette. The resident had ashes on his/her clothing and wheelchair;
- On 04/12/24 at 8:33 A.M., the resident smoked, sat in a wheelchair outside, wore a smoking apron, and supervised by SA O.
During an interview on 04/12/24 at 10:39 A.M., SA O said he/she kept the smoke apron in the cart with the cigarettes. SA O started putting the apron on the resident because the resident dropped ashes on him/herself yesterday.
During an observation on 04/15/24 at 1:36 P.M., the resident smoked outside with no smoking apron. The resident sat in a wheelchair and wore house shoes. Ashes fell off the lit cigarette onto the resident's shirt. The resident swept off the ashes on the shirt with his/her hand. One inch (in.) of ash lay by the resident's right leg and touched the wheelchair seat and the resident's pants. Another resident told SA O that the resident needed a smoking apron. A smoking apron sat on the cart. The SA did not provide a smoking apron to the resident. The resident smoked one cigarette and another resident took the cigarette from the resident, extinguished it, and disposed of it in an appropriate container.
During an observation on 04/15/24 at 3:40 P.M., the resident sat outside in the wheelchair, smoked with no smoking apron on, and supervised by CNA D. A 1/2 in. of ash sat on the resident's t-shirt.
During an interview, on 04/15/24 at 3:50 P.M., CNA D, said the resident told staff when he/she was finished and the staff extinguished the cigarettes.
3. Review of Resident #61's medical record showed:
- admitted on [DATE];
- Diagnoses of diabetes mellitus (DM - a condition that affects the way the body processes blood sugar), congestive heart failure (CHF - an inability of the heart to pump sufficient blood flow to meet the body's needs), lumbago with sciatica (low back pain that shoots down your legs), neuropathy (a disease of the nerves causing tingling, burning or loss of sensation), suicidal ideations, generalized osteoarthritis (a type of arthritis marked by cartilage deterioration of joints and vertebrae), psychotic disorder with hallucinations, spinal stenosis (the narrowing of one or more spaces within your spinal canal), unsteadiness on feet, and shortness of breath;
- No documentation of a smoking assessment since 02/20/23.
Review of the resident's Smoking Safety Evaluation, dated 02/20/23, showed:
- Resident used tobacco;
- Supervision required for all residents during designated smoking times;
- Balance problems while sitting or standing.
Review of the resident's admission MDS, dated [DATE], showed:
- Moderately cognitively impaired;
- Used tobacco.
Review of the resident's care plan, dated 03/19/24, showed:
- Did not address the resident used tobacco;
- Did not address the smoking safety or supervision during smoking;
- Did not address specific interventions during smoking.
Observations of the resident showed:
- On 04/10/24 at 1:40 P.M., the resident sat on a rollator walker (a walker with wheels and a seat) outside, smoked a cigarette and the ash from the cigarette fell on the resident's right pant leg. The resident did not wear a smoking apron, and was supervised by staff;
- On 04/12/24 at 8:33 A.M., the resident sat on a rollator walker outside smoking with no smoking apron on and supervised by staff. The resident held the cigarette with the first two fingers of the right hand. The resident tapped a 1/2 in. ash off the cigarette with a finger and the ash fell down the right side of the resident's jacket onto his/her right knee of the pants. The resident's jacket had six burn holes to the bottom right area and three burn holes to the left wrist area;
- On 04/12/24 at 10:30 A.M., the resident sat on a rollator walker outside smoking with no smoking apron on and supervised by staff;
- On 04/15/24 at 1:30 P. M., the resident sat on a rollator walker outside smoking with no smoking apron on and supervised by staff. The resident flicked the cigarette where the ash blew back on the resident's leg and clothing;
- On 04/15/24 at 1:42 P.M., the resident sat on a rollator walker outside, smoking the cigarette down to the butt and supervised by staff. The resident tapped the lit end of the butt with a fingertip and continued to smoke the butt.
During an interview on 04/12/24 at 10:30 A.M., the resident said he/she had never been talked to by staff about wearing a smoking apron while smoking.
4. Review of Resident #89's medical record showed:
- admitted on [DATE];
- A smoking assessment, dated 08/04/23, showed the resident a safe smoker;
- No documentation of a smoking assessment since 08/24/23.
- Schizoaffective disorder (a condition characterized by abnormal thought processes and deregulated emotions), PTSD, suicidal ideations, insomnia (difficulty sleeping) due to other mental disorder, Chronic Obstructive Pulmonary Disease (COPD, a chronic inflammatory lung disease that causes obstructed airflow from the lungs);
- Review of the resident's revised care plan, dated 01/30/24, showed it did not address resident smoking.
Observation on 04/15/24 at 1:35 P.M. and 3:39 P.M., showed the resident smoked with other residents and supervised by staff. The resident did not wear a smoking apron.
During an interview on 04/12/24 at 11:17 A.M., the resident said he/she was an independent smoker and had taken a smoke break today.
During an interview on 04/10/24 at 1:40 P.M., the MDS Coordinator said smoking assessments should be completed on admission and quarterly by a nurse on the floor. There was no current evaluation for Resident #89. Care plans should indicate concerns and interventions for residents that smoke.
During an interview on 4/12/24 at 11:05 A.M., SA O said that Resident #89 usually smoked outside in the afternoon and had been outside yesterday to smoke.
During an interview on 4/16/24 at 1:59 P.M., the Administrator said that a smoking assessment should be completed on all residents upon admission, when required and at least quarterly. The resident care plan should indicate smoking interventions.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0699
(Tag F0699)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to identify, assess and provide supportive interventions...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to identify, assess and provide supportive interventions for seven residents (Residents #33, #38, #57, #59, #78, #89 and #91) with a diagnosis of post traumatic stress disorder (PTSD - a mental health condition triggered by a terrifying event - either experiencing it or witnessing it; symptoms may include flashbacks, nightmares and severe anxiety, as well as uncontrollable thoughts about the event) out of seven sampled residents. The facility's census was 96.
The facility did not provide a PTSD policy.
1. Review of Resident #33's medical record showed:
- admitted on [DATE];
- discharged on 01/11/24, and readmitted on [DATE];
- Diagnoses of PTSD, major depressive disorder (MDD - long-term loss of pleasure or interest in life), schizophrenia (a long term mental disorder that affects a person's ability to think, feel, or behave clearly, sometimes including delusions or hallucinations), schizoaffective disorder (a condition characterized by abnormal thought processes and deregulated emotions), anxiety disorder (persistent worry and fear about everyday situations), bipolar (a mental disorder that causes unusual shifts in mood) disorder, paranoid (an unfounded and/or exaggerated mistrust of others) schizophrenia, and other seizures (a burst of uncontrolled electrical activity between brain cells that causes temporary abnormalities in muscle tone or movements like stiffness, twitching or limpness, behaviors, sensations, or states of awareness);
- No documentation of a PTSD assessment.
Review of the resident's Physician's Order Sheet (POS), dated April 2024, showed:
- An order for benztropine (an anti-tremor medication) 1 milligram (mg) three times a day for schizoaffective disorder, dated 04/03/24;
- An order for Celexa (an anti-depressant medication) 20 mg one tablet a day for MDD, dated 02/26/24;
- An order for clozapine (an anti-psychotic medication) 50 mg two times a day for schizoaffective disorder, bipolar disorder and paranoid schizophrenia, dated 04/03/24;
- An order for divalproex sodium (a seizure medication) 500 mg one tablet a day for seizures, dated 04/05/22;
- An order for Haldol (an antipsychotic medication used to treat certain types of mental disorders) 5 mg every 12 hours as needed for anxiety, dated 04/03/24;
- An order for hydroxyzine (an anti-anxiety medication) 25 mg every 6 hours as needed for anxiety, dated 04/03/24;
- An order for Invega (an antipsychotic medication) Sustenna intramuscular (IM) 234 mg injection every 28 days for schizoaffective disorder, dated 04/03/24;
- An order for lorazepam (an antianxiety medication) intensol oral concentrate 2 mg every 6 hours for anxiety related to schizoaffective disorder, dated 03/14/24.
Review of the resident's Preadmission Screening and Resident Review (PASARR - a federal program to prevent inappropriate admission and retention of people with mental disabilities in nursing facilities), dated 07/02/18, showed:
- Schizoaffective disorder, major depression, paranoid schizophrenia, anxiety and epilepsy (a disease that causes recurrent seizures);
- No behaviors documented.
Review of the resident's care plan, last updated 01/27/24, showed no documentation the resident had past trauma or any triggers that would cause the resident to have behaviors.
During an interview on 04/16/24 at 11:44 A.M., Resident #33 said he/she had not spoken with staff about PTSD triggers that included a fear of being talked about by other people. Speaking with certain nursing staff and having alone time to read helps him/her return to baseline.
2. Review of Resident #38's medical record showed:
- admitted on [DATE];
- Diagnoses of schizoaffective disorder bipolar type, PTSD, MDD, and obsessive-compulsive personality disorder (OCD - a mental health condition that causes an extensive preoccupation with perfectionism, organization and control);
- No documentation of a PTSD assessment.
Review of the resident's POS, dated April 2024, showed:
- An order for chlorpromazine (an antipsychotic medication) 25 mg by mouth twice daily for schizoaffective disorder bipolar type, dated 02/03/23;
- An order for clozapine 150 mg by mouth twice daily for schizoaffective disorder bipolar type, dated 10/04/23;
- An order for fluvoxamine (an anti-depressant medication) 25 mg give four tablets by mouth in the morning for schizoaffective disorder bipolar type, dated 06/22/23;
- An order for Haldol injection solution 5 mg IM every six hours as needed (PRN) for agitation, dated 07/12/23;
- An order for hydroxyzine 25 mg by mouth twice daily for anxiety, dated 06/01/22;
- An order for Invega Sustenna Suspension 234 mg IM on day shift every 28 days for schizoaffective disorder bipolar type, dated 06/18/23;
- An order for lorazepam 0.5 mg by mouth twice daily for schizoaffective disorder bipolar type, dated 01/29/24;
- An order for Seroquel (an antipsychotic medication) 200 mg by mouth at bedtime for schizoaffective disorder bipolar type, dated 09/13/23.
Review of the resident's PASARR, dated 12/02/21, showed:
- Required secured long term care placement for safety;
- Schizophrenia, command hallucinations with suicidal ideations, MDD, and borderline personality (a mental disorder characterized by unstable moods, behaviors, and relationships) disorder;
- Behaviors included suicidal and homicidal tendencies, violent outburst.
Review of the resident's care plan, updated 03/11/24, showed no documentation of PTSD triggers that would cause the resident to have behaviors.
3. Review of Resident #57's medical record showed:
- admitted on [DATE];
- Diagnoses of delusional disorders (mental health condition which a person can't tell what's reality and imagined), MDD, anxiety disorder, PTSD, bipolar disorder, and vascular dementia (impaired thought processes caused by impaired blood flow to the brain);
- No documentation of a PTSD assessment.
Review of the resident's POS, dated April 2024, showed:
- An order for Lexapro (an anti-depressant medication) 10 mg by mouth daily for MDD, dated 2/1/24;
- An order for Seroquel 25 mg by mouth twice daily for MDD with psychosis, dated 2/1/24.
Review of the resident's PASARR, dated,09/02/21, showed:
- Required secured long term care placement for safety;
- Unspecified psychosis, anxiety disorder, PTSD, and major neurocognitive disorder with behavioral disturbance;
- History of physical and sexual abuse;
- Behaviors include verbal threats and suspicion of others.
Review of the resident's care plan, dated 03/11/24, showed:
- PTSD not addressed;
- No documentation the resident had past trauma or any triggers that would cause the resident to have behaviors.
4. Review of Resident #59's medical record showed:
- admitted on [DATE];
- Diagnoses of encephalopathy (condition that causes brain dysfunction), PTSD, autistic disorder (developmental disability caused by differences in the brain), impulse disorder (inability to control impulses and behaviors), personality disorder (behavior that deviates from accepted behavior), muscle weakness (decrease in muscle strength), and difficulty in walking;
- No documentation of a PTSD assessment;
Review of the resident's POS, dated April 2024, showed:
- An order for clonazepam (a sedative medication) 1 mg by mouth three times daily for anxiety/agitation, dated 2/2/24;
- An order for duloxetine (an anti-depressant medication) 60 mg by mouth twice daily for depression, dated 2/2/24;
- An order for Latuda (an antipsychotic medication) 80 mg by mouth two times daily for mood disorder, dated 7/13/23;
- An order for lorazepam 1 mg by mouth every 12 hours PRN for anxiety, dated 1/12/24;
- An order for prazosin (an anti-hypertensive medication) 1 mg by mouth at bedtime for mood disorder, dated 11/1/23;
- An order for trazodone (an anti-depressant medication) 100 mg give 2 tablets by mouth at bedtime for sleep aid, dated 11/1/23.
Review of the resident's PASARR, dated, 06/30/23, showed:
- Required a secured long term care placement for safety;
- Intellectual disability, mood disorder, borderline personality disorder, psychotic disorder, disruptive behavior disorder, and PTSD;
- History of sexual abuse;
- Behaviors include elopement, suicidal threats and ideations.
Review of the resident's care plan, dated 02/02/24, showed:
- PTSD not addressed;
- No documentation the resident had past trauma or any triggers that would cause the resident to have behaviors.
5. Review of Resident #78's medical record showed:
- admitted on [DATE];
- discharged on 01/13/24, and readmitted on [DATE];
- Diagnoses of PTSD, schizoaffective disorder bipolar type, OCD, and homicidal ideations (thinking about, considering, or planning, a homicide);
- No documentation of a PTSD assessment.
Review of the resident's POS, dated April 2024, showed:
- An order for clozapine 100 mg three times a day for schizoaffective disorder, dated 12/13/22;
- An order for fluvoxamine 100 mg once a day for OCD, dated 01/26/24;
- An order for Haldol 10 mg every 8 hours PRN for psychosis related to schizoaffective disorder bipolar type/homicidal ideations, dated 01/12/24;
- An order for Invega Sustenna 234 mg IM every 28 days for schizoaffective disorder, dated 01/12/24.
Review of the resident's PASARR, dated 11/30/22, showed:
- Diagnosis of schizophrenia;
- No behaviors documented.
Review of the resident's care plan, revised 01/27/24, showed no documentation the resident had past trauma or any triggers that would cause the resident to have behaviors.
During an interview on 04/16/24 at 11:46 A.M., Resident #78 said he/she had not spoken with staff about his/her PTSD triggers. Writing was helpful in returning to his/her baseline.
6. Review of Resident #89's medical record showed:
- admitted on [DATE];
- discharged on 10/24/23, and readmitted on [DATE];
- Diagnoses of PTSD, insomnia (a common sleep disorder) due to other mental disorder, MDD, schizoaffective disorder depressive type;
- No documentation of a PTSD assessment.
Review of the resident's POS, dated April 2024, showed:
- An order for fluoxetine (an antidepressant medication) 40 mg 2 capsules by mouth in the morning related to schizoaffective disorder depressive type, dated 03/18/24;
- An order for Seroquel 300 mg at bedtime related to schizoaffective disorder depressive type, dated 01/01/24.
Review of the resident's PASARR, dated 07/31/23, showed:
- MDD and antisocial personality disorder (a mental health disorder characterized by a disregard for other people);
- No behaviors documented.
Review of the resident's care plan, revised 02/16/24, showed:
- Psychotropic (medications that affects behavior, mood, thoughts, or perception) medications related to PTSD and depression used;
- No documentation the resident had past trauma or any triggers that would cause the resident to have behaviors.
During an interview on 04/12/24 at 11:17 A.M., Resident #89 said no one had talked with him/her about his/her PTSD triggers. The triggers were mainly loud noises and loud talkers. Most help came from the medications and they were effective in the treatment of his/her PTSD, but talking to staff was also helpful.
7. Review of Resident #91's medical record showed:
- admitted on [DATE];
- Diagnoses of PTSD, autistic disorder, borderline personality disorder, oppositional defiant disorder (a disorder marked by defiant and disobedient behavior to authority figures), disruptive mood disorder (a condition in which children or adolescents experience ongoing irritability, anger, and frequent, intense temper outbursts), anxiety, attention deficit hyperactivity disorder (ADHD - a chronic condition including attention difficulty, hyperactivity and impulsiveness).
Review of the resident's Trauma informed Care Assessment, completed on 04/12/24, showed:
- The resident experienced a frightening, horrible or traumatic event;
- In the past month, the resident had nightmares or thought about the event when he/she didn't want to; tried hard not to think about it or went out of the way to avoid situations that reminded him/her of the event; been constantly on guard; watchful or easily startled; had felt numb or detached from people, activities or surroundings; and had felt guilty or unable to stop blaming him/herself or others for the events or problems the events may have caused;
- Did not identify the resident's triggers.
Review of the resident's POS, dated April, 2024, showed:
- An order for Effexor (an antidepressant medication) extended release (XR) 225 mg every morning for anxiety, dated 2/15/23;
- An order for Haldol 5 mg tablet every eight hours PRN for behaviors related to oppositional defiant disorder, dated 04/04/24;
- An order for Haldol 5 mg tablet give two tablets two times a day for disruptive mood disorder, dated 04/09/24;
- An order for lorazepam 0.5 mg one tablet two times a day for anxiety, dated 04/10/24;
- An order for oxcarbazepine (an anticonvulsant medication) 300 mg three tablets two times a day for borderline personality disorder, dated 11/29/23;
- An order for Invega Sustenna 234 mg IM in the afternoon every 28 days, dated 02/02/24;
- An order for prazosin 1 mg every morning for flash backs and anxiety, dated 02/05/24;
- An order for prazosin 5 mg at bedtime for frightening dreams/PTSD, dated 11/29/23;
- An order for trazodone (an antidepressant medication) 50 mg tablet give two tablets PRN at bedtime for trouble sleeping. dated 02/01/24.
Review of the resident's PASARR, dated 11/27/23, showed:
- Needs can be met in a nursing facility;
- PTSD;
- PASARR related disability, serious mental illness, intellectual developmental disability;
- Supports and services to be provided by the nursing facility: behavioral support services, structured environment, and crisis intervention services;
- Behaviors include impatience, demanding, and physically threatening;
- Extensive history of aggression, self-injurious behaviors, suicide attempts, attention seeking behavior, mood liability, anxiety, depression, impulse control issues, limited insight and judgement, poor decision making skills, and inability to keep self safe;
- Needs a provision of services to address the individuals mental health and behavioral needs;
- Obtain Individual Support Plan (ISP), Individualized Treatment Plan (ITP), and Behavioral Support Plan (BSP) from the Department of Mental Health (DMH) Community Mental Health Center and/or Developmental Disability Regional Office;
- Requires a structured environment, provide instruction at the individuals level of understanding, environmental supports to prevent elopement, assess and plan for the level of supervision required to prevent harm to self or others, provide individual personal space, provide sensory support, establish consistent routines, and provide schedule of daily tasks/activities;
- Crisis intervention services - assess and plan for crisis intervention that provides emotional support, education and safety. It should create clear steps that are taken to support the resident during a behavioral crisis, including who to contact for assistance, how to work together, how to determine when a crisis is over. The plan should also identify a physician and emergency medical services that should be contacted, the facility may also wish to utilize the DMH Behavioral Health Crisis Hotline;
- Suicide precautions, assault precautions, and elopement precautions;
- The crisis plan is warranted due to the resident has an extensive history of aggression, suicidal ideation, self injurious behaviors and elopements;
- Long term care placement recommended for the resident's safety.
Review of the resident's care plan, dated 03/22/24, showed:
- Did not identify the resident's triggers;
- Did not address suicidal ideations, elopements, or self-harm with interventions;
- Did not address a crisis plan.
During an interview on 04/12/24 at 4:40 P.M., the Social Service Designee (SSD) said there were no PTSD assessments completed. There should have also been care plans completed that address triggers and interventions for PTSD.
During an interview on 04/12/24 at 4:44 P.M., the Medical Records Director said there were no PTSD assessments completed. Residents with PTSD should have an assessment upon admission. There should have also been care plans completed that address triggers and interventions for PTSD.
During an interview on 04/16/24 at 11:51 A.M., Licensed Practical Nurse (LPN) A said residents were supposed to be seen by the psychiatrist routinely. PTSD concerns like triggers, interventions and medication information should be in the care plan so it could be reviewed by all staff. The care plan would be checked in order to know how to deal with a triggered resident. The PTSD assessments should be completed and used to help complete care plans.
During an interview on 04/16/24 at 1:01 P.M., the Minimum Data Set (MDS - a federally mandated assessment instrument completed by the facility staff) Coordinator said residents with a PTSD diagnosis should have a care plan that addressed the triggers with individualized interventions. Residents with PTSD should also have an assessment. Staff should know what triggers a resident with PTSD and so it should be identified on the care plan. The resident interventions should be on the care plan that speaks on how a resident was brought back to a baseline. There were no PTSD assessments completed and care plans will need to be corrected.
During an interview on 04/16/24 at 1:59 P.M., the Administrator said residents with PTSD did not have proper care plans or assessments completed. A PTSD assessment should have been completed on admission. The assessment should determine the best path for the resident. There was no PTSD policy at this time. There should be a plan of care that was individualized to the resident. Care plans should cover PTSD concerns including triggers for the resident, interventions that should be resident specific and help them calm and return to baseline when triggered.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected multiple residents
Based on observation, interview and record review, the facility failed to maintain proper infection control practices during colostomy (an opening for the colon through the abdomen) and suprapubic cat...
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Based on observation, interview and record review, the facility failed to maintain proper infection control practices during colostomy (an opening for the colon through the abdomen) and suprapubic catheter (a surgically created connection between the urinary bladder and the skin used to drain urine from the bladder in individuals with obstruction of normal urinary flow) care for one resident (Resident #25) out of one sampled resident. The facility failed to maintain proper infection control practices during blood sugar checks for three residents (Residents #22, #38, and #60) out of five sampled residents and insulin administration for one resident (Resident #22) of one resident, when staff failed to perform hand hygiene between each resident and tasks. The facility census was 96.
Review of the facility's policy titled Standard Precautions undated, showed:
- Wash hands before having direct contact with resident, putting on gloves, and preparing or eating food;
- Wash hands after removing gloves or other personal protective equipment, contact with body substances or articles/surfaces contaminated with body substances, contact with resident's intact skin (taking pulse, lifting resident);
- It may be necessary to wash hands between tasks and procedures on the same resident to prevent cross-contamination of different body sites;
- Remove gloves promptly after use, before touching non-contaminated items and surfaces, and before going to another resident;
- Wash hands as soon as possible after glove removal;
- Needles-take care to prevent injuries when disposing of used needles, place used disposable needles and other sharp items in appropriate puncture-resistant containers.
Review of the facility's policy titled, Urinary Catheter Care, undated showed:
- Nursing assistants must do catheter and perineal care with a.m. and p.m. care, and after each of the resident's bowel movements;
- Always wash your hands before and after handling the catheter, tube or bag, and wear gloves;
- Clean the area where the catheter is inserted by wiping away from the insertion site, to prevent germs from being moved from the anus to the urethra;
- Wash the catheter to remove any blood or other materials from the catheter, wiping downwards;
- Keep the bag below the level of the resident's bladder at all times;
- Use a catheter bag to cover to protect the resident's dignity.
1. Observation on 04/12/24 at 7:30 A.M., of colostomy and suprapubic catheter care for Resident #25 showed:
- Restorative Aide (RA) I and Certified Nursing Assistant (CNA) D did not perform hand hygiene upon entering the room;
- Resident lay in bed on his/her back;
- CNA D and RA I put on gloves and pulled the sheet back;
- RA I removed the gloves, failed to perform hand hygiene, touched the door knob to leave the room to gather supplies, and told a nurse the colostomy needed changed;
- CNA D removed the colostomy bag and the suprapubic catheter dressing soiled with fecal material from the leaking colostomy;
- CNA D removed the gloves, did not perform hand hygiene, and left the room to discard the waste;
- RA I entered the room without performing hand hygiene and put on gloves;
- RA I cleansed the resident's abdomen around the colostomy toward the suprapubic catheter insertion site;
- CNA D entered the room, did not perform hand hygiene, put on gloves, and rolled the resident to his/her side;
- RA I cleansed the resident's right side, removed the gloves, did not perform hand hygiene, and left the room with soiled wash cloths;
- Licensed Practical Nurse (LPN) K entered the room, put on gloves, did not perform hand hygiene, applied skin prep (wipes that forms a barrier between the patient's skin and adhesives to help preserve skin integrity) around the stoma (a surgically made hole in the abdomen that allows body waste to be removed from the body directly through the end of the bowel into a collection bag), and applied the new colostomy bag;
- LPN K removed the gloves, did not perform hand hygiene, and left the room;
- RA I entered the room, put on gloves, did not perform hand hygiene, and placed the catheter bag on top of the resident's abdomen with the urine flowing back towards the resident's bladder.
- RA I and CNA D transferred the resident from the bed to the wheelchair by the hoyer lift (a mechanical lift);
- RA I and CNA D removed their gloves.
During an interview on 04/12/24 at 8:10 A.M., RA I said fecal material should be cleansed away from the suprapubic catheter opening. Hands should be sanitized between glove changes, but he/she didn't have hand sanitizer during the resident's care. Catheter bags should always remain below the bladder so urine does not flow back to the bladder.
2. Observation on 04/15/24 at 11:26 A.M., of the blood sugar check and the insulin administration for Resident #38 showed:
- LPN H put on gloves, did not perform hand hygiene, and obtained the resident's blood sugar with a lancet (used to make a tiny prick in the skin to obtain a few drops of blood for testing);
- LPN H threw the used lancet away in the open trash container on the side of the medication cart;
- LPN H failed to perform hand hygiene when he/she changed, administered insulin, and removed the gloves;
- LPN H failed to place the used lancet in a sharps container.
Observation on 04/15/25 at 11:40 A.M., of the blood sugar check for Resident #22 showed:
- LPN H put on gloves and failed to perform hand hygiene;
- LPN H obtained the resident's blood sugar with a lancet;
- LPN H threw the used lancet away in the trash can in the resident's room;
- LPN H failed to place the used lancet in a sharps container.
Observation on 04/15/24 at 4:45 P.M., of the blood sugar check for Resident #60 showed:
- LPN A put on gloves and failed to perform hand hygiene;
- LPN A obtained the resident's blood sugar with a lancet;
- LPN A removed the gloves and failed to perform hand hygiene.
3. During an interview on 04/15/24 at 11:41 A.M., LPN H said only syringes go in the sharps container and insulin vials, meter strips and lancets can be thrown away in the regular trash because there was not enough blood on the strips, and the used lancets retracted.
During an interview on 04/15/24 at 1:30 P.M., the Assistant Director of Nursing (ADON) and the Administrator said hands should be sanitized between glove changes and when going from dirty to clean care. The catheter bag should always remain below the resident's bladder. Fecal material should not have been cleansed toward the suprapubic catheter site but away from it and the tubing should then be cleansed from the insertion point down.
During an interview on 04/16/24 at 10:30 A.M., the Administrator said hand hygiene should be completed between residents and tasks when performing blood sugars and insulin administration. Lancets should go in the biohazard container.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0925
(Tag F0925)
Could have caused harm · This affected multiple residents
Based on observation, interview, and record review, the facility failed to maintain an effective pest control program to control the insect population in the facility. The facility census was 96.
The ...
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Based on observation, interview, and record review, the facility failed to maintain an effective pest control program to control the insect population in the facility. The facility census was 96.
The facility did not provide a policy on pest control.
Review of the monthly pest control invoices provided for 2024 showed:
- January service targeted the German roach, the house mouse, and the Norway rat;
- February service targeted the German roach, the house mouse, and the Norway rat;
- March service targeted the German roach, the house spider, the house mouse, and house ants;
- April service targeted the German roach, house ants, and the house mouse.
Review showed the monthly pest control invoices did not include any services targeting flies.
Observations on 04/09/24 at 8:20 A.M., 04/10/24 at 1:27 P.M., and 04/12/24 at 8:35 A.M., of the kitchen showed four flies in the kitchen food prep area.
Observations on 04/09/24 at 8:30 A.M., 04/10/24 at 1:37 P.M., and 04/12/24 at 8:45 A.M., of the dry food storage room showed three flies flew around the storage shelves.
Observations on 04/09/24 at 8:40 A.M., 04/10/24 at 1:47 P.M., and 04/12/24 at 8:55 A.M., of the dining room showed 12 flies flew around the dining tables, the trash receptacle, the windows and the steam table serving area.
Observation of the meal preparation on 04/10/24 at 12:32 P.M., showed:
- A cart with unwrapped individual carrot cake desserts sat in the dining area while four flies circled the cart;
- Six flies flew around and crawled on the food debris in an open 32 gallon trash barrel partially filled.
Observation of room A17 on 04/16/24 at 9:43 A.M., showed two flies flew around the room.
Observation of A Hall nurses' office on 04/16/24 at 11:51 A.M., showed four flies flew around the room.
During an interview on 04/12/24 at 9:43 A.M., the resident in room A17 said flies were a problem in the room and made it hard to sleep.
During an interview on 04/10/24 at 1:04 P.M., the Assistant Dietary Manager said the kitchen had several issues that should be addressed, including flies.
During an interview on 04/16/24 at 11:51 A.M., Licensed Practical Nurse (LPN) A said it was normal for flies to be in the nurses' office and it had gotten worse in the last two weeks. They were noticed more inside the office than outside. Corporate was contacted about the flies and they were looking for options on fly control. The flies were also reported to maintenance and the pest control service was called but nothing was helping.
During an interview on 04/16/24 at 12:21 P.M., the Interim Maintenance Director said there should not be flies in the facility including the kitchen and the dining area. The Regional Maintenance Director was contacted to see what can be put in place to help with flies in the kitchen. They had gotten worse since it warmed up. The insect problem should be addressed.
During an interview on 04/16/24 at 1:59 P.M., the Administrator said there should not be flies in the kitchen and dining area. They were working on solutions to solve the problem including sprays to the outside windows and doors.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0727
(Tag F0727)
Could have caused harm · This affected most or all residents
Based on observation, interview and record review, the facility failed to provide a Registered Nurse (RN) for eight consecutive hours per day, seven days a week, and the facility failed to designate a...
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Based on observation, interview and record review, the facility failed to provide a Registered Nurse (RN) for eight consecutive hours per day, seven days a week, and the facility failed to designate a RN to serve as the Director of Nursing (DON) on a full-time basis. This deficiency had the potential to affect all residents residing in the facility. The facility census was 96.
Review of the facility's policy titled, Nursing Staff, undated, showed:
- The facility must use a RN for at least eight consecutive hours a day, seven days a week;
- The facility must designate a RN to serve as the DON on a full time basis. The DON can serve as a charge nurse only when the facility has an average daily occupancy of 60 or fewer residents.
Review of the facility's Facility Assessment Tool, last reviewed 02/12/23, showed:
- The facility required three RN's;
- The facility required a full time DON.
Review of the Nursing Schedules for 12/26/23 through 04/16/24, showed:
- No documentation of a RN scheduled for eight consecutive hours on 12/26/23 - 04/07/24, 04/12/24, and 04/13/24;
- No documentation a RN worked eight consecutive hours on 12/26/23 - 04/07/24, 04/12/24, and 04/13/24, with 106 out of 112 days missed;
- No documentation of a DON scheduled 04/01/24 - 04/16/24;
- No documentation a DON worked 04/01/24 - 04/16/24, with 16 out of 16 days missed.
Review of the current Nursing Assignment Sheets, dated 04/12/24 and 04/13/24, showed no documentation a RN worked eight consecutive hours.
Review of the facility's time sheets, dated 12/26/23 through 04/15/24, showed no documentation a RN worked eight consecutive hours on 12/26/23 - 04/07/24, 04/12/24 and 04/13/24.
Review of the DON's Termination Notice, dated 04/01/24, showed:
- Last day worked of 03/29/24;
- Termination date of 04/01/24.
Observations of the facility on 04/09/24 through 04/12/24, 04/15/24 and 04/16/24, showed no DON worked in the facility.
During an interview on 04/11/24 at 11:30 A.M., the Assistant Director of Nursing (ADON) and Administrator said they did not have a DON. The last one last worked on 03/29/24, and had a termination date of 04/01/24. The company had an advertisement for a new DON. They recently hired two RN's who just started orientation, but they need at least one more RN to cover all of the days.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0730
(Tag F0730)
Could have caused harm · This affected most or all residents
Based on interview and record review, the facility failed to provide the nurse aides an annual individual performance review or evaluation and failed to provide regular in-service education based on t...
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Based on interview and record review, the facility failed to provide the nurse aides an annual individual performance review or evaluation and failed to provide regular in-service education based on these reviews for two certified nursing assistants (CNAs) (CNA G and CNA M) out of two sampled CNAs. The facility census was 96.
Review of the facility's policy titled, Nursing Staff, undated, showed the facility must complete a performance review of every nurse aide at least once every 12 months and must provide regular in-service education based on the outcome of these reviews.
1. Review of CNA G's employee file showed:
- Hire date of 03/02/23;
- No documentation CNA G received any in-service education for 03/02/23 to 03/02/24;
- No documentation CNA G received an annual individual performance review or evaluation for 03/02/23 to 03/02/24.
2. Review of CNA M's employee file showed:
- Hire date of 01/26/23;
- No documentation CNA M received an annual individual performance review or evaluation for 01/26/23 to 01/26/24.
Review of the facility's in-service records showed:
- No documentation CNA M received any in-service education for 01/26/23 to 01/26/24;
- No documentation CNA M received an annual individual performance review or evaluation for 01/26/23 to 01/26/24.
During an interview on 04/16/24 at 10:15 A.M., CNA E said he/she had worked at the facility about one and one-half years. He/she should have received a performance evaluation but was told the facility wasn't doing them right now.
During an interview on 04/16/24 at 10:19 A.M., CNA C said he/she had not heard about performance evaluations and had not received one. CNA C had worked there over a year.
During an interview on 04/16/24 at 10:24 A.M., CNA N said he/she had received a performance evaluation in 02/23, but did not receive one in 02/24. CNA N had worked there over a year.
During an interview on 04/15/23 at 1:30 P.M., the Assistant Director of Nursing (ADON) said they could not find the in-services from the last Director of Nursing (DON) and the DON before that destroyed a bunch of paper work when he/she quit. They did in-services at least once a month.
During an interview on 04/16/23 at 10:30 A.M., the Administrator said they had not started performance reviews for the nurse aides yet.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Pharmacy Services
(Tag F0755)
Could have caused harm · This affected most or all residents
Based on interview and record review, the facility failed to ensure staff reconciled narcotics (a process that allows one staff to reconcile the exact narcotic inventory on hand with another staff) at...
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Based on interview and record review, the facility failed to ensure staff reconciled narcotics (a process that allows one staff to reconcile the exact narcotic inventory on hand with another staff) at each shift change for four out of four medication carts. This practice had the potential to affect all residents. The facility census was 96.
Review of the facility's policy titled, Medications, Narcotics, undated, showed:
- Narcotics will be counted at the beginning and end of every shift by the Unit Nurse ending the shift and the Unit Nurse beginning the shift;
- Both nurses will date and sign the narcotics count record;
- The Charge Nurse will be notified immediately if there is any discrepancy in the narcotics count;
- If the Unit Nurse must leave before the end of the shift, he/she will count the narcotics with the Charge Nurse before leaving the facility. The Charge Nurse will then count with the Unit Nurse from the oncoming shift.
1. Review of the A Hall Certified Medical Technician (CMT) Narcotic Count Log for Controlled Substances showed:
- For 02/21/24 through 03/03/24, the staff missed 25 out of 36 opportunities to reconcile the narcotics;
- For 03/04/24 through 03/16/24, the staff missed 32 out of 39 opportunities to reconcile the narcotics;
- For 03/17/24 through 03/31/24, no documentation provided. The staff missed 45 out of 45 opportunities to reconcile the narcotics;
- For 04/01/24 through 04/10/24, the staff missed 28 out of 29 opportunities to reconcile the narcotics;
- For 02/21/24 through 04/10/24, the staff missed a total of 130 out of 149 opportunities to reconcile the narcotics.
2. Review of the B Hall Nurses Narcotic Count Log for Controlled Substance showed for 04/03/24 through 04/09/24, the staff missed 12 out of 14 opportunities to reconcile the narcotics.
3. Review of the B Hall CMT Narcotic Count Log for Controlled Substances showed for 03/27/24 through 04/10/24, the staff missed 41 out of 44 opportunities to reconcile the narcotics.
4. Review of the Secured Units CMT Narcotic Count Log for Controlled Substances showed:
- For 02/21/24 through 03/27/24, the staff missed 72 out of 72 opportunities to reconcile the narcotics;
- For 03/28/24 through 04/10/24, the staff missed 28 out of 28 opportunities to reconcile the narcotics;
- For 02/21/24 through 04/10/24, the staff missed a total of 100 out of 100 opportunities to reconcile the narcotics.
During an interview on 04/10/24 at 4:30 P.M., CMT E said narcotic reconciliation log was signed on shift change by oncoming and off going CMT and/or Nurses. He/She said the narcotics should be counted together by both staff and for B hall, the off going CMT should count with the day shift nurse and the nurse should count with the night shift nurse.
During an interview on 04/10/24 at 4:49 P.M., CMT T said no one counted the secured unit cart with him/her because he/she followed him/herself on most days. One other CMT and him/herself were the only two that worked the secured unit medication cart. He/She came in, counted the cart, and if it had no discrepancies with the count, he/she started passing medications. If there was a discrepancy, he/she went to the nurse, the count was redone, and the error was found. A lot of times when he/she was done with medication pass, the nurses were in report, which could last two hours, and he/she didn't wait around until 9:00 P.M., to count. He/She hung the keys in the locked medication room.
During an interview on 04/10/24 at 4:54 P.M., Licensed Practical Nurse (LPN) A said narcotic counts were completed at shift change, the oncoming and off going staff counted together. He/She said the night CMT counted with the night nurse, the day nurse CMT counted with the night nurse, and off going nurse counted with the day nurse. He/She said there were no narcotics in the nurse cart at this time.
During a phone interview on 04/25/24 at 11:41 A.M., the Administrator said narcotic counts should be completed anytime there was a change in staff. If an employee left mid shift, the narcotic count should be completed with whoever took the keys to the cart. The narcotic log should be signed at that time. Discrepancies during the narcotic count should be reported to the nurse. The nurse should check the cart and double check the electronic medication administration record was correct. The Nurse and/or CMT should notify the supervisor, then the Assistant Director of Nursing (ADON) or the Director of Nursing (DON), and then the Administrator. If the discrepancy was not found at that point, an investigation would begin.
During a phone interview on 04/25/24 at 11:50 A.M., the ADON said narcotic counts should be completed before and after each shift by the on and off going staff. The narcotic count should be completed any time the keys to the medication cart were exchanged. Documentation in the narcotic log book should be completed at that time, and should show the number of medication cards, and number of narcotics in each card/bottle.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Food Safety
(Tag F0812)
Could have caused harm · This affected most or all residents
Based on observation, interview, and record review, the facility failed to store and distribute food under sanitary conditions, increasing the risk of cross-contamination and food-borne illness. This ...
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Based on observation, interview, and record review, the facility failed to store and distribute food under sanitary conditions, increasing the risk of cross-contamination and food-borne illness. This had the potential to affect all residents. The facility census was 96.
Review of the facility's policy titled, Cleaning Rotation, dated 2020, showed:
- Equipment and utensils will be cleaned and sanitized according to the following guidelines, or manufacturer's instructions;
- Items cleaned and sanitized after each use included can opener, utensils, worktables, and counters, pots and pans, dishes, dining room tables and chairs;
- Items cleaned daily included kitchen and dining room floors, steam table, hand washing sink, and exterior of large appliances;
- Items cleaned weekly included hoods, filters, trash barrels, storerooms, drawers, shelves, ovens, and cupboards;
- Items cleaned monthly included refrigerators, freezers, ingredient bins, ice machines, food containers, and walls;
- Items cleaned annually included ceilings and windows.
Review of the facility's policy titled, Food Storage Dry, Refrigerated, and Frozen, dated 2020, showed:
- Food shall be stored on shelves in a clean, dry area free from contaminants;
- Food shall be stored at appropriate temperatures and using appropriate methods to ensure the highest level of food safety;
- General storage guidelines to be followed, all food items will be labeled;
- The label must include the name of the food and the date by which it should be sold, consumed, or discarded;
- Poisonous materials, medications, and chemicals will be stored separately from food in a designated medication refrigerator, cleaning closet, or cabinet which can be locked;
- Place a thermometer in the warmest part of the refrigerator to monitor the air temperature in the refrigerator;
- Defrost freezers regularly to improve their efficiency;
- Store dry food on shelves two inches (in.) away from walls to allow ventilation, six in. off the floor to allow for proper sanitation, and 18 in. from the ceiling to ensure fire safety.
1. Observation on 04/09/24 at 8:20 A.M., 04/10/24 at 1:27 P.M., and 04/12/24 at 08:35 A.M., of the kitchen showed:
- Food debris and oily film build-up on the floor beneath the range;
- The commercial dishwasher exterior with flaky white grime (dirt ingrained on the surface of something) build-up, and a connected 1 in. water line leak;
- A 5-foot (ft.) section of wall baseboard with damage behind the commercial dishwasher and white grime build up on the floor below;
- Two 4 in. x 4 in. ceramic tiles missing on each wall section left and right of the door passage from the kitchen to the dishwashing area;
- A window mounted air conditioning unit with black grime and dust buildup above the dishwashing area counter;
- The commercial style can opener with a worn cutting edge, oily film and a black grime buildup;
- Four connected ceiling lights over the food preparation areas with black grime buildup and one broken fluorescent light fixture cover;
- Three ceiling diffusers (one of the few visible parts of an air conditioning system) with dust buildup and a brown substance on the front exterior surfaces and between the ventilation louvers;
- The floor below the reach-in freezer with scattered debris in the rear kitchen exit area;
- The reach-in refrigerator interior with scattered debris and no separate thermometer in the rear kitchen exit area;
- The chest freezer with 1 in. frost buildup and a damaged gasket along the upper interior surface in the rear kitchen exit area;
- One large and one small cookie sheet with brown carbon buildup;
- Four flies in the kitchen food prep area.
2. Observation on 04/09/24 at 8:30 A.M., 04/10/24 at 1:37 P.M., and 04/12/24 at 08:45 A.M., of the dry food storage room showed:
- Scattered debris below the food storage shelves;
- Undated, unlabeled onions stored in an uncovered plastic bin;
- Two non-intact floor tiles and black grime buildup on the floor;
- Two undated, unlabeled plastic zipper bags with chocolate chips and crackers on the storage cart;
- A food wrapper and debris below the food shelving;
- The chest freezer with 1 in. frost buildup and a damaged gasket along the upper interior surface;
- One light fixture without a plastic cover;
- Three flies flew around the storage shelves.
3. Observations on 04/09/24 at 8:40 A.M., 04/10/24 at 1:47 P.M., and 04/12/24 at 08:55 A.M., of the dining room showed:
- A buildup of dried white grime on the upper part of the left and right-side corner crevices of the ice dispenser machine located in the steam table serving area;
- An uncovered 32 gallon trash can partially filled near the kitchen entrance;
- A buildup of brown grime on the clear plastic dispensing area of the ice dispenser machine located in the steam table serving area;
- The ice dispensing machine drain with debris along the sides and the floor below, and the drain with no visible air gap;
- The ice dispensing machine exterior front and side surfaces with white grime buildup;
- The dining serving area with black grime on the floor;
- The dining area floor with scattered debris;
- The steam table shields with film buildup;
- The faucet and sink basin with white grime buildup in the steam table serving area;
- The countertop with a 2 ft non-intact Formica (a hard durable plastic laminate used for countertops) in the steam table serving area;
- A wooden cabinet with one missing cabinet door and drawer front in the steam table serving area;
- Twelve flies flew around the dining tables, the trash receptacle, the windows and steam table serving area.
4. Observation of the meal preparation on 04/10/24 at 12:32 P.M., showed:
- An uncovered one-half gallon red bucket with a dish cloth and gray liquid sat on the serving area counter near the steam table;
- Dietary Aide (DA) Q served salad and loaded the food trays without a proper restraint of exposed facial hair;
- DA R touched and opened a hot dog bun with his/her bare hand and placed a hot dog inside the bun with a utensil;
- A cart with unwrapped individual carrot cake desserts sat in the dining area while four flies circled the cart.
During an interview on 04/10/24 at 1:04 P.M., the Assistant Dietary Manager said the kitchen had several issues that should be addressed, including flies. The facility policy should be followed by dietary workers. The dishwashing sanitizer was used for cleaning tables in between dining and it was kept in a small red bucket in the serving area for emergency cleanings during the meals. Ready to eat foods should not be handled by staff with bare hands and staff should wear restraints over beard hair. Walls, floors, and counters should be clean and in good repair. Each refrigerator and freezer should have separate thermometers.
During an interview on 04/10/24 at 1:25 P.M., DA S said they had two workers quit recently and cleaning had been a challenge. The can opener was supposed to be cleaned after each use. Dietary workers were expected to follow the facility policy.
During an interview on 04/16/24 at 12:21 P.M., the Interim Maintenance Director said there should not be flies in the facility, including the kitchen and dining area. The Regional Maintenance Director was contacted to see what could be put in place to help with the flies in the kitchen. Kitchen repairs should be made by maintenance including plumbing leaks, replacing filters, fixing walls and cleaning vents. The facility should be kept in good repair.
During an interview on 04/16/24 at 1:59 P.M., the Administrator said she was aware the kitchen had several issues that should be addressed and had done her own tour recently. Dietary workers should be following facility policy. Overhead vents should be clean in the kitchen and dining areas. The dishwasher should be clean and leak free. Food should not be handled by staff with bare hands and staff should wear hair nets and cover beards. Deep cleaning was a concern and should be done more often. Lighting and ventilation should be clean and intact. All appliances should be clean. Walls, floors, and counters should be clean and intact. There should not be flies in the kitchen and dining area.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0838
(Tag F0838)
Could have caused harm · This affected most or all residents
Based on interview and record review, the facility failed to review and update the facility assessment (an assessment to determine what resources were necessary to care for residents competently durin...
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Based on interview and record review, the facility failed to review and update the facility assessment (an assessment to determine what resources were necessary to care for residents competently during both day-to-day operations and emergencies) at least annually. The facility census was 96.
Review of the facility assessment, dated 02/12/23, showed:
- Annual update due 02/12/24, not completed;
- No documentation the Quality Assessment and Assurance (QAA) and Quality Assurance Performance Improvement (QAPI) committees reviewed the facility assessment;
- The number of residents with intellectual and/or developmental disability not accurate;
- The assessment indicated no residents had behavioral healthcare needs (including trauma/post traumatic stress disorder (PTSD - a mental health condition triggered by a terrifying event - either experiencing it or witnessing it; symptoms may include flashbacks, nightmares and severe anxiety, as well as uncontrollable thoughts about the event)) with an individualized care plan;
- The competencies required by the facility did not include catheter care, falls, communication, behavioral health (including PTSD and trauma history), or meeting the needs of individuals with mental illness/ intellectual disability or development disability.
During an interview on 04/15/24 at 10:15 A.M., the Administrator and Assistant Director of Nursing (ADON) said they would expect the facility assessment to be completed and reviewed annually. They did it together sometime in February, but must not have changed the date. The facility did have intellectually disabled residents, multiple residents with PTSD, and most residents in the facility had behaviors. All the competencies listed should have been included as they had residents that fall in those categories.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0841
(Tag F0841)
Could have caused harm · This affected most or all residents
Based on interview and record review, the facility failed to ensure the medical director worked with the facility's clinical team to assure residents attain or maintain their highest practicable physi...
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Based on interview and record review, the facility failed to ensure the medical director worked with the facility's clinical team to assure residents attain or maintain their highest practicable physical, mental and psychosocial well-being and failed to ensure the medical director participated and was involved in conducting the Facility Assessment, implementation of resident care policies, and attending the Quality Assessment and Assurance (QAA) Committee. This deficient practice had the potential to affect all residents of the facility. The facility census was 96.
The facility did not provide a policy regarding the responsibilities of the Medical Director (MD).
Review of the Facility Assessment, dated 02/12/23, showed:
- Annual update due 02/12/24, not completed;
- No documentation that the QAA and the Quality Assurance Performance Improvement (QAPI) committees reviewed the Facility Assessment.
Review of the signature sheets for the QAPI meetings, dated 12/19/23 through 03/19/24, showed no MD signature for the QAPI meetings on 12/19/23, 01/16/24, 02/20/24 and 03/19/24.
During an interview on 04/16/24, the Administrator said she became the facility administrator in February 2024. She said the MD did not attend the QAA committee meetings.
During an interview on 04/16/24 at 2:59 P.M., the MD said the new administration scheduled the QA meetings on days he could not attend. He previously had attended when the meetings were not on clinical days. He did not participate in the completion of the Facility Assessment. It had been at least 2020 since he participated in the review of the facility's policies and procedures.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0844
(Tag F0844)
Could have caused harm · This affected most or all residents
Based on record review and interview the facility failed to provide written notice to the State agency responsible for licensing the facility when their Director of Nursing (DON) was no longer employe...
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Based on record review and interview the facility failed to provide written notice to the State agency responsible for licensing the facility when their Director of Nursing (DON) was no longer employed. This had the potential to affect all resident. The facility census was 96.
Review of the facility's policy titled, Nursing Staff, undated showed:
- The facility must designate a Registered Nurse (RN) to serve as the DON on a full time basis.
Review of the Facility Assessment Tool, last reviewed 02/12/23, showed the facility required a full time DON.
Review of the facility Nursing Schedule for 04/01/24 through 04/16/24, showed:
- No documentation of a DON scheduled 04/01/24 - 04/16/24;
- No documentation a DON worked 04/01/24 - 04/16/24, with 16 out of 16 days missed.
Review of the DON's Termination Notice, dated 04/01/24, showed:
- Last day worked 03/29/24;
- Termination date of 04/01/24.
Observations of the facility on 04/09/24 through 04/12/24, 04/15/24 and 04/16/24, showed no DON worked in the facility.
During an interview on 04/11/24 at 11:30 A.M., the Administrator said they did not have a DON. The last DON worked on 3/29/24 for the last time, and was terminated effective 04/01/24. They had an advertisement for a new DON. They had not sent in the notice to the State agency about the DON no longer working there because they did not have a new DON to fill the job title yet.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0865
(Tag F0865)
Could have caused harm · This affected most or all residents
Based on interview and record review, the facility failed to have a Quality Assurance and Performance Improvement (QAPI) (a program to improve the processes for the delivery of health care and quality...
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Based on interview and record review, the facility failed to have a Quality Assurance and Performance Improvement (QAPI) (a program to improve the processes for the delivery of health care and quality of life for the residents) program in place with policies and protocols describing how the facility will identify and correct its own quality deficiencies. This deficient practice had the potential to affect all residents in the facility. The facility census was 96.
The facility's policy titled, Policy and Procedure Quality Assurance and Improvement Plan (QAPI), dated, 04/10/19 showed:
PURPOSE: The primary purpose of the QAPI program is to establish data-driven facility wide processes that improve the quality of care, quality of life, and clinical outcomes of our residents;
- The QAPI program will be developed with governance and leadership;
- Members of the facility leadership are accountable for QAPI efforts;
- Adverse events will be tracked, monitored and investigated as they occur;
- Action plans will be implemented to prevent recurrence of adverse events;
- A summary of the reports and findings from meetings;
- A summary of any approaches, action plans to be implemented, conclusions and recommendations.
Review showed the facility did not follow their QAPI plan that contained the necessary policies and protocols describing how they would identify and correct their quality deficiencies, track and measure performance, and establish goals and thresholds for performance measurement.
During an interview on 04/16/24 at 11:30 A.M., the Administrator said the facility had no documentation showing what needed to be improved on, or outcomes of working on issues. The facility had a tracking tool of data, but nothing past that point.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
QAPI Program
(Tag F0867)
Could have caused harm · This affected most or all residents
Based on interview and record review, the facility failed to ensure the Quality Assurance and Performance Improvement (QAPI - the coordinated application of two mutually-reinforcing aspects of a quali...
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Based on interview and record review, the facility failed to ensure the Quality Assurance and Performance Improvement (QAPI - the coordinated application of two mutually-reinforcing aspects of a quality management system): Quality Assurance (QA) and Performance Improvement (PI)) committee developed and implemented policies and procedures that included how it collects and uses data, and monitors concerns for all departments. The facility failed to ensure the QAA committee developed and implemented action plans to correct identified quality deficiencies and failed to conduct at least one Performance Improvement Project (PIP) annually that focused on a high risk area identified by the facility. This had the potential to affect all residents in the facility. The facility census was 96.
The facility's policy, Policy and Procedure Quality Assurance and Improvement Plan (QAPI), dated, 04/10/19, showed:
- Performance Improvement Projects (PIPs) will be initiated when problems are identified;
- PIPs will involve systematically gathering information to clarify issues and to intervene for improvements;
- Root cause analysis (RCA) will be used to determine whether identified issues are exacerbated by the way care and services are organized or delivered and if so how;
-RCA serves as a highly structured approach to fully understanding the nature of an identified problem, its cause and implications of making changes to improve the problem.
During an interview on 04/16/24 at 1:30 P.M., the Administrator said the facility had not done a PIP since she started in February and there was no record of a PIP prior. The Administrator said the facility had an approved waiver for not having a RN for the required amount of time, but when the last Director of Nursing left, the waiver became null and void.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0868
(Tag F0868)
Could have caused harm · This affected most or all residents
Based on interview and record review, the facility failed to maintain quarterly Quality Assessment and Assurance (QAA) committee meetings with the required members. These practices had the potential t...
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Based on interview and record review, the facility failed to maintain quarterly Quality Assessment and Assurance (QAA) committee meetings with the required members. These practices had the potential to affect all staff and residents. The facility census was 96.
The facility's policy, Policy and Procedure Quality Assurance and Improvement Plan (QAPI), dated 04/10/19, showed:
- QAPI Committee Members will include at minimum: The Administrator, Director of Nursing, Medical Director, Activities Director, Social Service Director, Dietary Manager, Housekeeping and Laundry Supervisor, Maintenance Director, additional facility staff, contracted staff including but not limited to Pharmacy consultant, Dietician, Rehab Director;
- The Committee will meet monthly at an appointed time.
The Quality Assurance Director Job Description, undated, showed:
- Schedule meetings of the Quality Assurance Committee, whose membership consists of: Director of Nursing (DON), Medical Director or designee, Administrator, owner, a board member or other individual in a leadership role, infection control and prevention officer.
Review of the signature sheets for the Quality Assurance meetings dated 12/19/23 through 03/19/24, showed:
- No signature from the Medical Director on the 12/19/23, 01/16/24, 02/20/24 or 03/19/24 signature sheets;
- No signature from the DON on the 01/16/24. 02/20/24 or 03/19/24 signature sheets;
- No signature from the Administrator or other administrative personnel on the 01/16/24 signature sheet;
- No signature from the IP on the 01/16/24, 02/20/24 or 03/19/24 signature sheets.
During an interview on 04/16/24 at 1:30 P.M., the Administrator said the medical director does not attend the meetings. Not everyone attends the meetings every time. The only way to track attendance is to go by who signed the signature sheets. The Minimum Data Set ((MDS) a federally mandated assessment tool) Coordinator compiles all the data into the QAPI form. They go over the form during the meeting. There is no documentation showing issues found or plans to resolve issues.
During an interview on 04/16/24 at 02:59 P.M., the Medical Director said he/she has not attended a QAPI meeting since last year.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0940
(Tag F0940)
Could have caused harm · This affected most or all residents
Based on record review and interview, the facility failed to develop, implement and maintain an effective training program for all new and existing staff consistent with their expected roles, includin...
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Based on record review and interview, the facility failed to develop, implement and maintain an effective training program for all new and existing staff consistent with their expected roles, including keeping records of the trainings received by staff. This had the potential to affect all staff and residents. The facility census was 96.
The facility did not provide a a training program policy, records of completing the training, nor performance evaluations/appropriate return practice of the following required training programs:
- The abuse, neglect, and exploitation prevention and dementia management training program;
- The Quality Assurance and Performance Improvement ((QAPI) the coordinated application of two mutually-reinforcing aspects of a quality management system: Quality Assurance (QA) and Performance Improvement (PI). QAPI takes a systematic, interdisciplinary, comprehensive, and data-driven approach to maintaining and improving safety and quality in nursing homes while involving residents and families in practical and creative problem solving) program and the elements of the program including the goals and the roles played by various staff;
- The required in-service training for Nurse Aides;
- Behavioral Health training.
During an interview on 04/15/24 at 1:30 P.M., the Assistant Director of Nursing (ADON) said they could not find the in-services from the last Director of Nursing (DON), and the DON before that destroyed a bunch of paperwork when he/she quit. The ADON said he/she was in charge of the training until a new DON could be hired.
During an interview on 04/16/24, the Administrator said the facility should have documentation of all required trainings and should have policies in place for those programs.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0943
(Tag F0943)
Could have caused harm · This affected most or all residents
Based on record review and interview the facility failed to ensure all facility staff participated in an abuse, neglect, and exploitation prevention program and a dementia management training program,...
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Based on record review and interview the facility failed to ensure all facility staff participated in an abuse, neglect, and exploitation prevention program and a dementia management training program, with a process in place to track attendance. This had the potential to affect all residents. The facility census was 96.
The facility did not provide abuse, neglect, and exploitation prevention and dementia management training records.
On 04/15/24 at 1:30 P.M., the Assistant Director of Nursing (ADON) said they could not find the in-services from the last Director of Nursing (DON), and the DON before that destroyed a bunch of paper work when he/she quit. The ADON said they do inservices with staff once a month, but did not know when the abuse, neglect, and exploitation prevention and dementia management training program training had last been done. The ADON said he/she was in charge of the training until a new DON could be hired.
During an interview on 04/16/24, the Administrator said the facility should have documentation of the abuse and neglect training for all staff.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0944
(Tag F0944)
Could have caused harm · This affected most or all residents
Based on record review and interview, the facility failed to conduct mandatory training for all staff on the facility's Quality Assurance and Performance Improvement ((QAPI) the coordinated applicatio...
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Based on record review and interview, the facility failed to conduct mandatory training for all staff on the facility's Quality Assurance and Performance Improvement ((QAPI) the coordinated application of two mutually-reinforcing aspects of a quality management system: Quality Assurance (QA) and Performance Improvement (PI). QAPI takes a systematic, interdisciplinary, comprehensive, and data-driven approach to maintaining and improving safety and quality in nursing homes while involving residents and families in practical and creative problem solving) program and the elements of the program including the goals and the roles played by various staff. This had the potential to affect all resident and staff. The facility census was 96.
The facility's policy titled, Policy and Procedure Quality Assurance and Improvement Plan (QAPI), dated, 04/10/19 showed:
PURPOSE: The primary purpose of the QAPI program is to establish data-driven facility wide processes that improve the quality of care, quality of life, and clinical outcomes of our residents;
- The QAPI program will be developed with governance and leadership;
- Members of the facility leadership are accountable for QAPI efforts;
- Adverse events will be tracked, monitored and investigated as they occur;
- Action plans will be implemented to prevent recurrence of adverse events;
- A summary of the reports and findings from meetings;
- A summary of any approaches, action plans to be implemented, conclusions and recommendations;
- Providing frequent leadership and staff training on the QAPI plan and its underlying principles, including the concept that systems of care and business practices must support quality care or be changed.
The facility did not provide records of staff receiving training on the QAPI program.
Interviews with all levels of staff, throughout the survey showed none had received any information or training on a QAPI program.
During an interview on 04/15/24, the Assistant Director of Nursing (ADON) said the facility does not currently have a DON. The ADON has had to assume many of the DON's duties, including her role in the QAPI program. The ADON could not locate any training records regarding QAPI.
During an interview on 04/16/24, the Administrator said she could not find any records of training all staff members on the QAPI program.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0947
(Tag F0947)
Could have caused harm · This affected most or all residents
Based on record review and interview the facility failed to develop, implement and permanently maintain a nurse aide (NA) in-service training program that is appropriate and effective as determined by...
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Based on record review and interview the facility failed to develop, implement and permanently maintain a nurse aide (NA) in-service training program that is appropriate and effective as determined by nurse aide performance reviews and the facility assessment. This deficient practice had the potential to affect all residents and staff of the facility. The facility census was 96.
The facility did not provide a policy regarding nurse aide training or performance reviews.
The facility did not provide any nurse aide training records or performance reviews.
Review of the facility assessment, dated 02/12/23, showed:
- Facility assessment not reviewed annually since 2023;
- No documentation that the Quality Assessment and Assurance (QAA) and Quality Assurance Performance Improvement (QAPI) committee reviewed the facility assessment;
- The number of residents with intellectual and or developmental disability not accurate;
- The behavioral healthcare needs (Including Trauma/PTSD) who have an individualized care plan to be zero and inaccurate;
- The competencies required by the facility did not include catheter care, falls, communication, behavioral health (including PTSD and Trauma History), or meeting the needs of individuals with mental illness/intellectual disability or development disability.
During interviews:
- On 04/16/24 at 10:15 A.M., Certified Nurse Aide (CNA) E said he/she had worked at the facility for about one and one-half years. He/she should have received a performance evaluation but was told the facility wasn't doing them right now;
- On 04/16/24 at 10:19 A.M., CNA C said he/she had not heard about performance evaluations and had not received one. CNA C had worked there over a year;
- On 04/16/24 at 10:24 A.M., CNA N had received a performance evaluation in 02/23, but did not receive one in 02/24. CNA N had worked there over a year;
- On 04/15/23 at 1:30 P.M., the Assistant Director of Nursing (ADON) said they could not find the in-services from the last Director of Nursing (DON), and the DON before that destroyed a bunch of paper work when he/she quit. There is no current DON. The ADON said he/she is in charge of the NA inservice training, but did not know about the documentation of the training. The ADON said she has had to take a lot of the DON's responsibilities until they can hire a new one;
- On 04/16/23 at 10:30 A.M., the Administrator (ADM) said they had not started performance reviews for the nurse aides yet.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0949
(Tag F0949)
Could have caused harm · This affected most or all residents
Based on interview and record review the facility failed to develop, implement and maintain an effective training program for all staff which included an effective behavioral health care and services ...
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Based on interview and record review the facility failed to develop, implement and maintain an effective training program for all staff which included an effective behavioral health care and services training, as determined by staff need and the facility assessment. This deficient practice affected two sampled employees hired within the last year. The facility census was 96.
The facility failed to provide a policy regarding behavioral health training.
Review of the facility assessment, dated 02/12/23, showed:
- Facility assessment not reviewed annually since 2023;
- No documentation showing the Quality Assessment and Assurance (QAA) and Quality Assurance Performance Improvement (QAPI) committee reviewed the facility assessment;
- The number of residents with intellectual and or developmental disability not accurate;
- The behavioral healthcare needs (Including Trauma/PTSD) who have an individualized care plan to be zero and inaccurate;
- The competencies required by the facility did not include catheter care, falls, communication, behavior health (including PTSD and Trauma History), or meeting the needs of individuals with mental illness/ intellectual disability or development disability.
Review of the medical diagnoses (dx) of the 96 residents present during the on-site survey, as provided by the facility, showed:
- Thirty-one residents had dx of schizophrenia (disorder that affects a person's ability to think, feel and behave clearly);
- Eighteen residents had a dx of bipolar disorder (disorder associated with episodes of mood swings ranging from depressive lows to manic highs);
- Sixty-five residents had a dx of anxiety (intense, excessive and persistent worry and fear about everyday situations);
- Forty-six residents had dx of depression (loss of pleasure or interest in activities for long periods of time);
- Sixty-seven residents had dx of schizoaffective disorder (mental health condition including a combination of schizophrenia and a mood disorder like depression or bipolar);
- Eleven residents had dx history of suicide attempt/suicidal ideations (thoughts);
- Twenty-one residents had dx of personality disorder (condition where people have a lifelong pattern of seeing themselves and reacting to others in ways that cause problems);
- Twenty residents had dx of post traumatic stress disorder (disorder in which a person has difficulty recovering after experiencing or witnessing a terrifying event);
- Twenty-seven residents had dx of psychosis (mental disorder characterized by disconnection from reality).
1. Review of Certified Nurse Aide (CNA) G's employee file showed:
-A hire date of 03/02/23;
-No documentation of behavioral health training.
2. Review of CNA M's employee file showed:
-A hire date of 01/26/23;
-No documentation of behavioral health training.
During an interview on 04/15/24 at 1:30 P.M., the Assistant Director of Nursing (ADON) said they could not find the in-services from the last Director of Nursing (DON,) and the DON before that destroyed a bunch of paper work when he/she quit. The ADON said they do inservices with staff once a month, but did not know what the specific training for behavioral residents was, or when it had last been done. The ADON said he/she was in charge of the training until a new DON could be hired.
During an interview on 04/16/24 at 10:30 A.M., the Administrator said facility needed to offer behavioral health training.
Nov 2023
2 deficiencies
1 IJ (1 affecting multiple)
CRITICAL
(K)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Immediate Jeopardy (IJ) - the most serious Medicare violation
Infection Control
(Tag F0880)
Someone could have died · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program to provide a safe and sanitary environment to help prevent the potential spread of COVID-19 (an acute respiratory illness in humans caused by the Coronavirus, SARS-CoV-2) and other infections, when staff failed to follow acceptable infection control practices for COVID-19. The facility failed to implement infection control mitigation strategies, including separating 25 residents (Resident #1, #4, #10, #12, #15, #16, #17, #18, #22, #23, #24, #28, #33, #34, #37, #38, #40, #42, #44, #46, #49, #50, #52, #54, and #57) who had tested positive for COVID-19 from 32 residents (Resident #2, #3, #5, #6, #7, #8, #9, #11, #13, #14, #19, #20, #21, #25, #26, #27, #29, #30, #31, #32, #35, #36, #39, #41, #43, #45, #47, #48, #51, #53, #55, and #56) who had tested negative for COVID-19. These failures placed the residents at an increased risk of contracting COVID-19 due to prolonged exposure and Resident #5 and #45 who originally tested negative on 11/6/23 tested positive on 11/9/23 after sharing a room with residents who were positive for COVID-19. The facility census was 93.
The Administrator was notified on 11/09/23 at 5:00 P.M.,of an Immediate Jeopardy (IJ) which began on 11/04/23. The IJ was removed on 11/09/23, as confirmed by surveyor onsite verification.
Review of the Centers for Disease Control (CDC) Interim Infection Prevention and Control Recommendations for Healthcare Personnel (HCP) During the Coronavirus Disease 2019 (COVID-19) Pandemic, updated 05/8/23, showed:
- The recommendations in the guidance continue to apply after the expiration of the federal COVID-19 Public Health Emergency;
- The Infection Prevention and Control (IPC) recommendations described below (e.g., patient placement, recommended PPE) also apply to patients with symptoms of COVID-19 (even before results of diagnostic testing) and asymptomatic patients who have met the criteria for empiric Transmission-Based Precautions based on close contact with someone with SARS-CoV-2 infection. However, these patients should NOT be cohorted with patients with confirmed SARS-CoV-2 infection unless they are confirmed to have SARS-CoV-2 infection through testing;
- Place a patient with suspected or confirmed SARS-CoV-2 infection in a single-person room. The door should be kept closed (if safe to do so). Ideally, the patient should have a dedicated bathroom;
- If cohorting, only patients with the same respiratory pathogen should be housed in the same room;
- Facilities could consider designating entire units within the facility, with dedicated HCP, to care for patients with SARS-CoV-2 infection when the number of patients with SARS-CoV-2 infection is high. Dedicated means that HCP are assigned to care only for these patients during their shifts. Dedicated units and/or HCP might not be feasible due to staffing crises or a small number of patients with SARS-CoV-2 infection.
- Source control is recommended for individuals in healthcare settings who have had close contact (patients and visitors) or a higher-risk exposure with someone with SARS-CoV-2 infection, for 10 days after their exposure.
The facility did not provide an infection control policy that referenced COVID-19 outbreaks or infection control mitigation strategies.
1. Review of the facility's Testing Tracker showed staff documented Resident #1 tested positive for COVID-19 on 11/06/23. The report showed the resident's roommates, Resident #2 and #3 tested negative for COVID-19 on 11/06/23 and 11/09/23.
Observation on 11/09/23 at 9:45 A.M., showed Resident #1, #2 and #3, asymptomatic, residing in the same room with no infection prevention barrier, and none of the residents had masks on.
2. Review of the facility's Testing Tracker showed staff documented Resident #4 tested positive for COVID-19 on 11/06/23. The report showed the resident's roommates, Resident #5 tested negative for COVID-19 on 11/06/23, positive on 11/09/23, and Resident #6 tested negative for COVID-19 on 11/06/23 and 11/09/23.
Observation on 11/09/23 at 9:46 A.M., showed Resident #4, #5, and #6, asymptomatic, residing in the same room with no infection prevention barrier, and none of the residents had masks on.
3. Review of the facility's Testing Tracker showed staff documented Resident #10 tested positive for COVID-19 on 11/06/23. The report showed the resident's roommates, Resident #7, #8 and #9 tested negative for COVID-19 on 11/06/23 and 11/09/23.
Observation on 11/09/23 at 9:47 A.M., showed Resident #7, #8, #9 and #10, asymptomatic, residing in the same room with no infection prevention barrier, and none of the residents had masks on.
4. Review of the facility's Testing Tracker showed staff documented Resident #12 tested positive for COVID-19 on 11/06/23. The report showed the resident's roommates, Resident #11 tested negative for COVID-19 on 11/06/23 and 11/09/23, and Resident #13 tested negative on 11/06/23 and was not tested on [DATE].
Observation on 11/09/23 at 9:48 A.M., showed Resident #11, #12, and #13, asymptomatic, residing in the same room with no infection prevention barrier, and none of the residents had masks on.
5. Review of the facility's Testing Tracker showed staff documented Resident #15, #16, #17 tested positive for COVID-19 on 11/06/23. The report showed the resident's roommate Resident #14 tested negative for COVID-19 on 11/06/23 and 11/09/23.
Observation on 11/09/23 at 9:49 A.M., showed Resident #14, #15, #16, and #17, asymptomatic, residing in the same room with no infection prevention barrier, and none of the residents had masks on.
6. Review of the facility's Testing Tracker showed staff documented Resident #18 tested positive for COVID-19 on 11/06/23. The report showed the resident's roommates, Resident #19 and #20 tested negative for COVID-19 on 11/06/23 and 11/09/23.
Observation on 11/09/23 at 9:50 A.M., showed Resident #18, #19 and #20, asymptomatic, residing in the same room with no infection prevention barrier, and none of the residents had masks on.
7. Review of the facility's Testing Tracker showed staff documented Resident #22 and #23 tested positive for COVID-19 on 11/09/23. The report showed the residents' roommate Resident #21 tested negative for COVID-19 on 11/09/23.
Observation on 11/09/23 at 9:51 A.M., showed Resident #21, #22, and #23, asymptomatic, residing in the same room with no infection prevention barrier, and none of the residents had masks on.
Observation on 11/09/23 at 10:10 A.M. and 11:57 A.M., showed Resident #22 walking in the hallway with no mask on, with other unmasked residents.
Observation on 11/09/23 at 12:17 P.M. and 2:02 P.M., showed Resident #21, #22, and #23, asymptomatic, residing in the same room with no infection prevention barrier, and none of the residents had masks on, after the 11/09/23 COVID-19 testing.
8. Review of the facility's Testing Tracker showed staff documented Resident #24 tested positive for COVID-19 on 11/06/23. The report showed the resident's roommates, Resident #25, #26, and #27 tested negative for COVID-19 on 11/06/23 and 11/09/23.
Observation on 11/09/23 at 09:52 A.M., showed Resident #24, #25, #26, and #27, asymptomatic, residing in the same room with no infection prevention barrier, and none of the residents had masks on.
9. Review of the facility's Testing Tracker showed staff documented Resident #28 tested positive for COVID-19 on 11/06/23. The report showed the resident's roommate Resident #29 tested negative for COVID-19 on 11/06/23 and was not tested on [DATE].
Observation on 11/09/23 at 09:53 A.M., showed Resident #28 and #29, asymptomatic, residing in the same room with no infection prevention barrier, and none of the residents had masks on.
10. Review of the facility's Testing Tracker showed staff documented Resident #33 tested positive for COVID-19 on 11/09/23. The report showed the resident's roommates, Resident #30 tested negative for COVID-19 on 11/09/23, Resident #31 refused testing on 11/09/23, and Resident #32 tested negative for COVID-19 on 11/09/23.
Observation on 11/09/23 at 9:54 A.M., showed Resident #30, #31, #32, and #33, asymptomatic, residing in the same room with no infection prevention barrier, and none of the residents had masks on.
Observation on 11/09/23 at 12:17 P.M., 2:02 P.M., and 5:20 P.M., showed Resident #30, #31, #32 and #33, asymptomatic, residing in the same room with no infection prevention barrier, and none of the residents had masks on, after the 11/09/23 COVID-19 testing.
11. Review of the facility's Testing Tracker showed staff documented Resident #34 and #37 tested positive for COVID-19 on 11/09/23. The report showed the resident's roommate Resident #35 and #36 tested negative for COVID-19 on 11/09/23.
Observation on 11/09/23 at 9:55 A.M., showed Resident #34, #35, #36 and #37, asymptomatic, residing in the same room with no infection prevention barrier, and none of the residents had masks on.
Observation on 11/09/23 at 12:18 P.M., 2:03 P.M., and 5:21 P.M., showed Resident #34, #35, #36 and #37 asymptomatic, residing in the same room with no infection prevention barrier, and none of the residents had masks on, after the 11/09/23 COVID-19 testing.
12. Review of the facility's Testing Tracker showed staff documented Resident #38 tested positive for COVID-19 on 11/06/23. The report showed the resident's roommate Resident #39 tested negative for COVID-19 on 11/06/23 and 11/09/23.
Observation on 11/09/23 at 9:56 A.M., showed Resident #38 and #39, asymptomatic, residing in the same room with no infection prevention barrier, and none of the residents had masks on.
13. Review of the facility's Testing Tracker showed staff documented Resident #40 tested positive for COVID-19 on 11/06/23. The report showed the resident's roommate, Resident #41 tested negative for COVID-19 on 11/06/23 and 11/09/23.
Observation on 11/09/23 at 9:457 A.M., showed Resident #40 and #41, asymptomatic, residing in the same room with no infection prevention barrier, and none of the residents had masks on.
14. Review of the facility's Testing Tracker showed staff documented Resident #42 tested positive for COVID-19 on 11/06/23. The report showed the resident's roommate, Resident #43 tested negative for COVID-19 on 11/06/23 and 11/09/23.
Observation on 11/09/23 at 9:58 A.M., showed Resident #42 and #43, asymptomatic, residing in the same room with no infection prevention barrier, and none of the residents had masks on.
15. Review of the facility's Testing Tracker showed staff documented Resident #44 tested positive for COVID-19 on 11/06/23. The report showed the resident's roommate, Resident #45 tested negative for COVID-19 on 11/06/23 and positive on 11/09/23.
Observation on 11/09/23 at 9:59 A.M., showed Resident #44 and #45, asymptomatic, residing in the same room with no infection prevention barrier, and none of the residents had masks on in their room.
16. Review of the facility's Testing Tracker showed staff documented Resident #46 tested positive for COVID-19 on 11/06/23. The report showed the resident's roommate, Resident #47 tested negative for COVID-19 on 11/06/23 and 11/09/23.
Observation on 11/09/23 at 10:00 A.M., showed Resident #46 and #47, asymptomatic, residing in the same room with no infection prevention barrier, and none of the residents had masks on.
17. Review of the facility's Testing Tracker showed staff documented Resident #49 tested positive for COVID-19 on 11/09/23. Review of the report showed the resident's roommate, Resident #48 tested negative for COVID-19 on 11/09/23.
Observation on 11/09/23 at 10:01 A.M. showed Resident #48 and #49, asymptomatic, residing in the same room with no infection prevention barrier, and none of the residents had masks on.
Observation on 11/09/23 at 12:23 P.M., 2:05 P.M., and 5:22 P.M., showed Resident #48 and #49, asymptomatic, residing in the same room with no infection prevention barrier, and none of the residents had masks on, after the 11/09/23 COVID-19 testing.
18. Review of the facility's Testing Tracker showed staff documented Resident #50 tested positive for COVID-19 on 11/09/23. Review of the report showed the resident's roommate, Resident #51 tested negative for COVID-19 on 11/09/23.
Observation on 11/09/23 at 10:02 A.M., showed Resident #50 and #51, asymptomatic, residing in the same room with no infection prevention barrier, and none of the residents had masks on.
Observation on 11/09/23 at 12:24 P.M., and 2:06 P.M., and 5:23 P.M., showed Resident #50 and #51, asymptomatic, residing in the same room with no infection prevention barrier, and none of the residents had masks on, after the 11/09/23 COVID-19 testing.
19. Review of the facility's Testing Tracker showed staff documented Resident #52 tested positive for COVID-19 on 11/09/23. Review of the report showed the resident's roommate, Resident #53 tested negative for COVID-19 on 11/09/23.
Observation on 11/09/23 at 10:03 A.M. showed Resident #52 and #53, asymptomatic, residing in the same room with no infection prevention barrier, and none of the residents had masks on.
Observation on 11/09/23 at 12:25 P.M., and 2:07 P.M., and 5:24 P.M., showed Resident #52 and #53, asymptomatic, residing in the same room with no infection prevention barrier, and none of the residents had masks on, after the 11/09/23 COVID-19 testing.
20. Review of the facility's Testing Tracker showed staff documented Resident #54 tested positive for COVID-19 on 11/09/23. Review of the report showed the resident's roommate, Resident #55 tested negative for COVID-19 on 11/09/23.
Observation on 11/09/23 at 10:04 A.M. showed Resident #54 and #55, asymptomatic, residing in the same room with no infection prevention barrier, and none of the residents had masks on.
Observation on 11/09/23 at 12:26 P.M., and 2:08 P.M., and 5:25 P.M., showed Resident #54 and #55, asymptomatic, residing in the same room with no infection prevention barrier, and none of the residents had masks on, after the 11/09/23 COVID-19 testing.
21. Review of the resident's nurses notes, dated 11/04/23, showed Resident #57 complained of a sore throat and generally not feeling well. COVID-19 test negative on 11/04/23.
Review of the facility's Testing Tracker showed staff documented Resident #57 tested positive for COVID-19 on 11/06/23. The report showed the resident's roommate, Resident #56 tested negative for COVID-19 on 11/06/23 and 11/09/23.
Observation on 11/09/23 at 10:05 A.M. showed Resident #56 and #57, asymptomatic, residing in the same room with no infection prevention barrier, and none of the residents had masks on.
During an interview on 11/09/23 at 9:37 A.M., the Minimum Data Set (MDS) (a federally mandated assessment to be completed by the facility) Coordinator said the Administrator was testing residents for COVID and only had a few left to test.
During an interview on 11/09/23 at 9:43 A.M., the Administrator said she just finished COVID testing all of the residents.
During an interview on 11/09/23 at 12:17 P.M., Licensed Practical Nurse (LPN) A said residents were told they needed to stay in their room and wear masks in the hallways, but they were non-compliant. He/she said COVID positive residents should wear a mask. He/she said staff should try to get residents to wear a N95 mask, but most don't. He/she said residents can be in the same room as of now, because they are still coming up negative and positive. He/she said staff are trying to keep residents in their rooms, but they are not always compliant. He/she said Saturday, 11/4/23, staff had put the COVID positive resident in his/her room, put up isolation precautions, and the roommate was left in same room. The roommate tested positive the second day.
During an interview on 11/09/23 at 3:06 P.M., the Administrator said she would expect COVID-19 positive residents to be isolated separately from COVID-19 negative residents, but the residents got too upset when room changes were made, which caused behaviors. The COVID-19 negative residents were already exposed so they were left in their current rooms.
During an interview on 11/09/23 at 3:16 P.M., MDS Coordinator said the COVID-19 positive residents should be secluded from the COVID-19 negative residents, before room changes were made. The facility followed the CDC protocols regarding COVID-19. Residents had to stay in their rooms and wear a N95. The problem was the males on the A hall share two community bathrooms and came in contact with one another.
During an interview on 11/09/23 at 6:15 P.M., the Administrator said the process for separating the positive, the negative, and the exposed COVID-19 residents would be started soon.
Note: At the time of the survey, the violation was determined to be at the immediate and serious jeopardy level K. Based on observation, interview, and record review completed during the onsite visit, it was determined the facility had implemented corrective action to address and lower the violation at the time. A final revisit will be conducted to determine if the facility is in substantial compliance with participation requirements.
At the time of exit, the severity of the deficiency was lowered to the E level. This statement does not denote that the facility has complied with State law (Section 198.026.1 RSMo.) requiring that prompt remedial action be taken to address Class I violation(s).
Complaint #MO00227114
CONCERN
(F)
📢 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 F0727
(Tag F0727)
Could have caused harm · This affected most or all residents
Based on observation, interview, and record review, the facility failed to ensure a Registered Nurse (RN) was on duty 40 hours per week and to ensure a Director of Nursing (DON) worked full time. This...
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Based on observation, interview, and record review, the facility failed to ensure a Registered Nurse (RN) was on duty 40 hours per week and to ensure a Director of Nursing (DON) worked full time. This deficiency had the potential to affect all residents. The facility census was 93.
Review of a request for a waiver of nurse staffing requirements from the Centers for Medicare and Medicaid Services (CMS) showed a letter, dated 02/15/23, with waiver approved effective February 15, 2023, through February 14, 2024. The waiver included the following requirement:
- The facility has one full-time registered nurse regularly on duty 40 hours a week. This may be the same individual or part-time individuals. This nurse may or may not be the DON and may perform some DON and some clinical duties if the facility so desires.
Review of the nursing schedules for October 1, 2023 through November 9, 2023, showed:
- No RN names listed on the schedules;
- No RN scheduled for 10/21/23 - 11/09/23;
- No RN scheduled for 20 out of 40 days;
- No documentation of any DON hours.
Observation on 11/09/23 at 9:50 A.M., showed no DON or Registered Nurse (RN) working in the facility.
During an interview on 11/09/23 at 10:30 A.M., Licensed Practical Nurse (LPN) A said the facility currently did not have a DON.
During an interview on 11/09/23 at 11:10 A.M., the Administrator said the facility did not currently have a DON. The DON's last day was 10/18/23. They currently had a RN that was working part time as the DON. They had RN coverage on 10/20/23. The facility had a waiver for RN coverage.
During an interview on 11/09/23 at 3:20 P.M., the MDS Coordinator said the interim DON comes over from a sister facility and other DONs were supposed to come from other facilities to fill in, but the interim DON was the only one who had been there.
During interview on 11/14/23 at 1:37 P.M., the DON said she started as the DON at the facility on 10/23/23, however she worked between this facility and another one, training as a new DON at the other facility. She worked two to three days a week at this facility usually from 9:00 A.M. to 4:00 P.M. There was nothing to show exactly what days she worked where and she didn't really keep track of it. She was not full time at either facility, just full time between the two.
During interview on 11/09/23 at 2:23 P.M., the Administrator said the part-time DON started on 10/23/23. She was not in the facility everyday and was only there two to three days a week for eight to nine hours per day. The facility didn't have any other RNs on their payroll at this time. She was still currently looking for a full-time DON.
Oct 2022
17 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0578
(Tag F0578)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure five residents (Resident #23, #33, #70, #88, an...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure five residents (Resident #23, #33, #70, #88, and #350) of 20 sampled residents and two residents (Resident #16 and #250) outside the sample, had an order for code status and/or the resident's code status was consistently documented. The facility census was 97.
Record review of the facility's Advanced Directives policy, revised on [DATE], showed:
- Policy to recognize the resident's wishes for advanced directives will be known and followed;
- An Advanced Directive will be a written instruction, such as a living will, durable power of attorney (DPOA), or other health care decision makers as determined by state law;
- An Advanced Directive must be signed by the resident or responsible party and legally recognized by the state;
- The document must be available to the facility and placed in the resident's medical record;
- The policy did not address the colored dot system used for resident code status.
1. Record review on [DATE] of Resident #16's electronic medical record (EMR) showed:
- An admission date of [DATE];
- The resident's Advanced Directive indicated a full code (wants cardiopulmonary resuscitation (CPR) if the heart stops beating or the person stops breathing) status;
- A do not resuscitate (DNR) (does not want CPR if the heart stops beating or the person stops breathing) code status indicated on The Outside The Hospital Do Not Resuscitate Order (OHDNR) form signed by the resident and the physician, dated [DATE].
Observation on [DATE] at 4:15 P.M., of the resident's doorway name plate showed a green dot next to the resident's name.
2. Record review of Resident #23's electronic medical record (EMR) showed:
- An admission date of [DATE];
- The DNR order, dated [DATE], signed by the resident's guardian only and not by the physician;
- The facesheet and Physician Order Sheet (POS), dated [DATE], showed the resident with a DNR code status.
3. Record review of Resident #33's EMR showed:
- An admission date of [DATE];
- The facesheet and POS, dated [DATE], showed the resident with a DNR code status.
Observation on [DATE] at 9:30 A.M., of the resident's doorway name plate showed a green dot.
4. Record review of Resident #70's EMR showed:
- An admission date of [DATE];
- The facesheet and POS, dated [DATE], showed the resident with a DNR code status.
Observation on [DATE] at 9:50 A.M., of the resident's doorway name plate showed a green dot next to the resident's name.
5. Record review of Resident #88's EMR showed:
- An admission date of [DATE];
- No code status on the resident's face sheet;
- No physician's order for a code status.
Observation on [DATE] at 11:30 A.M., of the resident's doorway name plate showed a green dot next to the resident's name.
6. Record review of Resident #250's EMR showed:
- admitted on [DATE];
- No code status on the resident's face sheet;
- No physician's order for a code status.
Observation on [DATE] at 10:05 A.M., of the resident's doorway name plate showed a green dot next to the resident's name.
7. Record review of Resident #350's EMR showed:
- An admission date of [DATE];
- No code status on the resident's face sheet;
- No physician's order for a code status.
During an interview on [DATE] at 8:30 A.M., Licensed Practical Nurse (LPN) E said he/she would check the resident's face sheet for a code status. If the code status was not found on the resident's face sheet, then the physician's orders would be checked for a code status. If a code status could not be found on the physician's orders, someone from administration would be notified for further guidance.
During an interview on [DATE] at 8:38 A.M., LPN D said each door should have a color code by the resident's name indicating the resident's code status. He/she would check the resident's profile for a code status. If a code status could not be found on the resident's profile, the physician's orders would be checked for a code status. If a code status could not be found on the physician's orders, the resident would be considered a full code.
During an interview on [DATE] at 3:00 P.M., the Social Service Designee (SSD) and the Minimum Data Set (MDS) (a federally mandated assessment to be completed by the facility staff) Coordinator said everyone was considered a full code when admitted until the DNR paperwork was completed and received. The nurse was responsible for putting the code order in the physician's orders. The Medical Records person was responsible for putting the colored dots beside the resident's name plate.
During an interview on [DATE] at 2:34 P.M., the Assistant Director of Nursing (ADON) said the resident's facesheet and POS should indicate the resident's code status. Staff should look at the colored dot on the resident's doorway name plate next to the resident's name which indicated the resident's code status. A green dot means the resident was a full code and a red dot means the resident was a DNR. The staff should then verify the resident's code status by looking at the resident's facesheet and/or POS. A resident with a DNR code status should have it listed on their POS, facesheet, and have a signed order from a doctor.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Abuse Prevention Policies
(Tag F0607)
Could have caused harm · This affected 1 resident
Based on interview and record review, the facility failed to follow their policy to ensure completion of the required Nurse Aide (NA) Registry for all new staff before the employment hire date to ensu...
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Based on interview and record review, the facility failed to follow their policy to ensure completion of the required Nurse Aide (NA) Registry for all new staff before the employment hire date to ensure they did not have a federal indicator (a marker given by the federal government to individuals found guilty of abuse/neglect/misappropriation of property) for four employees of nine sampled employees. The facility census was 97.
Record review of the facility's Abuse, Neglect, Exploitation and Misappropriation of Property policy, revised on 3/16/17, showed:
- The goal of Belleview Valley Nursing Home (BVNH) will be to develop a system for screening potential employees and identifying, investigating, preventing, and reporting any incident, or suspected incident of mistreatment, neglect, misappropriation of property or abuse;
- It will be the responsibility of the Administrator and the Director of Nursing Services of the facility to ensure screening of potential employees for a history of abuse, neglect, or mistreatment of residents;
- Background checks will be done at the time of hire in accordance with the facility background screening policy;
- The Nurse Aide Registry will be checked prior to employment for each state where the nurse aide showed to have worked or with a listed certification;
- Nurse Aides will not be hired whose name to be on any state abuse registry.
1. Record review of Employee F's personnel file showed:
- Employee with a hire date of 7/6/22;
- No documentation of the NA Registry checked for the employee;
- The NA Registry not checked for a federal indicator before the employee's hire date.
2. Record review of Employee L's personnel file showed:
- Employee with a hire date of 4/5/22;
- No documentation of the NA Registry checked for the employee;
- The NA Registry not checked for a federal indicator before the employee's hire date.
3. Record review of Employee M's personnel file showed:
- Employee with a hire date of 5/11/22;
- No documentation of the NA Registry checked for the employee;
- The NA Registry not checked for a federal indicator before the employee's hire date.
4. Record review of Employee N's personnel file showed:
- Employee with a hire date of 7/27/22;
- No documentation of the NA Registry checked for the employee;
- The NA Registry not checked for a federal indicator before the employee's hire date.
During an interview on 10/19/22 at 10:53 A.M., the Administrator said she checked the NA registry herself and did not know why it was not in the employees' files, but she did know that it had to be checked on all new hires.
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 interview and record review, the facility failed to send a copy of the notice for transfer or discharge to the resident...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to send a copy of the notice for transfer or discharge to the resident, resident representative, and to the representative of the Office of the State Long-Term Care (LTC) Ombudsman for four residents (Resident #12, #23, #33, and #101) out of 20 sampled residents. The facility's census was 97.
Record review of the facility's Discharge Planning policy, dated 7/24/17, showed:
- The Social Service Director and Minimum Data Set (MDS) (a federal mandated assessment to be completed by the facility staff) Coordinator will assume responsibility for discharge planning and coordination;
- Transfer/discharge notification to the resident, resident representative and a representative of the Office of the State LTC Ombudsman not addressed.
1. Record review of Resident #12's medical record showed:
- admitted on [DATE];
- The resident transferred to the hospital on 7/13/22;
- No documentation of the notification with the reason for the hospital transfer provided to the resident and/or the resident's responsible party;
- No documentation of the resident transfer/discharge notification sent to the to the representative of the Office of the State LTC Ombudsman.
2. Record review of Resident #23's medical record showed:
- admitted on [DATE];
- The resident transferred to the hospital on 8/11/22;
- No documentation of the notification with the reason for the hospital transfer provided to the resident and/or the resident's responsible party;
- No documentation of the resident transfer/discharge notification sent to the to the representative of the Office of the State LTC Ombudsman.
3. Record review of Resident #33's medical record showed:
- admitted on [DATE]:
- The resident transferred to the hospital on 7/13/20, 8/13/22 and 8/17/22;
- No documentation of the notification with the reason for the hospital transfer provided to the resident and/or the resident's responsible party;
- No documentation of the resident transfer/discharge notification sent to the to the representative of the Office of the State LTC Ombudsman.
4. Record review of Resident #101's medical record showed:
- admitted on [DATE];
- The resident transferred to the hospital and given an immediate discharge on [DATE];
- No documentation of the notification with the reason for the hospital transfer provided to the resident and/or the resident's responsible party;
- No documentation of the resident transfer/discharge notification sent to the to the representative of the Office of the State LTC Ombudsman.
During an interview on 10/17/22 at 7:54 A.M., the Office of the State Long-Term Care Ombudsman Director said they had not received any monthly reports of resident discharges from the facility since January 2022.
During an interview on 10/18/22 at 11:31 A.M., the Social Service Director (SSD) said he/she was not aware of the transfer/discharge notification for the resident, resident representative and a representative of the Office of the State LTC Ombudsman. He/she was not aware a copy of the transfer/discharge notifications were supposed to be sent to the ombudsman on a monthly basis.
During an interview on 10/19/22 at 12:25 P.M., the Administrator said she would expect that a transfer/discharge notification would be given to the resident or resident representative when a resident was sent to the hospital. She would expect that resident transfer/discharge notifications be sent to the ombudsman on a monthly basis.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0625
(Tag F0625)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide written information to the resident and/or the resident's l...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide written information to the resident and/or the resident's legal representative of their bed hold policy at the time of transfer to the hospital for three residents (Resident #12, #23, and #33) out of 20 sampled. The facility's census was 97.
Record review of the facility's Bed Hold policy, revised on 4/17/2017, showed:
- The bed hold policy will be reviewed with the resident, designated family member, and/or the resident's legal representative;
- Before a resident will be transferred to a hospital or goes on therapeutic leave, a written Bed Hold policy will be given to the resident, designated family member, and/or the resident's legal representative;
- In case of an emergency transfer, the resident, designated family member, and/or the resident's legal representative will be issued a copy of the Bed Hold policy within 24 hours by sending a copy with the resident's records at the time of the transfer.
1. Record review of Resident #12's medical record showed:
- admitted on [DATE];
- The resident transferred to the hospital on 7/13/22;
- No documentation with the notification for the bed hold policy provided to the resident and/or the resident's responsible party.
2. Record review of Resident #23's medical record showed:
- admitted on [DATE];
- The resident transferred to the hospital on 8/11/22;
- No documentation of the notification for the bed hold policy provided to the resident and/or the resident's responsible party;
3. Record review of Resident #33's medical record showed:
- admitted on [DATE];
- The resident transferred to the hospital on 7/13/22, 8/13/22 and 8/17/22;
- No written documentation of the notification for the bed hold policy provided to the resident and/or the resident's responsible party.
During an interview on 10/18/22 at 11:31 A.M., the Social Service Director (SSD) said the nurse who transfers the resident out was responsible for giving the bed hold notice to the resident and/or representative. The SSD said he/she was not aware he/she should be keeping a copy of it.
During an interview on 10/19/22 at 12:25 P.M., the Administrator said she would expect that a bed hold policy to be given to the resident and/or responsible party.
During an interview on 10/19/22 at 1:03 P.M., Licensed Practical Nurse (LPN) E said they don't give the resident and/or their representative anything when a resident was transferred out to the hospital.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0637
(Tag F0637)
Could have caused harm · This affected 1 resident
Based on interview and record review, the facility failed to complete a significant change Minimum Data Set (MDS), a federally mandated assessment to be completed by the facility staff, within 14 days...
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Based on interview and record review, the facility failed to complete a significant change Minimum Data Set (MDS), a federally mandated assessment to be completed by the facility staff, within 14 days of an admission to hospice for two residents (Resident #23 and #33) out of five sampled residents. The facility census was 97.
1. Record review of Resident #23's medical record showed:
- The resident admitted to hospice services on 8/16/22.
Record review of the resident's MDS records showed:
- No significant change MDS dated on or after 8/16/22;
- The facility failed to complete an significant change MDS within 14 days of the resident's admission to hospice.
2. Record review of Resident #33's medical record showed:
- The resident admitted to hospice services on 8/19/22.
Record review of the resident's MDS records showed:
- No significant change MDS dated on or after 8/19/22;
- The facility failed to complete an significant change MDS within 14 days of the resident's admission to hospice.
During an interview on 10/18/22 at 2:00 P.M., the MDS Coordinator said he/she wasn't aware a significant change MDS needed to be completed when a resident started on hospice services.
During an interview on 10/26/22 at 12:25 P.M., the Director of Nursing (DON) said it was expected that a significant change MDS would be completed when a resident had a significant change.
The facility did not provide a significant change MDS policy.
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 observation, interview and record review, the facility failed to implement a care plan with specific interventions tail...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to implement a care plan with specific interventions tailored to meet individual needs for two residents (Resident #67 and #88) out of 20 sampled residents. The facility census was 97.
Record review of the facility's Care Plan policy, revised on 7/7/19, showed:
-The facility should develop and maintain a plan of care for each resident upon admission and review at least quarterly;
- The care plan should include care to be given, short and long-term goals, and professional service responsible for each element of care.
1. Observations of Resident #67 showed:
- On 10/16/22 at 12:30 P.M., the resident lay in bed with 2 liters (L) of oxygen via a nasal cannula (a thin tube) (NC);
- On 10/17/22 at 9:03 A.M.,the resident lay in bed on 2L of oxygen via a NC;
- On 10/18/22 at 8:45 A.M., the resident lay in bed on 2L of oxygen via a NC;
- On 10/18/22 at 9:00 A.M., the resident lay in bed on 2L of oxygen via a NC.
Record review of resident's medical record showed:
- An admission date of 11/21/17;
- Diagnosis of Multiple Sclerosis (MS) (a disease of the central nervous system resulting in muscle weakness and loss of coordination);
- The Physician Order Sheet (POS) with an order for oxygen 2 liters per minute (L/min) via a NC, dated 5/20/22;
- The hospice coordinated plan of care, last updated 10/17/22, indicated oxygen therapy;
- The quarterly Minimum Data Set (MDS), a federally mandated assessment to be completed by the facility staff, dated 9/10/22, did not address oxygen therapy.
Record review of the resident's care plan, dated 9/10/22, showed:
- Did not address oxygen therapy with interventions.
2. Record review of Resident #88's medical record showed:
- The resident admitted on [DATE], with a weight of 166 pounds (lbs);
- On 9/28/22 the resident weighed 147.4 lbs.;
Record review of the resident's care plan, dated 7/22/22, showed:
- Did not address weight loss with interventions.
During an interview on 10/21/22 at 12:51 P.M., the MDS Coordinator said oxygen use and weight loss should be care planned on the comprehensive care plans.
During an interview on 10/21/22 at 12:52 P.M., the Director of Nursing (DON) said oxygen and weight loss should be care planned on the comprehensive care plans.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0657
(Tag F0657)
Could have caused harm · This affected 1 resident
Based on interview and record review, the facility failed to update care plans for one resident, (Resident #40) and the facility failed to ensure care plan conferences included an interdisciplinary te...
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Based on interview and record review, the facility failed to update care plans for one resident, (Resident #40) and the facility failed to ensure care plan conferences included an interdisciplinary team approach (consisting of a minimum of the resident's physician, a registered nurse, a nurse aide and other professionals as needed) for one resident (Resident #19) out of 20 sampled residents. This practice had the potential to affect all residents. The facility census was 97.
Record review of the facility's Care Plan policy, revised on 7/7/19, showed:
-The facility should develop and maintain a plan of care for each resident upon admission and review at least quarterly;
- The nursing staff, in coordination with other resident care services, develops and maintains a care plan;
- The plan will be developed in coordination with the attending physician's plan of medical care and will be reviewed, as necessary, but at least quarterly, by all professional personnel involved in the care of the resident;
- The care plan should include care to be given, short and long-term goals, and professional service responsible for each element of care.
1. During an interview on 10/17/22 at 10:11 A.M., Resident #19 said he/she had not been to any meetings where his/her care was discussed.
Record review of the resident's care plan conference attendance record, dated 7/29/22, showed:
- The Social Services Designee (SSD) present;
- The Minimum Data Set (MDS)(a federally mandated assessment completed by the facility) Coordinator present.
During an interview on 10/18/22 at 12:00 P.M., the MDS Coordinator said only the resident, the SSD, and his/herself were present at the care plan conferences. The MDS coordinator said no other disciplines attended the conferences.
During an interview on 10/18/22 at 3:30 P.M., the Director of Nursing (DON) said neither herself or the Assistant Director of Nursing (ADON) attended the care plan conferences. The DON said in the past, other disciplines used to attend the conferences. The DON said she knew the care plan conferences should include more than the SSD and the MDS coordinator.
2. Record review of Resident # 40's Physician Order Sheet (POS), dated October 2022, showed:
- Diagnoses of adult failure to thrive (a downward spiral of poor nutrition, weight loss, inactivity, depression and decreased functional ability), congestive heart failure (CHF) (a condition causing the heart to not pump blood as it should);
- An order for a regular diet, pureed texture with nectar thick liquids (easily pourable and comparable to heavy syrup found in canned fruit);
- No order for a nutritional supplement.
Record review of the resident's weights showed:
- On 5/1/22, 191 pounds (lb.);
- On 6/6/22, 194.2 lb;
- On 7/5/22, 189.8 lb;
- On 8/1/22, 185.2 lb;
- On 9/1/22, 182.4 lb;
- On 9/28/22, 174.8 lb;
- On 10/12/22, 169.0 lb;
- A 6 percent (%) weight loss from 9/1/22 through 10/12/22;
- A 10.95% weight loss from 7/5/22 through 10/12/22.
Record review of the Registered Dietician (RD) notes showed:
- On 9/1/22, a late entry note from 8/31/22, the resident's weight of 182.4 lbs. and a recommendation of a mighty shake (a drink that adds dietary calories and protein) once daily;
- On 9/29/22, the resident's weight of 174.8 lbs, with loss continued despite recent intervention, and a recommendation to add 2 Cal (a dietary supplement) 90 milliliters twice a day.
Record review of the resident's medical record showed:
- No documentation the facility provided the RD's recommendations for the resident to his/her physician;
- The facility failed to provide the RD recommendations to the resident's physician.
Observations on 10/16/22 at 11:52 A.M., showed the resident in the dining room with his/her meal tray with no mighty shake as recommended per the RD.
Record review of the resident's care plan, revised on 10/12/22, showed;
- The resident's weight loss with interventions not addressed.
During an interview on 10/19/22 at 8:36 A.M., the Administrator said the facility had interdisciplinary team meetings weekly, and did review weights at that time. If there were weight losses, the RD would see the resident and the dietary recommendations would go to the DON, the Dietary Manager (DM), and to the Administrator. The recommendations were reviewed and were sent to the physician. She did not know why this was overlooked, and would expect weight loss with interventions to be care planned.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0658
(Tag F0658)
Could have caused harm · This affected 1 resident
Based on observation, interview, and record review, the facility failed to obtain physician orders for three residents (Resident #20, #51, and #71) out of 20 sampled residents. The facility census was...
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Based on observation, interview, and record review, the facility failed to obtain physician orders for three residents (Resident #20, #51, and #71) out of 20 sampled residents. The facility census was 97.
Record review of the facility's Oxygen Administration policy, revised on 6/15/20, showed:
- Policy will provide guidelines for safe oxygen administration;
- Verify physician's order for the procedure.
1. Observation of Resident #20 showed:
- On 10/16/22 at 3:33 P.M., the resident lay in bed with oxygen (O2) on at 4 liters per minute (L/min) per nasal cannula (NC) (a device used to deliver supplemental oxygen or increased airflow to a person);
- On 10/17/22 at 10:15 A.M., the resident lay in bed with O2 on at 4 L/min per a NC;
- On 10/18/22 at 12:05 P.M., the resident sat on the side of the bed with O2 on at 5 L/min per a NC.
Record review of the resident's Physician Order Sheet, dated 10/18/22, showed:
- No physician's order for oxygen therapy.
During an interview on 10/16/22 at 3:33 P.M., Resident #20 said he/she did not know what level the oxygen should be set on.
2. Observation of Resident #51 showed:
- On 10/16/22 at 12:47 P.M., the resident sat in a geri chair (a fully reclining chair with wheels that can be used for mobility) with O2 on at 4 L/min per a NC;
- On 10/17/22 at 9:08 A.M., the resident sat in a geri chair in the dining room with O2 on at 4 L/min per a NC;
- On 10/18/22 at 9:30 A.M., the resident lay in bed with O2 on at 4 L/min per a NC;
- On 10/19/22 at 8:50 A.M., the resident sat in a geri chair with O2 on at 4 L/min per a NC.
Record review of the resident's POS, dated 10/17/22, showed:
- No physician's order for oxygen therapy.
During an interview on 10/18/22 at 8:35 A.M., Certified Nurse Aide (CNA) O said Resident #51 had been on oxygen for awhile, but did not know what the setting should be at.
During an interview on 10/18/22 at 8:39 A.M., Licensed Practical Nurse (LPN) E said there should be an order for oxygen therapy. He/she looked on the POS for Resident #51, and could not find an oxygen therapy order.
3. Observation of Resident #71 showed:
- On 10/17/22 at 10:59 A.M., the resident lay in bed with O2 on at 2 L/min per a NC.
Record review of Resident's POS, dated 10/17/22, showed:
- No physician's order for oxygen therapy.
During an interview, Resident #71 said he/she thought the setting should be on 2 L/min.
During an interview on 10/19/22 at 9:06 A.M., the Director of Nursing said she would expect there to be a physician's order for a resident on oxygen therapy and nursing staff should be able to verify what level the the oxygen output should be set on.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Quality of Care
(Tag F0684)
Could have caused harm · This affected 1 resident
Based on interview and record review, the facility failed to failed to complete a coordinated plan of care (COPOC) for one resident (Resident #16) and failed to obtain a written physician's order for ...
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Based on interview and record review, the facility failed to failed to complete a coordinated plan of care (COPOC) for one resident (Resident #16) and failed to obtain a written physician's order for hospice services for two residents (Resident #23 and #33) out of a sample of six residents. The facility census was 97.
1. Record review of Resident #16's Physician's Telephone Order, dated 7/18/22, showed:
- Admit resident to hospice services.
Record review of the resident's Hospice/Facility Coordinated Task Plan of Care, dated 7/18/22, showed:
- No documentation of the resident's code status;
- No documentation of an emergency contact for a change in the resident's condition;
- No documentation of the assigned Registered Nurse (RN) case manager, Hospice Aide, Hospice Chaplain, Hospice Social Worker, and Hospice Volunteer;
- No documentation of the Hospice Nurse and Aide frequency of visits and days scheduled;
- No documentation of the Hospice Social Worker, Chaplain, and Volunteer frequency of visits;
- No documentation of the specific activities hospice and/or the facility provided;
- No documentation of the specific resident medical care/monitoring hospice and/or the facility provided;
- No documentation of the specific hospice and/or facility wound care scheduled;
- No documentation of the specific medical supplies provided by hospice and/or the facility;
- No documentation of the specific durable medical equipment (DME) provided by hospice and/or the facility.
2. Record review of Resident #23's medical record showed:
- A nurse's note, dated 8/16/22, the resident admitted to the facility from the hospital on hospice;
- A Coordinated Care Plan between the facility and hospice, dated 8/16/22.
Record review of the resident's Physician Order Sheet (POS), dated 10/18/22, showed:
- No order for hospice.
3. Record review of Resident #33's nurses's note, dated 8/19/22, showed:
- The resident admitted to hospice services on 8/19/22.
Record review of the resident's POS, dated 10/17/22, showed:
- No order for hospice.
During an interview on 10/19/22 at 11:10 A.M., the Director of Nursing (DON) said a resident admitted to hospice should have a physician's order.
During an interview on 10/19/22 at 1:30 P.M., Licensed Practical Nurse (LPN) F said there should be an order if the resident was admitted to hospice. He/she reviewed the Resident #33's POS and did not see an order for hospice.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0692
(Tag F0692)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure the Registered Dietician's (RD) recommendation...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure the Registered Dietician's (RD) recommendations for a resident with weight loss were provided to the resident's physician which affected one resident (Resident #40) and the facility also failed to acknowledge weight loss for one resident (Resident #88) out of a sample of 20 residents. The facility census was 97.
Record review of the facility's Nutritional policy, revised on 9/30/20, showed:
- All residents will be assessed for nutritional needs with implemented interventions as appropriate to maintain proper nutritional balance;
- All residents will have a nutritional assessment completed as part of the admission process;
- Nutritional assessments will be completed quarterly and as needed thereafter;
- Residents identified to be at nutritional risk may include, but not limited to, a significant unplanned weight loss of 5 percent (%) in one month, 7.5% in three months, and/or 10% in six months;
- Approaches to be taken will be, but not limited to, fortified (extra nutrients added) foods with meals and for snacks, high calorie snacks between meals, and/or in-house nutritional supplements per a physician's order.
1. Record review of Resident # 40's Physician Order Sheet (POS), dated October 2022, showed:
- Diagnoses of adult failure to thrive (a downward spiral of poor nutrition, weight loss, inactivity, depression and decreased functional ability) and congestive heart failure (CHF) (a condition causing the heart to not pump blood as it should);
- An order for a regular diet, pureed texture with nectar thick liquids (easy pourable liquid and comparable to heavy syrup found in canned fruit);
- No order for a nutritional supplement.
Record review of the resident's weights showed:
- On 5/1/22, 191 pounds (lb.);
- On 6/6/22, 194.2 lb;
- On 7/5/22, 189.8 lb;
- On 8/1/22, 185.2 lb;
- On 9/1/22, 182.4 lb;
- On 9/28/22, 174.8 lb;
- On 10/12/22, 169.0 lb;
- A 6 percent (%) weight loss from 9/1/22 through 10/12/22;
- A 10.95% weight loss from 7/5/22 through 10/12/22.
Record review of the Registered Dietician (RD) notes showed:
- On 9/1/22, a late entry note from 8/31/22, the resident's weight of 182.4 lbs. and a recommendation of a mighty shake (a dietary supplement) once daily;
- On 9/29/22, the resident's weight of 174.8 lbs, with loss continued despite recent intervention, and a recommendation to add 2 Cal (a dietary supplement) 90 milliliters twice a day.
Record review of the resident's medical record showed:
- No documentation the facility provided the RD's recommendations for the resident to his/her physician;
- The facility failed to provide the RD recommendations to the resident's physician.
Observations on 10/16/22 at 11:52 A.M., showed the resident in the dining room with his/her meal tray with no mighty shake as recommended per the RD.
Record review of the resident's care plan, revised on 10/12/22, showed;
- The resident's weight loss with interventions not addressed.
During an interview on 10/19/22 at 8:32 A.M., the Director of Nursing (DON) said she was unable to find where the health shakes or supplements were ever ordered.
During an interview on 10/19/22 at 8:36 A.M., the Administrator said the facility had interdisciplinary team meetings weekly, and went over weights at that time. If there were weight losses, the RD would see the resident and make recommendations, which go to the DON, the Dietary Manager (DM), and the Administrator. The recommendations were reviewed and sent to the physician. She did not know why this was overlooked, but she would expect weight loss recommendations to be sent to the physician and interventions to be care planned.
During an interview on 10/19/22 at 9:08 A.M., Certified Nursing Assistant (CNA) O said, he/she didn't know if the resident would drink the mighty shakes or not, he/she had never seen them on the meal tray.
Observations on 10/19/22 at 10:20 A.M., showed the resident was not on the supplement list posted in the kitchen.
During an interview on 10/19/22 at 10:22 A.M., [NAME] A said he/she didn't think the resident had ever been on the supplement list.
During an interview on 10/19/22 at 12:49 P.M., the Registered Dietician (RD) said he/she saw the resident on 8/31/22, and made a late entry on 9/1/22, for a recommendation of a mighty shake once daily for the resident. Then on 9/28/22, the recommendation of 2 Cal 90 milliters twice a day and to continue the one mighty shake daily was made. His/her recommendations were sent to the DM, the DON and the Administrator. They should be review the recommendations and provide them to the physician. He/she was unsure of ever being made aware of the first recommendation not being provided to the physician.
2. Record review of Resident #88's medical record showed:
- admitted on [DATE];
- Diagnoses of Bipolar Disorder (disorder causes extreme mood swings), anxiety, Post-traumatic Stress Disorder, insomnia (a sleep disorder), mood disorder (a mental health condition which mainly affects emotional state), genetic intellectual disability (intellectual disability caused by heredity) and schizoaffective disorder (a condition where symptoms of both psychotic and mood disorders present together);
- The resident's current weight of 150.2 lbs., highlighted in red on the face sheet;
- No interventions in place for the weight loss;
- No nurses' notes in regards to the weight loss;
- No RD notes in regards to the weight loss.
Record review of the resident's weights showed:
- On 7/6/22, 166.0 Lbs;
- On 8/1/22, 158.2 Lbs;
- On 9/1/22, 155.4 Lbs;
- On 9/28/22, 147.4 Lbs;
- On 10/3/22, 150.2 Lbs.
- An 11.2 % weight loss from 7/6/22 - 9/28/22.
During an interview on 10/18/22 at 2:49 P.M., the DON said they don't have any actual weight committee, but they do meet once a week after the morning meeting and discuss weights, falls and wounds. The DON was not aware if there was any documentation for those meetings.
During an interview on 10/19/22 at 10:20 A.M., Licensed Practical Nurse (LPN) F said the restorative aide brings the residents' weights to their attention. The weights in the top right hand corner of the resident's medical record will light red when there were significant weight changes and Resident #88's were in red.
During an interview on 10/19/22 at 8:37 A.M., the Administrator said they had a weekly wound/weight/fall meeting but they didn't document any minutes. The restorative aide was there and weights were discussed. If a weight change was noticed, then they may ask if an intervention needed to be put in place.
During an interview on 10/19/22 at 12:40 P.M., the RD said when he/she visits, weight records were pulled and reviewed. He/she talks with the DON and the DM, pulls the quarterly/annual Minimum Data Sets (MDS) (a federally mandated assessment to be completed by the facility staff), pulls the wound list, and interviews staff. If the resident's weights had been flagged or if the staff had brought the resident's weights to his/her attention, the RD would have seen the resident. The RD said would have expected staff to have alerted him/her about the resident's weight when he/she was there on 9/29/22.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Safe Environment
(Tag F0921)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to provide a safe environment for the residents and staff...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to provide a safe environment for the residents and staff by not placing a protective cover over exposed wiring connected to light fixtures. The exposed wiring could be a safety and fire hazard if left uncovered. The deficient practice had the potential to affect all residents and staff in the facility. The facility census was 97.
Record review of the facility's Preventive Maintenance Program policy, dated 7/24/17, showed:
- The facility maintains a written Preventive Maintenance Program to ensure the clean, orderly, attractive, and safe upkeep of the exterior and interior areas of the building and that equipment will be maintained in operative working order including the mechanical, electrical, and resident care equipment.
- The Preventative Maintenance Program will provide for the inspection of light fixtures.
Observations on 10/16/22 at 12:42 P.M., 10/17/22 at 9:04 A.M., and 10/18/22 at 8:10 A.M., showed:
- room [ROOM NUMBER] with exposed wires and no protective cover attached to a light fixture above the bed by the left side window;
- room [ROOM NUMBER] with exposed wires and no protective cover attached to a light fixture above the bed by the left side of the door entrance.
Record review on 10/18/22 at 8:22 A.M., of the work order request forms located at the A and B Hall nurse's station showed:
- No completed work orders.
During an interview on 10/18/22 at 8:25 A.M. and 10/19/22 09:39 A.M., the Maintenance Supervisor said if something needs fixed, staff should be filling out a work order request addressing any safety concerns or needed repairs. The work order requests were given to the Administrator after completion of a repair or after an area of concern had been addressed.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0924
(Tag F0924)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure the handrails on the A Hall were properly maint...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure the handrails on the A Hall were properly maintained. This deficient practice had the potential to affect all residents on this hall. The facility census was 97.
Record review of the facility's Preventive Maintenance Program policy, dated 7/24/17, showed:
- The facility maintains a written Preventive Maintenance Program to ensure the clean, orderly, attractive, and safe upkeep of the exterior and interior areas of the building and that equipment will be maintained in operative working order including the mechanical, electrical, and resident care equipment.
- The Preventative Maintenance Program will provide for the inspection of handicap rails.
Observations on 10/16/22 at 12:58 P.M., 10/17/22 at 9:11 A.M., and 10/18/22 at 8:10 A.M., on A Hall showed:
- The hand rail loose near room [ROOM NUMBER];
- The hand rail loose near room [ROOM NUMBER];
- The hand rail loose near room [ROOM NUMBER];
- The hand rail loose between rooms [ROOM NUMBERS].
Observation on 10/19/22 at 8:56 A.M., on B Hall showed:
- The hand rail loose and cracked near room [ROOM NUMBER];
- The hand rail loose near room [ROOM NUMBER];
- The hand rail loose near room [ROOM NUMBER];
- The hand rail loose near room [ROOM NUMBER];
- The hand rail loose near room [ROOM NUMBER].
Record review on 10/18/22 at 8:22 A.M., of the work order request forms located at the A and B Hall nurse's station showed:
- No completed work orders.
During an interview on 10/18/22 at 8:25 A.M. and 10/19/22 09:39 A.M., the Maintenance Supervisor said if something needs fixed, staff should be filling out a work order request addressing any safety concerns or needed repairs. Work order requests were given to the Administrator after completion of a repair or after an area of concern had been addressed. He/she was aware of the handrails being loose and this was an ongoing task.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Safe Environment
(Tag F0584)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide a safe, clean, and comfortable homelike envir...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide a safe, clean, and comfortable homelike environment. This deficient practice had the potential to affect all residents in the facility. The facility census was 97.
Record review of the facility's Preventive Maintenance Program policy, dated 7/24/17, showed:
- The facility maintains a written Preventive Maintenance Program to ensure the clean, orderly, attractive, and safe upkeep of the exterior and interior areas of the building and that equipment will be maintained in operative working order including the mechanical, electrical, and resident care equipment;
- The Preventative Maintenance Program will provide for the inspection of the inside of the facility.
1. Observation on 10/18/22 at 9:19 A.M., of the unit showed:
- Sunlight could be seen through a 1/2 inch (in.) gap at the bottom of the exit door;
- A six in. area of missing baseboard trim in the dining area;
- A seven foot (ft) long, one inch gap between the wall and floor in the dining area;
- Thirteen ft of missing trim in the dining room;
- A one ft by eight in. brown stain on the ceiling in room [ROOM NUMBER] in front of the bathroom door;
- A five ft by two ft brown stain on the ceiling in room [ROOM NUMBER] by the window and over the bed;
- Twenty-four brown stains on the ceiling of room [ROOM NUMBER]. The stains ranged in size from two in. by two in. up to 1 1/2 ft by one ft and were located over the beds and throughout the room;
- A six in. by two in. crack in the wall to the right side of the heat/air conditioner wall unit in room [ROOM NUMBER];
- A two ft by one ft brown stain on the ceiling by the window of room [ROOM NUMBER];
- A one in. crack along the top of the heat/air conditioner wall unit in room [ROOM NUMBER];
- A three ft by three ft dark gray area on the hall ceiling outside of room [ROOM NUMBER];
- No cover on the light above the shower in the shower room;
- A 1 1/2 ft by one in. peeling area on the ceiling above the shower;
- A one in. by five in. crumbled area in the shower between the concrete floor and the brick wall of the shower room.
Observation of A hall, room [ROOM NUMBER] on 10/18/22 at 4:16 P.M., showed:
- Two eight ft walls adjacent to the hallway without a vinyl cove base attached to the wall;
- One four ft wall section without a vinyl cove base attached to the wall behind the resident's headboard.
Observation on 10/19/22 at 8:56 A.M., of the men's and women's shower rooms, dining room, and halls A and B showed:
- Five, one ft by one ft ceiling tiles with gray stains by the fire door near the women's shower room;
- A three ft by two ft brown stain on the ceiling tile above the plate storage in the dining room;
- A one ft by one ft square ceiling tile missing in room [ROOM NUMBER];
- A 1/4 in. to one in. black and brown substance above the tile around the floor along the whole men's shower;
- A one in. by seven in. crack in the ceiling by the light in the women's shower room;
- The light fixture without a cover between rooms [ROOM NUMBERS];
- A chair in the TV area across from the main dining room with a red plastic seat and a red pattern cloth back with a tear across the back of the chair with exposed foam;
- A 1 1/2 in. opened area in the wall across the top of the heating/air conditioner unit in room [ROOM NUMBER];
- The handrail between rooms 23-24 with a two ft crack.
Record review on 10/18/22 at 8:22 A.M., of the work order request forms located at the A and B Hall nurse's station showed:
- No completed work orders.
During an interview on 10/19/22 at 9:07 A.M., Housekeeper K said he/she used bleach water and Biomedic (a disinfectant, cleaning spray for hard surfaces) spray on the discoloration in the men's shower. Some of the discoloration was glue but some was not.
During an interview on 10/19/22 at 9:28 A.M., the maintenance staff said that once the work orders were completed, they were given to the Administrator or put in the Administrator's mailbox. The facility had a new rubber roof put on. The roof was no longer leaking and new tile had been purchased to replace the areas that had been stained from the previous leaks.
During an interview on 10/19/22 at 12:36 P.M., the Administrator said she would expect staff to report any areas related to safety or in need of repair verbally and in a timely manner. Staff could request a work order to address any issues or concerns as well.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0727
(Tag F0727)
Could have caused harm · This affected multiple residents
Based on interview and record review, the facility failed to provide a Registered Nurse (RN) for eight consecutive hours per day, seven days a week. The facility maintained a census of greater than 60...
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Based on interview and record review, the facility failed to provide a Registered Nurse (RN) for eight consecutive hours per day, seven days a week. The facility maintained a census of greater than 60 residents and this deficiency had the potential to affect all residents. The census was 97.
Record review of the facility's Staffing Policy, dated 8/1/2017, showed:
- The facility provides 24 hour nursing service by licensed nurses, one of which will be a RN on duty eight hours per day, seven days per week;
- A RN will be on duty in this facility for eight hours during the day shift;
- The Director of Nursing (DON) will normally be employed to work eight hours per day and work a minimum of 40 hours per week. In addition, at least one RN will be employed to work an eight hour tour of duty for relief of the DON thus providing coverage of a RN in the facility seven days a week.
1. Record review of the nursing schedules for September 16, 2022 through October 17, 2022 showed:
- No RN scheduled for 9/16/22 through 9/30/22;
- No RN scheduled for 10/2/22 through 10/15/22, and 10/17/22;
- No RN scheduled for 30 days out of 32 days.
Observations made during the day shift on 10/17/22, showed:
- The DON only RN in the facility.
Record review of the current staff list showed:
- Two RN's which included the DON.
During an interview on 10/19/22 at 11:32 A.M. the Administrator said she knows they are out of compliance for the daily RN coverage because there were several days with no RN coverage. The facility was using agency staff but there were just not having any luck getting RN's.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0882
(Tag F0882)
Could have caused harm · This affected most or all residents
Based on interview and record review, the facility failed to ensure at least one person had completed specialized training in infection prevention and control for the infection preventionist (a profes...
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Based on interview and record review, the facility failed to ensure at least one person had completed specialized training in infection prevention and control for the infection preventionist (a professional who makes sure healthcare workers and residents are doing all the things they should to prevent infections) position. This had the potential to affect all residents. The facility census was 97.
Record review of the facility's infection preventionist's (IP) training records, showed;
- Three people shared the IP duties, the Director of Nursing (DON), the Assistant Director of Nursing (ADON), and the Minimum Data Set (MDS) (a federal assessment to be filled out by the facility) Coordinator;
- No staff members with certificates to show they had completed the specialized training for the IP position;
- No records of any staff member enrolled in the specialized training for the IP position.
During an interview on 10/19/22 at 10:16 A.M., the Director of Nursing (DON) said there were three people at this time sharing the IP's duties, the DON, the ADON, and the MDS Coordinator. The DON stated there had been two previous staff members in the IP position, but they no longer worked at the facility. The DON said he/she had not enrolled in any specialized training for the IP, and neither had the ADON or the MDS Coordinator. The DON said he/she knew the training was available but was not sure where to find it at.
During an interview on 10/19/22 at 10:38 A.M., the Administrator said at this time there were three people sharing the IP position and its duties. She said there had been other staff in this position, but they were no longer employed at the facility. At this time, no one had done the specialized training for the IP position or was enrolled in the training.
MINOR
(C)
Minor Issue - procedural, no safety impact
Deficiency F0570
(Tag F0570)
Minor procedural issue · This affected most or all residents
Based on interview and record review, the facility failed to maintain the bond amount for at least one and one-half times the average monthly balance of the residents' personal funds for the last twel...
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Based on interview and record review, the facility failed to maintain the bond amount for at least one and one-half times the average monthly balance of the residents' personal funds for the last twelve consecutive months from October 2021 to September 2022. The facility census was 97.
1. Record review on 10/17/22 of the residents' personal funds account for the last twelve consecutive months from October 2021 to September 2022 showed:
- The facility's current approved bond amount equaled $100,000.00;
- The average monthly balance for the residents' personal funds equaled $94,000.00;
- An average monthly balance of $94,000.00 required a bond of at least $141,000.00.
During an interview on 10/17/22 at 10:22 A.M., the Administrator said their bond was too low and he/she had made a request to increase the bond from $100,000.00 to $150,000.00 to cover the increase in personal funds.
MINOR
(C)
Minor Issue - procedural, no safety impact
Deficiency F0838
(Tag F0838)
Minor procedural issue · This affected most or all residents
Based on record review and interview, the facility failed to ensure the facility assessment (an assessment to determine what resources are necessary to care for residents competently during both day-t...
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Based on record review and interview, the facility failed to ensure the facility assessment (an assessment to determine what resources are necessary to care for residents competently during both day-to-day operations and emergencies) was complete and reviewed annually.
Record review of the Facility Assessment policy, dated 9/25/17, showed:
- The purpose of the assessment will be to determine what resources will be necessary to care for residents day-to-day and in an emergency;
- The initial assessment due on 11/28/17, and then annually thereafter;
- The intent of the Facility Assessment will be to describe the patient population, the facility resources and do a risk assessment, both a facility-based and community-based.
Record review of the facility assessment, showed:
- No signatures to show the assessment reviewed since 2017;
- No records to show the facility assessment reviewed by the Quality Assessment and Assurance (QAA) and Quality Assurance Performance Improvement (QAPI) committee.
During an interview on 10/19/22 at 12:00 P.M., the Administrator said she had been at the facility about a year and they had started to review and update the facility assessment, but it was never finished.
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?"
- "Why is there high staff turnover? How do you retain staff?"
- "Can I speak with families of current residents?"
- "What's your RN coverage like on weekends and overnight?"
Our Honest Assessment
Strengths
- • Licensed and certified facility. Meets minimum state requirements.
Concerns
- • Multiple safety concerns identified: 5 life-threatening violation(s), Special Focus Facility, 2 harm violation(s), $206,655 in fines, Payment denial on record. Review inspection reports carefully.
- • 81 deficiencies on record, including 5 critical (life-threatening) violations. These warrant careful review before choosing this facility.
- • $206,655 in fines. Extremely high, among the most fined facilities in Missouri. Major compliance failures.
- • Grade F (0/100). Below average facility with significant concerns.
Bottom line: This facility is on CMS's Special Focus list for poor performance. Consider alternatives strongly.
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About This Facility
What is Belleview Valley's CMS Rating?
BELLEVIEW VALLEY NURSING HOME does not currently have a CMS star rating on record.
How is Belleview Valley Staffed?
Staff turnover is 59%, which is 13 percentage points above the Missouri average of 46%. High turnover can affect care consistency as new staff learn residents' individual needs. RN turnover specifically is 57%, which is notably high. RNs provide skilled clinical oversight, so turnover in this role can affect medical care quality.
What Have Inspectors Found at Belleview Valley?
State health inspectors documented 81 deficiencies at BELLEVIEW VALLEY NURSING HOME during 2022 to 2025. These included: 5 Immediate Jeopardy (the most serious level, indicating potential for serious harm or death), 2 that caused actual resident harm, 72 with potential for harm, and 2 minor or isolated issues. Immediate Jeopardy findings are rare and represent the most serious regulatory concerns. They require immediate corrective action.
Who Owns and Operates Belleview Valley?
BELLEVIEW VALLEY NURSING HOME is owned by a for-profit company. For-profit facilities operate as businesses with obligations to shareholders or private owners. The facility operates independently rather than as part of a larger chain. With 109 certified beds and approximately 89 residents (about 82% occupancy), it is a mid-sized facility located in BELLEVIEW, Missouri.
How Does Belleview Valley Compare to Other Missouri Nursing Homes?
Compared to the 100 nursing homes in Missouri, BELLEVIEW VALLEY NURSING HOME's staff turnover (59%) is significantly higher than the state average of 46%.
What Should Families Ask When Visiting Belleview Valley?
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?" "How do you ensure continuity of care given staff turnover, and what is your staff retention strategy?" "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?" These questions are particularly relevant given the facility's Immediate Jeopardy citations and the facility's high staff turnover rate.
Is Belleview Valley Safe?
Based on CMS inspection data, BELLEVIEW VALLEY NURSING HOME has documented safety concerns. Inspectors have issued 5 Immediate Jeopardy citations (the most serious violation level indicating risk of serious injury or death). The facility is currently on the Special Focus Facility watch list (a federal program monitoring the lowest-performing 1% of nursing homes nationwide). The facility has a 0-star overall rating and ranks #100 of 100 nursing homes in Missouri. Families considering this facility should ask detailed questions about what corrective actions have been taken since these incidents.
Do Nurses at Belleview Valley Stick Around?
Staff turnover at BELLEVIEW VALLEY NURSING HOME is high. At 59%, the facility is 13 percentage points above the Missouri average of 46%. Registered Nurse turnover is particularly concerning at 57%. RNs handle complex medical decisions and coordinate care — frequent RN changes can directly impact care quality. High turnover means new staff may not know residents' individual needs, medications, or preferences. It can also be disorienting for residents, especially those with dementia who rely on familiar faces. Families should ask: What is causing the turnover? What retention programs are in place? How do you ensure care continuity during staff transitions?
Was Belleview Valley Ever Fined?
BELLEVIEW VALLEY NURSING HOME has been fined $206,655 across 2 penalty actions. This is 5.9x the Missouri average of $35,145. Fines at this level are uncommon and typically indicate a pattern of serious deficiencies, repeated violations, or failure to correct problems promptly. CMS reserves penalties of this magnitude for facilities that pose significant, documented risk to resident health or safety. Families should request specific documentation of what issues led to these fines and what systemic changes have been implemented.
Is Belleview Valley on Any Federal Watch List?
BELLEVIEW VALLEY NURSING HOME is currently on the Special Focus Facility (SFF) watch list. This federal program identifies the roughly 1% of nursing homes nationally with the most serious and persistent quality problems. SFF facilities receive inspections roughly twice as often as typical nursing homes. Factors in this facility's record include 5 Immediate Jeopardy findings and $206,655 in federal fines. Facilities that fail to improve face escalating consequences, potentially including termination from Medicare and Medicaid. Families considering this facility should ask for documentation of recent improvements and what specific changes have been made since the designation.