BLUE SPRINGS WELLNESS & REHABILITATION
For profit - Limited Liability company
120 Beds
Independent
Data: November 2025
2 Immediate Jeopardy citations
Trust Grade
11/100
#231 of 479 in MO
Photo by Shangri-La Rehab & Living Center
Photo by Alyssa Green
Photo by Alyssa Green
1 / 5 photos
Last Inspection: March 2025
Within standard 12-15 month inspection cycle. Federal law requires annual inspections.
Overview
Blue Springs Wellness & Rehabilitation has received a Trust Grade of F, indicating significant concerns about the quality of care provided, which is below acceptable standards. Ranked #231 out of 479 facilities in Missouri, they sit in the top half, but this is misleading considering their overall poor performance. The facility is worsening, with issues increasing from 3 in 2024 to 12 in 2025, raising red flags about ongoing care quality. Staffing is a weakness, with a low rating of 1 out of 5 stars, although the turnover rate is commendably 0%, meaning staff remain but may not be adequately supported. Additionally, the facility has accrued $116,230 in fines, which is concerning and suggests chronic compliance issues. RN coverage is average, which may not be sufficient given the reported incidents. For example, there was a critical finding where a resident was injured due to a lack of a gait belt during a transfer, leading to hospitalization. Another incident involved staff failing to maintain comfortable air temperatures, affecting many residents. While the facility has some strengths, such as a low staff turnover, the serious concerns regarding care and safety cannot be overlooked.
- Trust Score
- F
- In Missouri
- #231/479
- Safety Record
- High Risk
- Inspections
- Getting Worse
- Staff Stability ○ Average
- Turnover data not reported for this facility.
- Penalties ○ Average
- $116,230 in fines. Higher than 53% of Missouri facilities. Some compliance issues.
- Skilled Nurses ⚠ Watch
- Each resident gets only 19 minutes of Registered Nurse (RN) attention daily — below average for Missouri. Fewer RN minutes means fewer trained eyes watching for problems.
- Violations ⚠ Watch
- 66 deficiencies on record. Higher than average. Multiple issues found across inspections.
11/100
Top 48%
Review needed
3 → 12 violations
★★☆☆☆
2.0
Overall Rating
★☆☆☆☆
1.0
Staff Levels
★★★★★
5.0
Care Quality
★★☆☆☆
2.0
Inspection Score
↔
Stable
2024: 3 issues
2025: 12 issues
The Good
-
5-Star Quality Measures · Strong clinical quality outcomes
-
Full Sprinkler Coverage · Fire safety systems throughout facility
-
No fines on record
Facility shows strength in quality measures, fire safety.
The Bad
2-Star Overall Rating
Near Missouri average (2.5)
Below average - review inspection findings carefully
Federal Fines: $116,230
Well above median ($33,413)
Significant penalties indicating serious issues
The Ugly 66 deficiencies on record
2 life-threatening
Mar 2025
12 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0578
(Tag F0578)
Could have caused harm · This affected 1 resident
Based on interview and record review, the facility failed to honor refusal of treatment for one sampled resident (Resident #6) out of 20 sampled residents. The facility census was 84 residents.
Review...
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Based on interview and record review, the facility failed to honor refusal of treatment for one sampled resident (Resident #6) out of 20 sampled residents. The facility census was 84 residents.
Review of the facility Resident's Rights Policy dated August 2020 showed treat the decisions of a resident representative as the decision of the resident to the extent required by court or delegated by the resident, in accordance with applicable law.
1. Review of Resident #6's Probate (court division that handles cases involving guardianships) Court order dated 4/18/13 showed:
-The resident was determined to be an incapacitated (physically and/or mental unable to make informed, rational judgments and decisions) person.
-His/her brother was appointed guardian of his/her person (In Missouri, a guardian of the person, appointed by the Probate Court, was entrusted with the care and custody of an adult legally determined to be incapacitated, and had the authority to make decisions for their ward regarding care, treatment, shelter, education, support, and maintenance).
Review of the resident's Face Sheet showed he/she admitted to the facility with the following diagnoses Traumatic Brain Injury (TBI - a brain injury caused by an external force, such as a blow to the head; TBI's can cause physical, cognitive, emotional, and behavioral problems).
Review of the resident's Intravenous (IV) Therapy Consent Form dated 3/13/25 showed:
-The resident's legal guardian refused consent for the resident to receive IV fluids.
-The form was signed and dated by Medical Records staff A.
Review of the resident's Physician's Orders Sheet (POS) dated March 2025 showed:
-Start peripheral IV dated 3/17/25.
-Derma IV therapy infusion - one time - 500 milliliters (ml) normal saline (salt solution of the same concentration as blood) at 500 ml per hour, total additive volume 17 ml including vitamins and minerals and other supplements for micronutrient hydration therapy, dated 3/17/25.
Review of the resident's Medication Administration Record (MAR) dated March 2025 showed Derma IV therapy infusion - one time - 500 ml normal saline at 500 ml per hour, total additive volume 17 ml including vitamins and minerals and other supplements for micronutrient hydration therapy was administered on 3/17/25.
Review of the resident's nurse's note dated 3/17/25 at 2:15 P.M. showed:
-Assessment completed by IV Infusion Registered Nurse (RN).
-Infusion started at 2:15 P.M.
-Infusion completed at 3:15 P.M.
-Dressing applied.
-Report of infusion of infusion completed given to facility staff licensed nurse.
During an interview on 3/27/25 at 1:13 P.M. Medical Records staff A said:
-In March 2025 he/she had been assigned to call resident representatives for verbal consent for IV Therapy.
-He/she called the resident's guardian on 3/17/25 and the resident's guardian said no to the resident having IV therapy.
-He/she wrote on the form that the guardian refused consent, dated and timed the form for 3/13/25 at 12:46 P.M.
-On 3/13/25 he/she told the Director of Nursing (DON) that the resident's guardian had refused for the resident to have IV therapy.
-He/she recalled that the DON acknowledged that he/she understood that the resident's guardian had refused IV therapy.
-He/she uploaded the form to the resident's Electronic Medical Record (EMR) on 3/14/25.
-NOTE: the DON was unavailable for interview during the survey.
During an interview on 3/27/25 at 2:16 P.M. the Assistant Director of Nursing (ADON) was asked to review the resident's IV Therapy Consent Form dated 3/13/25; March 2025 MAR, and Nurse's Notes dated 3/17/25 regarding the resident receiving IV fluids; he/she said:
-The resident's guardian had refused for the resident to have IV therapy.
-He/she had not previously been aware that the resident's guardian had refused for the resident to have the IV therapy.
-It looked like the resident had received the IV therapy.
-He/she declined to say what should have happened and said that was all new information to him/her.
During an interview on 3/27/25 at 2:57 P.M. the resident's guardian said:
-He/she was contacted by telephone on 3/13/25 and was asked to consent to the resident having IV fluids with vitamins.
-He/she said no to the resident having IV fluids because the resident had bad veins, when he/she was in the hospital special equipment had to be used to visualize his/her veins because of his/her skin condition from having had severe burns over most of his/her body and he/she did not think it would be a good idea to try to start an IV at the facility.
-Hopefully the facility had not started an IV and had not given the resident IV fluids because he/she had said no.
During an interview on 3/28/25 at 2:48 P.M., the ADON said:
-The DON had been responsible for IV therapy, and he/she could not answer for him/her.
-He/she assumed the IV nurse would have verified consent for IV therapy.
-The IV therapy should not have been given.
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 follow manufacturers recommendation and ensure priming (helps ensure that the needle is clear of air bubbles and that the insu...
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Based on observation, interview and record review, the facility failed to follow manufacturers recommendation and ensure priming (helps ensure that the needle is clear of air bubbles and that the insulin flows freely, guaranteeing you receive the correct dose) Novolog Insulin Flex-Pen (is a pre-filled, disposable insulin pen containing intermediate-acting U-100 isophane insulin human solution) prior to use for one sampled resident (Resident #5) out 20 sampled residents. The facility census was 84 residents.
Review of the facility Injectable Medication Administration policy dated September 2018 showed Insulin Pen Devices, dial the dose as instructed by the pen manufacturer.
Review of the Novolog Flex Pen manufacturer instruction pamphlet revised February 2023 showed:
-Before each injection small amounts of air may collect in the cartridge during normal use. To avoid injecting air and to ensure proper dosing: Turn the dose selector to select 2 units of insulin.
-Hold your NovoLog Flex Pen with the needle pointing up. Tap the cartridge gently with your finger a few times to make any air bubbles collect at the top of the cartridge.
-Keep the needle pointing upwards, press the push-button all the way in. The dose selector until returns to 0.
-Turn the dose selector to the number of units you need to inject. The pointer should line up with your dose prescribed.
-Insert the needle into the resident skin. Inject the dose by pressing the push-button all the way in until the 0 lines up with the pointer. Be careful only to push the button when injecting.
-Keep the needle in the skin for at least 6 seconds and keep the push-button pressed all the way in until the needle has been pulled out from the skin.
1. Review of Resident #5's admission Record showed the resident admitted with following diagnoses:
-Type II Diabetes Mellitus (is a complex disorder of carbohydrate, fat, and protein metabolism that is primarily a result of a deficiency or complete lack of insulin secretion in the pancreas or resistance to insulin).
-Diabetic nephropathy (damage to the nerves resulting in sensory loss in the extremities).
Review of the resident's admission Minimum Data Set (MDS - a federally mandated assessment instrument completed by facility staff for care planning) dated 12/27/24, showed he/she:
-Was cognitively intact.
-Was able to understand others and make his/her needs known.
-Required total assistant for staff for all cares and transfers.
Review of the resident's Physician Order Sheet dated 3/12/25 showed:
-NovoLog Flex-Pen (insulin) Subcutaneous (SQ) Solution Pen-injector 100 unit/Milliliter (ml)
Inject as per sliding scale (amount of insulin to be given pending blood sugar results); if blood sugar range was 0 - 150 = 0 units of insulin; 151 - 200 = 1 unit; 201 - 250 = 3 units; 251 - 300 = 4 units; 301 - 350 = 5 units; 351 - 400 = 6 units; 401 - 450 = 8 units; 451 - 1000 = 8 units, if over 450 give 8 units insulin and call provider. Give insulin subcutaneously with meals related to Type II Diabetes Mellitus with Diabetic Nephropathy.
Observation on 3/25/25 at 11:36 A.M. of the resident's insulin administration showed:
-Licensed Practical Nurse (LPN) C checked the resident's blood sugar which was 369.
-Physician's orders showed to give NovoLog Flex-Pen Subcutaneous Solution Pen-injector 100 unit/ml inject as per sliding scale:
--The resident's blood sugar reading was 369, following the sliding scale range from 351- 400, the resident was to be given 6 units of Novolog insulin.
-LPN C obtained the resident's flex-insulin pen, cleaned the tip, placed the needle on the tip and dialed up 6 units of NovoLog insulin. He/she had gave the 6 units of insulin in the resident left lower stomach area.
-LPN C did not prime flex insulin pen with 2 units of insulin prior to use and then dialing up the required amount of insulin.
During interview on 3/25/25 at 11:55 A.M., LPN C said:
-He/She was not aware it was required to prime the flex-insulin pen with 2 units of insulin and then waste it, prior to providing the required dose of insulin.
-He/She was not aware of the facility insulin pen policy related to priming the insulin pen prior to each use.
During an interview on 3/27/25 12:38 P.M., Certified Medication Technician (CMT) A said:
-He/She was an insulin certified CMT.
-He/She would clean the insulin pen tip with an alcohol wipe, then put the needle on, and then dial up the amount of insulin prescribed by the physician orders.
-During CMT training he/she was never taught to prime the insulin pen prior to use and had not been educated by the facility on priming the insulin pen prior to use.
-The facility nursing staff were responsible for completing resident blood sugar checks and insulin administration.
-He/She would only assist with administration of insulin if requested by licensed nurse.
During an interview on 3/28/25 at 10:25 A.M., LPN A said:
-He/She would clean the tip of the pen with alcohol wipe, then place the needle.
-He/She would dial up the prescribed amount of insulin ordered and give the insulin as ordered.
-He/She was new to the facility and was not aware of the recommendation to prime with 2 units of insulin prior to dialing up the amount of insulin ordered.
-He/She had not been educated or reviewed the facility insulin pen policy.
During an interview on 3/28/25 at 10:35 A.M., LPN B said:
-He/She would check the physician's orders and dosage needed prior to administration.
-He/She would clean the tip of the flex pen, place the needle on the pen, then prime with 2 units of insulin prior, then dial up the prescribed insulin dose to be given.
-Facility policy was to prime the insulin flex pens prior to use.
-He/she was not aware any current training related to insulin pen priming.
During an interview on 3/28/25 at 2:48 P.M., the Assistant Director of Nursing (ADON) and Infection Control Preventionist (ICP) said:
-Administration of insulin by a pen would include cleaning the tip of the pen, then applying the needle. Dial up 2-units to prime the pen, waste those 2-units and then dial up prescribed insulin dosage for the resident.
-He/she would expect staff to follow the facility policy from pharm script insulin pen process.
-He/she would expect nursing staff to prime the insulin pen with 2-units prior to use to ensure giving amount insulin prescribed without air bubbles.
-Insulin certified CMT's and licensed nursing staff should have been educated on priming insulin pens during orientation and during compliance skill check off.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Tube Feeding
(Tag F0693)
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 physician's orders were complete and contained ...
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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 physician's orders were complete and contained details for how nursing staff was to check placement of the gastronomy tube (a feeding tube surgically inserted through the abdomen and into the stomach to provide nutrition and medication delivery, or to drain stomach contents), including orders to check residual (the amount of fluid, including formula and gastric secretions, remaining in the stomach after a feeding) prior to adding any fluid to the stomach; failed to ensure handwashing was completed to prevent contamination during care and failed to update the resident's care plan to show the resident no longer received liquid nutrition through the tube for one sampled resident (Resident #14) with tube feeding flushes only out of 20 sampled residents. The facility census was 84 residents.
Review of the facility Gastronomy Placement policy and procedure dated June 2020, showed the purpose was to ensure correct placement of the gastronomy tube prior to initiating a feeding, hydration and or medication. The procedure showed:
-Prior to the administration of feeding, hydration and or medication through a gastronomy tube, the placement of the tube shall be verified.
-This process should be completed by a nurse.
-There must be a physician's order for feeding, hydration and or medication through a gastronomy tube.
-The nurse should assess the resident for bowel sounds and distention.
-Check the placement of the feeding tube externally to be sure it hasn't slipped out since the last feeding-observe for a change in the external length of the tube by determining whether the mark placed at the tube's exit site has moved.
-To assess gastric emptying aspirate (to withdraw fluid or contents from the stomach through the tube, often to check for gastric residual volume (GRV) or to remove excess fluid or gas) and measure residual volume-hold feeding if residual volume is greater than the specified physician order.
-Inform the physician if feeding or hydration is held.
1. Review of Resident #14's Face Sheet showed the resident was admitted on [DATE], with diagnoses including gastrostomy status (refers to the presence of a gastrostomy, which is a surgical opening into the stomach, often used to facilitate feeding or drainage via a gastrostomy tube), dysphagia (impairment of the power to speak or to understand speech, as a result of brain injury, stroke, or disease), muscle weakness, difficulty walking and anxiety disorder.
Review of the resident's revised Care Plan dated 3/3/25 showed the resident required tube feeding related to a chewing problem, depression and dysphagia. The goal was for the resident to maintain adequate nutrition and hydration status, and maintain stable weight with no signs or symptoms of malnutrition or dehydration. Interventions showed:
-Check for tube placement and gastric contents/residual volume per facility protocol. And record. Hold feeding when greater than that amount.
-Clean the insertion site daily as ordered, monitor for signs and symptoms of infection or skin breakdown.
-Monitor, document and report to the physician all signs and symptoms of abnormal lab values, abdominal pain, distension (swollen abdomen), abnormal lung sounds, nausea/vomiting, infection, displacement of the tube.
-Obtain and monitor lab work as ordered and report to physician.
-Provide local care to the site as ordered and monitor.
-The Registered Dietician is to evaluate nutritional status quarterly-caloric intake and make recommendations as needed.
-Speech Therapist to evaluate if needed.
-The resident needed assistance and supervision with tube feeding and water flushes. See physician's orders for current feeding orders.
-Keep the head of the resident's bed elevated at least 30 degrees during and thirty minutes after tube feeding.
Review of the resident's quarterly Minimum Data Set (MDS-a federally mandated assessment tool to be completed by facility staff for care planning) dated 3/4/25, showed the resident:
-Was alert and oriented with minimum memory loss.
-Needed only set up to eat and ate independently.
-Had no chewing or swallowing problems.
-Had a feeding tube, but took in less than 25 percent of fluids through the tube and less than 500 cubic centimeters (cc) of fluids.
Review of the resident's Physician's Order Sheet (POS) dated March 2025, showed physician's orders for:
-A regular diet with regular texture and thin liquids (ordered 2/14/25).
-Flush gastronomy tube with 30 milliliters (ml) of water to maintain patency every shift (ordered 12/6/24).
-Check gastronomy tube placement every shift (ordered 12/6/24).
-Cleanse gastronomy area daily with normal saline, pat dry, use split dressing on site every shift (ordered 12/7/24).
-NOTE: The physician's orders did not show how staff should check for residual contents in the resident's stomach and when to hold the flush; and did not show how staff was to check the placement of the gastronomy tube to ensure it was in place.
Review of the resident's Nursing Note dated 3/18/25, showed the physician visited the resident on 3/17/25 and wrote a new order to schedule the resident with the specialty clinic to have his/her gastronomy tube removed.
Observation and interview on 3/24/25 at 3:26 P.M., showed the resident was sitting in his/her wheelchair in his/her room watching television. He/She said:
-He/She ate by mouth and no longer used a feeding tube.
-He/She only received water through the tube and the nurse completed the flushes daily.
Observation and interview on 3/26/25 at 2:53 P.M., showed Registered Nurse (RN) A was preparing to flush the resident's gastronomy tube. He/She had already prepared a clean table and placed the distilled water and syringe to flush the tube. He/She pulled a red biohazard bag, donned a gown and a mask. Once inside the resident's room, he/she gloved. The syringe was already filled with 30 cc of water and was laying on a paper towel on the resident's vanity. The resident was sitting up in his/her wheelchair. The resident lifted his/her shirt and RN A opened the tube and unclamped the tubing. Without checking for residual, he/she inserted 30 cc of water that was already in the syringe into the tube. After the water went in he/she clamped the end of the tube. The resident said he/she was not in any pain or overfull. RN A then removed his/her gown and gloves and put them in the trash bin. RN A said:
-When he/she was in nursing school they were taught to check for placement of the tube in the stomach by aspirating but here they checked for placement by looking at the marking on the tube.
-There was a black mark on the resident's tube that indicated the tube was in place.
-He/She was also taught to check for residual by inserting the syringe in the tube and pulling back fluid to see how much fluid was in the resident's stomach prior to adding fluids.
-He/She would assume that they would check for residual to ensure there was nothing in the resident's stomach or it was not too full or to check for acidity, but at this facility he/she was told that because the resident did not take liquid nutrition, they didn't need to check for residual prior to flushing the resident's tube.
During an interview on 3/27/25 at 12:38 P.M., RN A said:
-The physician's orders should include specifically how they need to check for placement.
-They should check for residual and it should show what they were to do when they drew back so much fluid or when to notify the physician.
During an interview on 3/28/25 at 2:47 P.M. with the Assistant Director of Nursing (ADON) and Infection Control Preventionist (ICP), the ADON said:
-The physician's orders for tube feeding should show the amount of tube feeding, rate, how administered (continuous or as needed), on and off time, and type of feeding.
-It should also show to check placement of the tube. The orders didn't state to verify placement-their policy showed they should observe for placement by noting the mark on the tube which indicated the tube was in place.
-The order should also show to check residual and to notify the physician if the residual was greater than a certain amount.
-They did expect staff to check residual before adding any contents through the tube.
-If the resident no longer received nutrition through the tube, that should be updated on the resident's care plan and the care plan should be updated within a few days after the order was changed.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Respiratory Care
(Tag F0695)
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 properly store respiratory nebulizer mask/mouthpiece (...
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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 properly store respiratory nebulizer mask/mouthpiece ( medical device used to deliver medication in the form of mist) and tubing when not in use for two sampled residents (Resident #9 and #18) out of 20 sampled residents. The facility census was 84 residents.
Review of the facility Oxygen Administration policy dated June 2020 showed all oxygen tubing and masks will be changed weekly and when visibly soiled.
1. Review of Resident #9's admission Record showed the resident had a diagnosis of Chronic Bronchitis (refers to a chronic cough with the production of phlegm resulting from inflammation in the airways).
Review of the resident's Quarterly Minimum Data Set (MDS- a federally mandated assessment instrument completed by facility staff for care planning) dated 3/17/25, showed he/she:
-Was moderately cognitively impaired.
-Was able to understand others and make his/her needs known.
Review of the resident's Physician Order Sheet (POS) dated March 2025 showed:
-DuoNeb Solution 0.5-2.5 (3) Milligrams (mg)/3 milliliter (ml) (Ipratropium-Albuterol, (It works by opening airways and reducing inflammation in your lungs to help you breathe better) one vial inhale orally via Nebulizer two times a day for Shortness of breath and cough. (ordered on 2/5/25).
-Change respiratory tubing, mask, bottled water, clean filter every seven days during night shift on Sundays. Date and initial the tubing when changed. (ordered on 2/9/25)
-Oxygen (O2) at 2 liters (of oxygen flowing into the patient's lungs every minute). via Nasal Cannula (NC) as needed to maintain Oxygen Saturation (O2 Sat, is a measure of how much oxygen is in your blood) above 90% (ordered on 12/10/24)
Review of the resident's Nursing Medication Administration Record (MAR) dated 3/1/25 to 3/31/25 showed:
-DuoNeb Solution 0.5-2.5 (3) mg/3 ml give one vial inhale orally via Nebulizer two times a day.
-Change respiratory tubing, mask, bottled water, clean filter every seven days during night shift and Sundays. Date and initial the tubing when changed.
Observation on 3/24/25 at 9:05 A.M., of the resident's room showed:
-He/She had Nebulizer tubing and mask not stored in a plastic bag.
-Tubing was laid on top of the Nebulizer machine uncovered.
Observation on 3/24/25 at 12:06 P.M., of the resident's room showed his/her Nebulizer face mask and tubing laid uncovered on top of his/her bedside dresser.
Observation on 3/26/25 at 9:46 A.M., of the resident's room showed his/her Nebulizer face mask and tubing were not covered or stored in a plastic bag when not in use.
Observation on 3/26/25 at 11:31 A.M., of the resident's room showed:
-His/Her Nebulizer machine was located on top of the resident dresser.
-The Nebulizer face mask and tubing remained uncovered or not stored in plastic bag when not in use.
-The Nebulizer tubing was not dated when last changed.
2. Review of Resident #18's admission Record showed, he/she had diagnoses that included:
-Chronic Obstructive Pulmonary Disease (COPD, prevents airflow to the lungs, causing breathing problems).
-Chronic Respiratory Failure (occurs when the respiratory system cannot adequately provide oxygen to the body, leading to hypoxemia, is a lack oxygen).
Review of the resident's POS dated 12/24/24 showed:
-Ipratropium-Albuterol Inhalation Solution 0.5-2.5 (3) mg/3 ml give 3 ml inhale orally four times a day related to COPD.
-Change respiratory tubing and mask every 7 days during the night shift.
Review of the resident's Plan of Care dated 12/24/24 showed he/she did not have a care plan for oxygen therapy or Nebulizer treatments provided.
Review of the resident's admission MDS dated [DATE], showed he/she:
-Was cognitively intact.
-He/she was able to understand others and make his/her needs known.
-Required oxygen therapy while a resident at the facility.
-Required assistance from staff for setup assist with personal care and treatments.
Review of the resident Nursing MAR dated 3/1/25 to 3/31/25 showed:
-Change respiratory tubing and mask every 7 days during the night shift.
--Last changed on 3/23/25.
-Ipratropium-Albuterol Inhalation Solution 0.5-2.5 (3) mg/3 ml give 3 ml inhale orally four times a day.
Observation on 3/24/25 at 2:28 P.M., of the resident showed:
-He/She was in his/her room in bed with the O2 in place.
-His/Her Nebulizer machine located on tall dresser with Nebulizer tubing and face mask not covered and did not have plastic bag to store when not in use.
Observation on 3/25/25 at 9:33 A.M., of the resident showed:
-He/She was sitting in his/her wheelchair with O2 in place.
-The Nebulizer tubing and mouthpiece were not covered and did not have a plastic bag to store breathing supplies in when not in use.
Observation on 3/26/25 at 9:01 A.M., of the resident showed:
-His/Her Nebulizer tubing was uncovered on top of the dresser.
-He/She was in bed with O2 in place set at rate 3-4 liter per minute.
Observation on 3/26/25 at 9:15 A.M., of the resident's breathing treatment showed:
-Registered Nurse (RN) A provided breathing treatment for the resident.
-The resident's O2 sat was at 96% with O2 in place. (Normal range O2 sats from 95% to 100%)
-He/she removed the uncovered old Nebulizer mask & tubing, he/she replaced with new Nebulizer supplies.
-He/she listened to the resident's lungs and noted the left lobe was diminished (hard to hear breath sounds), and wheezes (noise make when breathing) were noted.
-RN A prepped the breathing medication of Ipratropium-Albuterol Inhalation Solution place in mouthpiece setup.
-Resident was able to hold the mouthpiece to provide breathing treatment.
Observation on 3/26/25 at 11:15 A.M., of the resident showed his/her Nebulizer mouthpiece and tubing were uncovered on top of the dresser.
3. During an interview on 3/27/25 at 12:38 P.M., Certified Nursing Assistant (CNA) B said:
-O2 and Nebulizer supplies should be stored in a plastic bag when not in use.
-Nebulizer mouthpiece should be rinsed after use and placed on a paper towel barrier to dry.
During an interview on 3/27/25 12:55 P.M., CNA A, said:
-CNA's and nursing staff would ensure Nebulizer tubing was stored in a plastic bag when not in use.
-The storage bag should be labeled with the date changed by nursing staff.
During an interview on 3/28/25 10:25 A.M., Licensed Practical Nurse (LPN) A said:
-Nebulizer tubing, mask/mouthpiece should be stored in a plastic bag when not in use.
-The Nebulizer tubing and storage bag should be dated and have the name of the resident.
-Nursing staff were responsible for ensuring Nebulizer supplies were stored in a bag and Nebulizer mouthpieces were cleaned after use.
During an interview on 3/28/25 at 10:35 A.M., LPN B said:
-Nebulizer tubing/mask/mouthpiece should be stored in a plastic bag when not in use.
-Nursing staff or CMT's would be responsible to ensure mouthpieces were cleaned and stored in a plastic bag when not in use.
During the interview on 3/28/25 at 2:48 P.M., Infection Control Preventionist (ICP) A and Assistant Director of Nursing (ADON) said:
-He/she would expect the Nebulizer face mask/mouthpiece to be stored in a plastic bag when not in use.
-The night nursing staff were responsible to ensure the resident had a dated and labeled storage bag for oxygen therapy supplies including Nebulizer tubing and mask.
-The night nursing staff were responsible for changing out the O2 and Nebulizer tubing and mask weekly as ordered.
-The Nebulizer storage bag should be labeled with the date changed and the resident's name.
-All nursing staff would be responsible to ensure Nebulizer face masks and tubing were stored in a plastic bag when not in use.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0699
(Tag F0699)
Could have caused harm · This affected 1 resident
Based on interview and record review, the facility failed to identify, assess and provide supportive interventions for one sampled resident (Resident #34), with a diagnosis of Post-Traumatic Stress Di...
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Based on interview and record review, the facility failed to identify, assess and provide supportive interventions for one sampled resident (Resident #34), 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 20 sampled residents. The facility census was 84 residents.
Review of Trauma-Informed Care Implementation Center (https://www.traumainformedcare.chcs.org/what-is-trauma-informed-care/) copyright 2021 showed:
-Trauma-informed care shifts the focus from What's wrong with you? to What happened to you?
-A trauma-informed approach to care acknowledges that health care organizations and care teams need to have a complete picture of a patient's life situation - past and present - in order to provide effective health care services with a healing orientation.
-Adopting trauma-informed practices can potentially improve patient engagement, treatment adherence, and health outcomes, as well as provider and staff wellness. It can also help reduce avoidable care and excess costs for both the health care and social service sectors.
-Trauma-informed care seeks to:
--Realize the widespread impact of trauma and understand paths for recovery;
--Recognize the signs and symptoms of trauma in patients, families, and staff;
--Integrate knowledge about trauma into policies, procedures, and practices; and
--Actively avoid re-traumatization.
A policy was requested, and the facility did not have a policy on PTSD/trauma informed care.
1. Review of Resident #34's Level One Pre-Admissions Screening and Resident Review (PASRR) (federally mandated screening process for individuals with serious mental illness and/or intellectual disability/developmental disability related diagnosis who apply or reside in Medicaid Certified beds in a nursing facility regardless of the source of payment.) dated 3/15/21 showed the resident had a diagnosis of PTSD.
Review of the resident's admission Record showed the resident was admitted to the facility with a diagnosis of PTSD.
Review of the Order Summary Report (OSR) dated 2/25/25 showed the following physician's orders for Escitalopram Oxalate ((a type of antidepressant drug (used to relieve depression) that inhibits the reabsorption of serotonin (a compound present in blood platelets and serum, which constricts the blood vessels and acts as a neurotransmitter (a chemical substance that is released at the end of a nerve fiber by the arrival of a nerve impulse and, by sending it across the nerve junction, causes the transfer of the impulse to another nerve fiber, a muscle fiber, or some other structure) by neurons, so increasing the availability of serotonin as a neurotransmitter) medication give 10 milligrams (mg) by mouth in the evening for Depression (a state of intense sadness or despair that has advanced to the point of being disruptive to an individual's social functioning and/or activities of daily living).
Review of the resident's care plan revised 3/5/25 showed:
-PTSD was not addressed in the care plan.
-The resident's triggers were not addressed.
-The resident's interventions were not addressed.
Review of the resident's Annual Minimum Data Set (MDS-a federally mandated assessment instrument completed by facility staff for care planning) dated 3/17/25 showed:
-The resident had severe cognitive impairment.
-Had PTSD.
During an interview on 3/25/25 at 11:26 A.M. the resident was non-interviewable.
During an interview on 3/27/25 at 9:33 A.M., Certified Nurse's Assistant (CNA) C said:
-If a resident had a medical diagnosis of PTSD the resident's triggers would be listed in the computer health record.
-The triggers and interventions would be in the care plan.
-If the resident was missing this in the care plan he/she would inform the nurse.
-He/She did not know if the interventions or triggers were in the care plan.
During an interview on 3/27/25 at 9:38 A.M., Licensed Practical Nurse (LPN) B said:
-The MDS Coordinator was responsible for care plan development.
-He/She did not know if the resident had a diagnosis of PTSD.
-He/She did not know the resident's triggers or interventions.
-Triggers and interventions would be written down at the nurses station.
-The information of the resident's triggers and interventions should have been in the care plan.
-The cause of the PTSD would have been listed in the care plan.
-If PTSD was not addressed in the care plan the Director of Nursing (DON) and Assistant Director of Nursing (ADON) should have been told.
During an interview on 3/28/25 at 8:46 A.M., the MDS Coordinator said:
-He/She was responsible for care plan development.
-The care plan should accurately reflect the resident's condition at the time it was developed along with diagnosis.
-He/She just found out that a resident with a diagnosis of PTSD needed a care plan for that diagnosis.
-The care plan should have had the triggers and the interventions.
-The staff should have been made aware of the resident's triggers and interventions.
-The care plan did not address a PTSD diagnosis.
-No one audited the care plans as far as he/she knew.
During an interview on 3/28/25 at 9:13 A.M., Certified Medication Technician (CMT) A said:
-The resident had PTSD.
-He/She was unsure what his/her triggers were, or what his/her interventions were.
-The resident had not had any behaviors.
-He/She would look at the care plan for the triggers and interventions.
During an interview on 3/28/25 at 2:48 P.M., the ADON said:
-The MDS Coordinator was responsible for the care plans.
-It was his/her expectation that if the resident had a diagnosis of PTSD, it would be addressed in the care plan to include triggers and interventions.
-The MDS Coordinator was responsible for the information for the PTSD care plan.
-The care plan should have addressed the triggers and the interventions.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0744
(Tag F0744)
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 ensure residents with a diagnosis of dementia had a personalized ca...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure residents with a diagnosis of dementia had a personalized care plan to ensure services to promote the resident's highest level of functioning and psychosocial needs for one sampled resident (Resident #22) out of 20 sampled residents. The facility census was 84 residents.
A policy was requested on dementia care planning and the facility failed to provide one.
1. Review of Resident #22's admission Record showed he/she was admitted to the facility on [DATE] with the following diagnoses:
-Dementia (a progressive organic mental disorder characterized by chronic personality disintegration, confusion, disorientation, stupor, deterioration of intellectual capacity and function, and impairment of control of memory, judgment, and impulses) in other diseases classified elsewhere, moderate, with mood disturbance.
-Unspecified psychosis (a mental state involving loss of contact with reality and causing deterioration of normal social functioning) not due to a substance or know physiological condition.
-Major Depressive Disorder (a mental disorder characterized by a persistently depressed mood and long-term loss of pleasure or interest in life, often with other symptoms such as disturbed sleep, feelings of guilt or inadequacy, and suicidal thoughts).
- Alzheimer's disease (a slowly progressive disease of the brain that is characterized by impairment of memory and eventually by disturbances in reasoning, planning, language, and perception)
Review of the resident's undated care plan dated showed:
-Dementia was not addressed in the care plan.
-Alzheimer's disease was not addressed in the care plan.
-The resident had the potential to be verbally/physically aggressive, at risk for harm to self and others due to impaired judgment, impaired cognition, and decreased safety awareness.
-The resident would yell at staff and peers, cuss at staff, refuse his/her medications, and could be sexually inappropriate with staff.
--Staff were directed to monitor his/her behaviors and to document observed behaviors and attempted interventions.
Review of the resident's Annual Minimum Data Set (MDS - a federally mandated assessment instrument completed by facility staff for care planning) dated 1/15/25 showed he/she:
-Was severely cognitively impaired.
-Required maximal staff assistance for bed mobility, transfers, walking, locomotion, dressing, bathing, toileting, and personal hygiene.
-Had diagnoses of Dementia and Alzheimer's Disease.
-Had psychosis.
-Had no behaviors during the look-back period.
-Was taking an antipsychotic medication (used to treat mental health conditions characterized by psychosis, such as schizophrenia and bipolar disorder).
-Was taking an antidepressant medication (used to treat depression and other mental illnesses) .
During an interview on 3/28/24 at 8:46 A.M., the MDS Coordinator said he/she did not know that a resident needed to have a care plan for dementia/Alzheimer's when the resident had those diagnoses.
During an interview on 3/28/25 at 2:48 P.M., the Assistant Director of Nursing (ADON) said:
-Resident's that had diagnoses of dementia/Alzheimer's needed to have a care plan for those diagnoses.
-It was his/her expectation that the nurses would have informed the MDS Coordinator when things needed to be added to the care plan and this included required items.
-The Director of Nursing (DON) signed off on all the care plans.
-The DON was ultimately responsible for all care plans.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Pharmacy Services
(Tag F0755)
Could have caused harm · This affected 1 resident
Based on interview, and record review, the facility failed to ensure the shift change narcotic count was completed and signed by both the on-coming and off-going nursing staff. The facility census was...
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Based on interview, and record review, the facility failed to ensure the shift change narcotic count was completed and signed by both the on-coming and off-going nursing staff. The facility census was 84 residents.
Review of the facility's Storage of Controlled Substances policy revised on September 2018 showed:
-Medications classified by the Drug Enforcement Administration (DEA) as controlled substances were subjected to special handling, storage, disposal, and recordkeeping in the facility in accordance with federal, state, and other applicable laws and regulations.
-The Director of Nursing (DON), in collaboration with the consultant pharmacist, maintained the facility's compliance with federal and state laws and regulations in the handling of controlled substances.
-At each shift change, or when keys were transferred, a physical inventory of all controlled substances was conducted by two licensed personnel and was documented.
-Current controlled substances accountability records were kept in the Medication Administration Record (MAR) or a designated book.
1. Review of the facility's Controlled Drug Count sheet dated 1/24/25 through 2/1/25 for the 400 hall medication cart showed:
-Seven out of 46 opportunities were not signed by either the on-coming or off-going staff.
-Three out of 23 opportunities where the number of narcotic packages were not documented on the sheet.
Review of the facility's Controlled Drug Count sheet dated 2/2/25 through 2/10/25 for the 400 hall medication cart showed:
-Five out of 46 opportunities were not signed by either the on-coming or off-going staff.
-One out of 46 opportunities were not signed by both the on-coming or off-going staff.
-One out of 23 opportunities where the number of narcotic packages were not documented on the sheet.
Review of the facility's Controlled Drug Count sheet dated 2/11/25 through 2/22/25 for the 400 hall medication cart showed:
-One out of 46 opportunities were not signed by either the on-coming or off-going staff.
-Four out of 23 opportunities where the number of narcotic packages were not documented on the sheet.
Review of the facility's Controlled Drug Count sheet dated 2/22/25 through 3/2/25 for the 400 hall medication cart showed:
-One out of 46 opportunities were not signed by either the on-coming or off-going staff.
-Two out of 23 opportunities where the number of narcotic packages were not documented on the sheet.
Review of the facility's Controlled Drug Count sheet dated 3/3/25 through 3/13/25 for the 400 hall medication cart showed:
-Seven out of 46 opportunities were not signed by either the on-coming or off-going staff.
-Three out of 23 opportunities where the number of narcotic packages were not documented on the sheet.
Review of the facility's Controlled Drug Count sheet dated 3/21/25 through 3/26/25 for the 400 hall medication cart showed:
-One out of 46 opportunities were not signed by either the on-coming or off-going staff.
-One out of 23 opportunities where the date was not documented for the count.
-Two out of 23 opportunities where the number of narcotic packages were not documented on the sheet.
During an interview on 3/26/25 at 11:25 A.M., Certified Medication Technician (CMT) A said:
-The narcotics were counted at the beginning and end of each shift by the on-coming nurse and off-going nurse or CMT.
-Both nurses and/or CMT signed the count sheet when the count has been completed to verify the count was correct.
-The number of packages or narcotics was to be recorded on the sheet.
-The date would be listed for each narcotic count.
-If the narcotic count was not signed by both the CMT and nurse then the count was not done.
During an interview on 3/26/25 at 11:30 A.M., Licensed Practical Nurse (LPN) B said:
-The narcotics were counted at the beginning and end of each shift by the on-coming nurse and off-going nurse or CMT.
-Both nurses and/or CMT signed the count sheet when the count had been completed to verify the count was correct.
-The number of packages or narcotics was to be recorded on the sheet.
-The date would be listed for each narcotic count.
-If the narcotic count was not signed by both the CMT and nurse then the count was not done.
During an interview on 3/28/25 at 2:48 P.M., the Assistant Director of Nursing (ADON) said:
-The on-coming and off-going shifts should count the narcotics and sign the narcotic book each shift.
-The number of packages or narcotics was to be recorded in the narcotic book.
-The narcotic count should be dated.
-The unit managers were to have audited the narcotic count books to ensure that counts were done correctly and signed by both the on-coming and off-going shifts.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Medication Errors
(Tag F0758)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Review of Resident #181's Face Sheet showed the resident was admitted on [DATE], with diagnoses including emphysema (a condit...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Review of Resident #181's Face Sheet showed the resident was admitted on [DATE], with diagnoses including emphysema (a condition in which the air sacs of the lungs are damaged and enlarged, causing breathlessness), sepsis (a life-threatening condition that occurs when the body's immune system overreacts to an infection, leading to widespread inflammation and organ damage), malnutrition (a condition resulting from deficiencies, excesses, or imbalances in a person's intake of energy and/or nutrients, leading to measurable adverse effects on body composition, function, and clinical outcomes), iron deficiency, open wound to the left foot, malaise (a general feeling of discomfort, illness, or uneasiness) and Chronic Obstructive Respiratory Disease (COPD-a condition involving constriction of the airways and difficulty or discomfort in breathing). The Face Sheet did not show a psychological diagnosis, dementia or mental health diagnosis.
Review of the resident's admission Minimum Data Set (MDS a federally mandated assessment tool to be completed by facility staff for care planning) dated 3/21/25, showed it had not been completed yet.
Review of the resident's Physician's Order Sheet (POS) dated March 2025, showed a physician's order for:
-Olanzapine Oral Tablet 2.5 milligrams (mg), give 1 tablet by mouth two times a day for 30 days for confusion (ordered 3/22/25).
-The POS did not show a diagnosis associated with the symptom of confusion.
Review of the resident's admission Care Plan dated 3/22/25, showed the resident had no interventions showing he/she had a mental health disorder or mental health need. It did not show he/she had a psychological diagnosis that required psychotropic medication and did not show the resident had confusion that resulted in behaviors that would require a psychotropic medication. There were no interventions for monitoring Olanzapine.
Review of the resident's Drug Regimen Review dated 3/22/25 showed:
-No recommendations.
-There was no indication that there was a rationale needed for Olanzapine.
Review of the resident's Hospital Discharge record dated 3/22/25, showed:
-The resident was homeless and was admitted due to an untreated foot wound.
-While in the hospital, the resident received a partial foot amputation and was placed on antibiotics for a wound infection.
-The resident had confusion but did not show a psychiatric condition, mental health condition or behaviors that indicated mental health issues/concerns warranting a psychiatric medication.
-The psychiatric assessment in the hospital record showed resident was inattentive, perceived auditory hallucinations, mood was anxious, affect was flat, speech was rapid and pressured, behavior was cooperative, cognition and memory were impaired, and judgement was impulsive.
-The record showed the resident received Olanzapine for confusion without an associated diagnosis.
Review of the resident's Nursing assessment dated [DATE], showed there were sections to describe the resident's mental health needs, behavioral concerns, psychiatric recommendations and the entries showed the resident had no behavioral health concerns, mental health needs or psychiatric recommendations for medication or care/therapy.
Review of the resident's Medical Record showed there were no physician's notes or assessment nor was there a psychiatric assessment.
Observation and interview on 3/24/25 at 10:14 A.M., showed the resident was sitting on his/her bed dressed for the weather. Facility staff was in the resident's room assisting him/her. The resident was alert and oriented and was tearful about a pet he/she had that was no longer with him/her. Staff was consoling the resident and trying to divert his/her attention. Certified Nursing Assistant (CNA) D said the resident just came into the facility on Friday and had been tearful because he/she did not have his/her pet and was new to the facility. He/She did not know if or why the resident was on Olanzapine.
Observation and interview on 3/24/25 at 2:49 P.M., showed the resident was sitting in his/her wheelchair in the lobby congregational area talking with other residents and staff. The resident spoke about receiving a television and was no longer tearful nor did he/she talk about his/her pet. No adverse behaviors were noted.
Observation and interview on 3/25/25 at 10:00 A.M., showed the resident was dressed for the weather and was sitting in his/her wheelchair watching television. He/She said he/she was homeless before entering the hospital and received the amputation of part of his/her foot and medications while in the hospital. He/She was not sure of all of the medications he/she was prescribed. He/She did not say he/she had any mental health issues or was being treated for a mental health diagnosis. The resident was pleasant. No issues were noted.
During an interview on 3/27/25 at 12:48 P.M., Registered Nurse (RN) A said:
-Usually when a resident was prescribed an antipsychotic medication, there was a corresponding mental health diagnosis for the script.
-He/She had not seen residents being prescribed an antipsychotic for a diagnosis of confusion.
-When a resident entered from the hospital, if they had a prescription for the antipsychotic, they would give the medication according to the physician's orders.
-Usually the physician came in to review the medications and would determine any changes to the medication that were needed or they would notify the physician of the medications so he/she could authorize the medications to be given and make any changes needed.
During a telephone interview on 3/27/25 at 1:07 P.M., Pharmacist A said:
-Olanzapine was an antipsychotic medication used to treat schizophrenia (a chronic mental health condition characterized by persistent disruptions in thought processes, perceptions, emotions, and social interactions.), bipolar disorder (a chronic mental health condition characterized by extreme mood swings between periods of mania (elevated mood) and depression), psychosis (a mental health condition characterized by a loss of touch with reality), delirium (a temporary state of mental confusion and disorientation that can cause significant changes in a person's behavior, thinking, and perception) and treatment of resistant depression (occurs when a person's depression symptoms persist despite adequate treatment with multiple antidepressants and/or other therapies).
-Confusion was not a diagnosis. It was a symptom and it was a very broad term that would need to be more specific to the behavior exhibited to warrant the medication.
-The physician would need to clarify the use of this medication prior to ordering it for the resident.
-He had seen Olanzapine prescribed for confusion but this was not common. There would need to be a diagnosis, a more descriptive and specific use for the medication.
During an interview on 3/28/25 at 2:47 P.M., with the Assistant Director of Nursing (ADON) and Infection Control Preventionist (ICP), The ICP said:
-With a resident that was admitted from the hospital with medication orders, the first person to review the orders was the admitting nurse.
-They call the physician or Nurse Practitioner (NP) to authorize and verify the orders the same day the resident was admitted and the physician or NP would authorize the orders or make any changes necessary to the orders.
-The same day or following day the clinical manager would review the resident's admission orders and medications and they would notify the physician of anything that they think was [NAME] or needed to be reviewed again by the physician.
-Psychotropic medications should not be prescribed for a resident without an adequate clinical diagnosis for use.
-Olanzapine was considered a psychotropic medication and was used for mood disorders, psychosis, and other mental health diagnoses.
-Cognition on its own was not an adequate diagnosis for Olanzapine, but if there was another diagnosis to go along with it then it could be included on the order.
-He/She was not aware the resident was on Olanzapine for cognition. The resident did have a mental health diagnosis but he/she was not sure what his/her diagnosis was.
Based on observation, interview and record review, the facility failed to ensure a drug regimen review (DRR)was completed monthly for one sampled resident (Resident #22), that was on psychotropic medications; failed to complete a gradual dose reduction when needed since the drug regimen review was not performed; and failed to ensure that the resident's psychotropic medication was ordered and used to treat a psychological condition for one sampled resident (Resident #181) out of 20 sampled residents. The facility census was 84 residents.
Review of facility policy entitle Drug Regimen Review revised June 2020 showed:
-The pharmacist would review each resident's medication regimen at least once a month to identify irregularities and to identify irregularities, clinically significant risks and/or actual or potential adverse consequences which might have resulted from or be associated with medications.
-It might have been necessary for the pharmacist to have conducted the DRR more frequently.
-The requirement for the DRR applied to all residents (whether short or long-stay) without exception.
-DRR's may be needed for residents who experienced and acute change of condition.
-The pharmacist would report any irregularities to the attending physician to identify clinically significant risks and/or potential adverse consequences which might have resulted from or be associated with medications.
-The Director of Nursing (DON) or designee would have reviewed any irregularities as identified.
Review of undated facility policy entitled Guidelines for Psychotherapeutic Medications showed:
-Residents with a mental health diagnosis could be admitted on psychotropic (drugs which affect psychic function, behavior, or experience) medications were not subject to dose guidelines; however the lowest maintenance dose would be given.
-Residents unless clinically contraindicated, had a gradual dose reduction of the antipsychotic (a group of psychoactive drugs (pertaining to a drug or other agent that affects such normal mental functioning as mood, behavior, or thinking processes) commonly but not exclusively used to treat psychosis(when people lose some contact with reality) medication attempted twice in one year.
-If the dose reduction resulted in the return of symptoms for which the drug was prescribed to a degree that a cessation in the Gradual Dose Reduction (GDR), or a return to previous dose was necessary, it was not necessary to have continued the dose reduction attempts. The physician would document this justification in the physician progress notes.
1. Review of Resident #22's admission Record showed the resident admitted to the facility on [DATE] with the following diagnosis:
-Unspecified Dementia (a progressive organic mental disorder characterized by chronic personality disintegration, confusion, disorientation, stupor, deterioration of intellectual capacity and function, and impairment of control of memory, judgment, and impulses), unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety (anticipation of impending danger and dread accompanied by restlessness, tension, fast heart rate, and breathing difficulty not associated with an apparent stimulus).
-Major Depressive Disorder (a state of intense sadness or despair that has advanced to the point of being disruptive to an individual's social functioning and/or activities of daily living).
Review of the resident's order summary report dated 1/13/25 showed the resident was taking the following medications:
-Sertraline (an antidepressant that belongs to a group of medicines called selective serotonin reuptake inhibitors (stop or delay the body from reabsorbing a substance called serotonin, which leaves more of it available for the body to use raising serotonin levels can help regulate mood, appetite, digestion, sleep, and many other bodily functions) 50 milligrams (mg) one time a day for depression order dated 12/15/2024
-Olanzapine (an antipsychotic that may be used to treat schizophrenia (serious mental health condition that affects how people think, feel and behave) or bipolar disorder (a mental illness that causes clear shifts in a person's mood, energy, activity levels, and concentration) 2.5 mg two times a day take after lunch and at bedtime for psychosis order dated 12/15/2024.
Review of the residents undated care plan showed:
-Antipsychotic medications were not addressed in the care plan.
-Monthly drug regimen reviews were not addressed in the care plan.
-Gradual dose reductions were not addressed in the care plan.
Review of the resident's progress notes dated April 2024 to March 2025 showed:
-No gradual dose reductions had been done.
-No documentation of why a gradual dose reduction had not been done for the past year.
Review of the resident's monthly drug regimen reviews showed:
-There were no drug regimen reviews dated April 2024, June 2024, July 2024, September 2024, October 2024, November 2024, December 2024, January 2025, and February 2025.
-The monthly drug regimen reviews dated March 2024, May 2024, and August 2025 had no recommendations for psychotropic medications gradual dose reductions.
-There were no gradual dose reductions requested from the pharmacist.
During an interview on 3/26/25 at 1:52 P.M., the Regional Nurse Consultant said:
-Pharmacy had not been coming to the building for the past two months.
-Monthly drug regimen reviews and gradual dose reductions were not being performed since the new company took over operations in December 2024.
-It was the DON's responsibility to ensure the monthly drug regimen reviews and gradual dose reductions were being performed, or the rational as to why no gradual dose reduction was documented in the resident's electronic medical record.
-Resident #22 did not have any drug regimen reviews done.
-Resident #22 did not have any gradual dose reduction recommendations because the drug regimen reviews had not been done.
-The drug regimen reviews and the gradual dose reductions should have been done for Resident #22.
During an interview on 3/27/25 at 9:02 A.M., Licensed Practical Nurse (LPN) B said:
-He/She did not follow up on the monthly drug regimen reviews or gradual dose reductions.
-The DON handled the monthly drug regimen reviews and gradual dose reductions.
During an interview on 3/28/25 at 2:48 P.M., the Assistant Director of Nursing (ADON) said:
-Drug regimen reviews should be done monthly to include psychotropic medications.
-Any recommendations from the pharmacist would be sent to the physician to be addressed.
-The monthly drug regimen reviews came to the Administrator and DON, and then were printed.
-The monthly drug regimen review was where the Pharmacist addressed the gradual dose reductions for residents that required them.
-If a resident had not received a monthly drug regimen review for two months, the facility should have reached out to the Pharmacist.
-He/She would have expected the DON to have done this.
-Residents on psychotropic medications needed to have a gradual dose reduction done at least twice in the first year unless there was a clinical rational documented in the residents' medical record.
-The facility should have been able to show why a gradual dose reduction was not being performed for the resident and the past year of monthly drug regimen reviews.
-Resident #22 should have had drug regimen reviews and gradual dose reductions done or documentation indicating why a gradual dose reeducation was not recommended.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0761
(Tag F0761)
Could have caused harm · This affected 1 resident
Based on observation, interview and record review, the facility failed to label medications with resident's name on the medication container when the box was first opened. The facility census was 84 r...
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Based on observation, interview and record review, the facility failed to label medications with resident's name on the medication container when the box was first opened. The facility census was 84 residents.
Review of the facility Medication Storage policy dated September 2018 showed:
-The provider pharmacy dispensed medications in containers that met regulatory requirements, included standards set forth by the United States Pharmacopeia (USP).
-Medication storage conditions were monitored on a regular basis by the consultant pharmacist and corrective actions were taken if a problem was identified.
-The policy did not show where the individual medication container needed to be labeled when the box was labeled.
1. Observation on 3/26/25 at 10:50 A.M. of the 400/500 hall Certified Medication Technician (CMT) medication cart showed:
-One Ellipta inhaler (for Chronic Obstructive Pulmonary Disease (COPD process that decreases the ability of the lungs to perform ventilation), which includes chronic bronchitis (an inflammation of the lining of your bronchial tubes) and emphysema (inner walls of the lungs' air sacs called alveoli are damaged, causing them to eventually rupture and creates one larger air space instead of many small ones and reduces the surface area available for gas exchange) the box was opened and the medication container was not labeled with the residents name.
-One Trelegy inhaler (prescription medicine used long term to treat COPD, including chronic bronchitis, emphysema) the box was opened, and the medication container was not labeled with the resident's name.
2. Observation on 3/26/25 at 11:04 A.M. of the 100/200 hall CMT medication cart showed two Over the Counter (OTC) Nasal allergy medication with box open and no resident names on the medication container.
3. During an interview on 3/26/25 at 11:25 A.M., CMT A said:
-He/She did not know that the residents name needed to be on the actual medication container when the medication came in a box and the box was labeled.
-He/She was not told that the resident's name needed to be on the medication container.
During an interview on 3/26/25 at 11:30 A.M., Licensed Practical Nurse (LPN) B said:
-He/She did not know that the residents name needed to be on the medication container when the medication came from pharmacy in a box.
-No one had ever told him/her that the name of the resident needed to be on the actual medication when the medication came from pharmacy in a box and was labeled.
During an interview on 3/28/25 at 2:48 P.M., the Assistant Director of Nursing (ADON) said:
-Medications should be labeled with residents name on the actual medication container when the medication came from pharmacy in a box that was labeled.
-Unit mangers were responsible for auditing and checking the medication carts.
-The Director of Nursing was responsible to ensure the staff were educated on these things along with himself/herself.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0805
(Tag F0805)
Could have caused harm · This affected 1 resident
Based on observation, interview and record review, the facility failed to serve pureed (food that has been processed into a smooth, uniform, and pudding-like texture, often by blending, mashing, or st...
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Based on observation, interview and record review, the facility failed to serve pureed (food that has been processed into a smooth, uniform, and pudding-like texture, often by blending, mashing, or straining) food items in the correct texture. This deficient practice had the potential to affect all residents who received pureed diets. The facility census was 84 residents.
Review of the Facility Instructions for pureed food items dated 2025, showed:
-Any liquid specified in the recipe is a suggested amount of liquid if needed.
-Some recipe items will require no liquid added to achieve the desired consistency.
-If the product needs thinning, gradually add an appropriate amount of liquid, not water, to achieve a smooth, pudding or soft mashed potato consistency.
-If the product needs thickening, gradually add a commercial or natural food thickener (potato flakes or baby rice cereal) to achieve a smooth, pudding or soft mashed potato consistency.
1. Observation and interview on 3/25/25 at 12:46 P.M., showed the test tray contained the pureed hamburger, pureed rice and pureed cream of corn. All textures were smooth and with a potato consistency except the pureed rice which was not pureed to a smooth texture and the rice kernels were visible in the puree. [NAME] A said:
-He/She had tasted all of the the pureed food items prior to serving.
-Could see the rice in the puree.
Observation on 3/26/25 at 11:03 A.M., showed [NAME] A was preparing the pureed food items-beans, greens and cornbread. The Dietary Manager and Registered Dietician were both observing. [NAME] A prepared all pureed items according to the recipes. When blending the greens, [NAME] A added thickener and continued to blend. Once he/she completed blending he/she scooped the greens into a serving pan. Upon tasting the pureed greens, they were not smooth and there were small pieces of onion and stalk that needed more grinding. When completing the cornbread puree, [NAME] A added milk as needed to thin it. When done, [NAME] A poured the pureed cornbread into a serving pan. The Registered Dietician tasted the puree and said it tasted gritty. [NAME] A put the cornbread back into the blender and ground it to a smoother consistency. The taste of the corn bread was then smooth like mashed potatoes. [NAME] A also ground the greens to a smooth consistency prior to putting on the steam table.
During an interview on 3/26/25 at 12:59 P.M., the Dietary Manager said:
-They could use other vegetables because greens were difficult to blend as was rice.
-All of the cooks were experienced and knowledgeable on how to prepare puree foods.
-He/She ordered a new blade for the blender.
-The consistency of the pureed foods should be mashed potato smooth, not chunky.
-He/She didn't see the pureed rice that was served yesterday, but was aware it was not a smooth consistency.
-The correct texture and consistency should be served to residents who required a pureed diet.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure infection control handwashing practice was follo...
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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 infection control handwashing practice was followed to prevent cross contamination during a gastronomy (which is a surgical opening into the stomach) water flush for one sampled resident (Resident #14); and failed to ensure infection control practices performed hand hygiene between each glove change during care of indwelling Foley Catheter (a urinary bladder catheter inserted through urethra); and failed to ensure to place Personal Protective Equipment (PPE, refers to protective clothing for the eyes, head, ears, hands, respiratory system, body, and feet. To be worn to minimize exposure to a variety of hazards) while providing direct contact care for one sampled resident (Resident #5) who required Enhanced Barrier Precaution (EBP, for residents with chronic wounds or indwelling medical devices during high-contact resident care activities regardless of their multi-drug-resistant organism status) due to the indwelling Foley catheter and was at risk for Urinary Tack Infections (UTI - an infection of one or more structures in the urinary system) out of 20 sampled residents. The facility census was 84 residents.
Review of the facility Hand Hygiene Policy dated June 2020 showed:
-The use of gloves did not replace hand hygiene.
-Hands should be washed after removal of personal protective equipment (PPE) and before moving to another resident in the same room or before exiting the room.
Review of the facility Standards and Enhanced Precaution Policy dated 4/1/24 showed:
-EBP should be used for residents when performing the following high-contact resident care activities to include dressing, personal care and providing urinary catheter care.
Review of the facility Indwelling Foley Catheter Care Policy dated June 2020 showed:
-Wash hands and don (put on) gloves prior to handling catheter.
-Cleanse the perineum and urinary meatus with soap and water, cleansing wipe or a perineal rinse as part of care.
-Cleanse the outside of the catheter wiping away from the meatus.
-Remove gloves and wash hands.
-Clean the drainage spout tip with alcohol wipe before and after when emptying the drainage bag.
1. Review of Resident #14's Face Sheet showed the resident was admitted on [DATE], with diagnoses including gastrostomy status (refers to the presence of a gastrostomy, often used to facilitate feeding or drainage via a gastrostomy tube), dysphagia (impairment of the power to speak or to understand speech, as a result of brain injury, stroke, or disease), muscle weakness, difficulty walking and anxiety disorder.
Review of the resident's quarterly Minimum Data Set (MDS-a federally mandated assessment tool to be completed by facility staff for care planning) dated 3/4/25, showed the resident:
-Was alert and oriented with minimum memory loss.
-Needed only set up for eating, transfers and toileting; minimal assistance to substantial assistance for bathing, dressing, transfers, and mobility.
-Used a wheelchair for mobility.
-Had a feeding tube but took in less than 25 percent of fluids through the tube and less than 500 cubic centimeters (cc) of fluids.
Review of the resident's Physician's Order Sheet (POS) dated March 2025, showed physician's orders to:
-Flush gastronomy tube with 30 milliliters (ml) of water to maintain patency every shift (ordered 12/6/24).
-Check peg tube placement every shift (ordered 12/6/24).
-Cleanse gastronomy area daily with normal saline, pat dry, use split dressing on site every shift (ordered 12/7/24).
Observation and interview on 3/26/25 at 2:53 P.M., showed:
-Registered Nurse (RN) A was preparing to flush the resident's gastronomy tube.
-He/She had already prepared a clean table and placed the distilled water and syringe to flush the tube.
-He/She pulled a red biohazard bag, donned a gown and a mask.
-Once inside the resident's room, without washing or sanitizing his/her hands, he/she gloved.
-Once RN A completed the resident's flush, he/she removed his/her gown and gloves and put them in the trash bin.
-RN A collected the trash and without washing or sanitizing his/her hands, left the resident's room.
During an interview on 3/27/25 at 12:38 P.M., RN A said he/she should have washed or sanitized his/her hands before and after completing the resident's care or procedure, before putting on gloves and after completing resident care.
During the interview on 3/28/25 at 12:06 P.M., Infection Control Preventionist (ICP) A and the Assistant Director of Nursing (ADON) said he/she would expect care staff to use hand sanitizer or wash hands, upon entering the resident's room, before and after resident care, going from a dirty to clean process and between each glove change.
2. Review of Resident #5's admission Record showed the resident admitted with following diagnoses:
-Benign prostatic hyperplasia (BPH, is a condition in which the prostate gland grows larger than normal) with lower urinary tract symptoms.
-Chronic Urinary Retention (bladder does not empty completely or does not empty at all).
-History of UTI.
Review of the resident's admission MDS dated [DATE], showed he/she:
-Was cognitively intact.
-Was able to understand others and make his/her needs known.
-Required total assistant from staff for all cares and transfers.
-Had a UTI in the last 30 days of admission.
-admitted with an indwelling Foley catheter.
Review of the resident's POS dated December 2024 showed:
-Indwelling Foley Catheter Care and Monitor every shift and as needed (Ordered 12/24/24).
-Indwelling Foley Catheter 16 French (Fr) 10 ml balloon. Indwelling Catheter Indication for Chronic Urinary Retention (ordered on 12/24/25).
-EBP: staff to wear a clean gown and gloves while performing high contact resident care activities to include personal hygiene cares and caring for indwelling devices, Foley catheter. (ordered 12/26/24)
Review of the resident's Care Plan dated 1/17/24 showed:
-The resident had a Foley catheter.
-Monitor for signs and systems of a urinary infection.
Review of the resident's POS dated March 2025 showed:
-Indwelling Foley Catheter 16 Fr, 5 ml balloon, Indwelling Catheter Indication for wound healing and Urinary Retention (ordered on 3/7/25).
-Urinalysis (UA, check urine sample for infections) due to urethra meatus (opening were urine exits the body) pain (ordered on 3/17/25).
Review of the resident's Medication Administration Record (MAR) dated March 2025 showed Ampicillin Oral Capsule 500 milligram (mg) (Antibiotic) give one tablet by mouth three times a day for UTI ordered on 3/10/25 and last dose given on 3/17/25.
Observation on 3/24/25 at 9:44 A.M., of the resident showed:
-Was on EBP and had an isolation cart outside his/her room.
-The resident had a Foley catheter located on side of the bed in a privacy bag.
Observation on 3/25/25 at 11:58 A.M., of the resident showed his/her catheter bag was under his/her wheelchair in a privacy bag. Had clear yellow urine in tubing.
Observation on 3/26/25 at 9:50 A.M., of the resident's catheter care showed:
-Had EBP signage posted outside of his/her room and had a isolation cart outside room with PPE supplies.
-Certified Nursing Assistant (CNA) A, entered the resident room to provide the resident's catheter care.
-CNA A did not put on a gown or mask prior to entering the resident's room and he/she did not wear a PPE of gown or mask during the resident's direct high-contact Foley catheter care process.
-He/she washed his/her hands prior to donning clean gloves.
-CNA A with clean gloved hands, assisted the resident in removing under garments for care.
-CNA A started to clean the resident's urethral meatus with alcohol wipes, resident voiced did sting while cleaning the area.
-CNA A continued to use the alcohol wipe to clean stuck on substance around that area.
-CNA A removed his/her gloves, did not wash or sanitize his/her hands prior to donning clean gloves.
-He/she cleansed the urethral meatus using a wash cloth with soap and water.
-CNA A removed his/her gloves and did not wash or sanitize his/her hands prior to donning clean gloves.
-He/she then used alcohol wipe and cleaned the drainage tubing in a downward motion.
-He/she completed catheter care removed his/her gloves and exited the resident room.
-When he/she entered the hallway, CNA A performed hand hygiene using the wall hand sanitizer.
During an interview on 3/26/25 at 10:15 A.M. CNA A, said:
-He/she was not aware of any Foley catheter care issue during resident care process.
-He/she did not remember if he/she was observed performing Foley catheter care and going over EBP during the skills check off during orientation.
During an interview on 3/27/25 at 12:38 P.M., CNA B said:
-He/She had training related to the facility policy on EBP.
-During high-contact care (Foley catheter care) for a resident on EBP, he/she was required to wear PPE to include gloves, gown, face shield or mask if potential splatter.
-The resident was placed on EBP related to his/her catheter and wounds.
-When providing Foley catheter care staff would be required to wear gown, mask and gloves.
-Alcohol wipes should only be used to clean catheter tubing not on any open skin area.
-He/She would wash or sanitize his/her hands before and after care, from a dirty to clean process and between each glove change.
During an interview on 3/27/25 at 12:55 P.M., CNA A, said:
-When working with resident's on EBP, staff should wear gown and gloves for any direct high-contact resident care.
-He/She did put on a gown prior or during catheter care.
-Staff should wash or sanitize their hands before and after care and between each glove change.
-Should only clean Foley catheter insertion site with soap and water or personal hygiene wipes.
-He/She used alcohol wipes to try and get the substance that was on and around catheter insertion site.
During an interview on 3/28/25 10:25 A.M., Licensed Practical Nurse (LPN) A said:
-He/she would expect nursing staff to provide Foley catheter care as ordered.
-CNA's would be responsible for daily care of the Foley catheter site while providing incontinence care.
-Resident's with a Foley catheter would be on EBP and during direct contact resident care, staff would be required to wear PPE to include gown and gloves.
-Staff should clean the Foley catheter insertion site area with personal care wipes, or with soap and water.
-Staff should not use alcohol wipes to clean around the Foley catheter insertion site/opening.
-Use the alcohol wipe or personal care wipe to clean the Foley catheter drainage tubing.
During an interview on 3/28/25 at 10:35 A.M., LPN B said:
-CNA's would be responsible for daily care of the Foley catheter site during peri care.
-Resident's with Foley catheters would be on EBP and direct care contact with the resident would require PPE of gown and gloves.
-He/She has not had recent training related to EBP.
During the interview on 3/28/25 at 12:06 P.M., Infection Control Preventionist (ICP) A and the Assistant Director of Nursing (ADON) said:
-He/She would expect care staff to use hand sanitizer or wash their hands before and after resident care, from a dirty to clean process and between each glove change.
-Hand Hygiene skills competency would be included in the facility training calendar for the year and ICP and the ADON would provide hand hygiene training if they saw a trend of infection on a hallway related to resident care.
-Resident #5 was placed on EBP, he/she was at risk for infection due to having an indwelling device in place, such as his/her Foley catheter.
-He/she would expect all care staff to don PPE to include gown and gloves while providing direct high-contact care for a resident on EBP, which would include Foley catheter care.
-He/She would expect care staff to clean the Foley catheter insertion site with with soap and water.
-Should not use alcohol wipe to clean around Foley catheter insertion site/opening.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Drug Regimen Review
(Tag F0756)
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 ensure a drug regimen review was completed monthly for three sample...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure a drug regimen review was completed monthly for three sampled residents (Resident #59, #53 and #14) out of 20 sampled residents. The facility census was 84 residents.
Review of the facility Drug Regimen Review policy dated June 2020 showed:
-The intent was the facility maintained the resident's highest practicable well-being and prevented or minimized adverse (negative or harmful) consequences related to medication.
-The pharmacist would review at least once monthly to identify irregularities and any clinically significant risks and/or actual or potential adverse consequences which may result from or be associated with medications.
-The Director of Nursing (DON) was responsible for following up with the physician as indicated.
1. Review of Resident #59's Physician's Order Sheet (POS) dated March 2025 showed physician's orders for:
-Allopurinol 100 milligrams (mg) at bedtime for gout (type of arthritis that usually affects one joint at a time, often the big toe and causes periods of severe pain and swelling).
-Amlodipine Besylate 2.5 mg in the evening for high blood pressure.
-Aspirin 81 mg a day for prophylaxis (reducing the risks of heart disease and cancer).
-Atorvastatin Calcium 40 mg at bedtime for hyperlipidemia (high levels of fats in the blood).
-Clopidogrel Bisulfate 75 mg on time daily for stroke prevention.
-Cyanocobalamin 1000 micrograms (mcg) daily for vitamin B12 supplement.
-Duloxetine 30 mg at bedtime for depression.
-Famotidine 20 mg at bedtime for gastroesophageal reflux disease (GERD - a condition in which stomach acid repeatedly flows back up into the tube connecting the mouth and stomach).
-Fish oil 1000 mg daily for dietary supplement.
-Furosemide 20 mg daily related to acute kidney failure (sudden decline in the functioning of your kidneys).
-Losartan 50 mg in the afternoon for high blood pressure.
-Methimazole 10 mg in the evening for hypothyroidism (underactive thyroid).
-Mirtazapine 7.5 mg at bedtime for depression, appetite stimulant.
-Oxybutynin 15 mg daily for overactive bladder.
-Polyethylene glycol one scoop in the afternoon for constipation.
-Sodium bicarbonate 650 mg daily for acute kidney failure.
-Timolol solution 0.2-0.5% one drop in both eyes two times daily for glaucoma (increased pressure in the eye).
-Carvedilol 25 mg two times daily for high blood pressure.
-Cranberry 500 mg tablet two times daily for prevention of urinary tract infection (UTI).
-Senokot 8.6-50 mg two tablets twice daily for constipation.
-Midodrine 5 mg three times daily for orthostatic hypotension (a sudden drop in blood pressure that occurs upon standing).
-Novolin 70/30 insulin 8 units at bedtime for diabetes.
-Novolin 70/30 insulin 8 units in the morning for diabetes.
-Oxycodone (opioid pain medication) 5 mg every eight hours as needed for pain.
Review of the resident's medical record showed there were no Drug Regimen Reviews in the resident's medical record.
2. Review of Resident #53's POS dated March 2025 showed physician's orders for:
-Ondansetron 4 mg every 8 hours as needed for nausea.
-Lorazepam 0.5 mg every 4 hours as needed for anxiety/restlessness.
-Morphine Sulfate 15 mg tablet two times a day for pain/discomfort.
-Morphine Sulfate Oral Solution 100 mg/5 milliliter (ml), give 0.25 ml by mouth every 1 hour as needed for shortness of air (a severe feeling of being unable to breathe).
-Buspirone 10 MG tablet by mouth three times daily for anxiety.
-Lorazepam 0.5 mg, one tablet every 4 hours as needed for anxiety/restlessness.
-Carvedilol 12.5 mg, two times a day for high blood pressure.
-Escitalopram Oxalate 20 mg, one time a day for depression.
-Eliquis 5 mg, one tablet two times a day for stroke prevention.
-Bumetanide 2 mg, one time a day for edema.
-Mirtazapine 7.5 mg one time daily for depression/appetite stimulation.
Review of the resident's medical record showed there were no Drug Regimen Reviews in the resident's medical record.
3. Review of Resident #14's Face Sheet showed the resident was admitted on [DATE], with diagnoses including gastrostomy status (refers to the presence of a gastrostomy, which is a surgical opening into the stomach, often used to facilitate feeding or drainage via a gastrostomy tube), dysphagia (impairment of the power to speak or to understand speech, as a result of brain injury, stroke, or disease), muscle weakness, difficulty walking, high cholesterol, high blood pressure, edema (swelling in the tissues), seizures (a neurological condition characterized by recurrent, unprovoked brief episodes of involuntary movement or altered awareness caused by abnormal electrical activity in the brain), depression, bipolar disorder (a chronic mental health condition characterized by extreme mood swings between periods of mania (elevated mood) and depression), schizophrenia (a chronic mental health condition characterized by persistent disruptions in thought processes, perceptions, emotions, and social interactions) and anxiety disorder.
Review of the resident's POS dated March 2025 showed physician's orders for:
-Atorvastatin 40 milligrams (mg) daily for high cholesterol (1/16/25).
-Baclofen 10 mg every 12 hours as needed for muscle spasms (12/6/24).
-Benztropine Mesylate 0.5 mg twice daily for Parkinson's Disease (12/6/24).
-Buspirone 15 mg three times daily for anxiety (12/6/24).
-Celecoxib 200 mg daily for pain (12/6/24).
-Divalproex Sodium 500 mg two tablets twice daily for seizures (12/6/24).
-Furosemide 20 mg on Monday, Wednesday and Friday for edema (swelling) (12/6/24).
-Gabapentin 50 mg at bedtime for pain (3/17/25).
-Levetiracetam 500 mg twice daily for seizures (12/6/24).
-Loperamide 2 mg every four hours as needed for loose stools (12/6/24).
-Melatonin 5 mg at bedtime (3/7/25).
-Metoprolol 12.5 mg once daily for high blood pressure (12/19/24).
-Ondansetron 4 mg every 8 hours as needed for nausea (12/6/24).
-Oxybutynin 5 mg daily for overactive bladder (12/6/24).
-Oxycodone 5 mg every 6 hours as needed for pain (12/6/24).
-Prazosin 2 mg at bedtime for nightmares (12/6/24).
-Pregabalin 50 mg twice daily for pain (12/6/24).
-Sertraline 100 mg two tablets daily for depression (1/2/25).
-Trazodone 150 mg at bedtime for depression (12/6/24)'
-Vraylar 3 mg daily for schizophrenia (12/6/24).
Review of the resident's medical record showed there were no Drug Regimen Reviews in the resident's medical record.
4. Review of the facility's Drug Regimen Review binder dated January 2024 to March 2025, showed:
-The pharmacist visited the facility in November 2024 and December 2024, but the resident's medications were not reviewed in either month.
-There were no Drug Regimen Reviews documented for January 2025, February 2025 and March 2025 for Resident #59, Resident #53, or Resident #14.
During an interview on 3/26/25 at 1:52 P.M., the Regional Nurse Consultant said:
-The pharmacy had not been coming out for the past three months.
-He/She was told that they had not had any gradual dose reductions or any pharmacy recommendations since they purchased the facility in December 2024.
-The company had a pharmacist that was contracted to come to all of their facilities including this one.
-The pharmacist they were contracted with had not been coming to review the medications in the facility since December 2024.
-There was a miscommunication with the pharmacist, they were under the impression there was no longer a contract to provide services to the facility.
-Facility staff had not notified him/her that the pharmacist was not coming to the facility to complete the Drug Regimen Reviews.
-The Director of Nursing (DON) was responsible for ensuring the drug regimen reviews were completed monthly.
During an interview on 3/28/25 at 2:47 P.M., with the Assistant Director of Nursing (ADON) and the Infection Control Preventionist (ICP) present, the ADON said:
-The facility completed a drug regimen review upon admission, but the pharmacist completed monthly reviews.
-The physician would review the resident's medication list within a weeks time post admission, but the pharmacist may not see the resident for up to a month after admission.
-The pharmacist had not been coming to the facility to review resident medications.
Dec 2024
1 deficiency
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Safe Environment
(Tag F0584)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, the facility failed to maintain the floors of the following rooms in a clean condition in re...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, the facility failed to maintain the floors of the following rooms in a clean condition in resident rooms 204, 105, 101, 304, 310, 514, 504, 501, 411, 406, and 407. This practice potentially affected 12 residents. The facility census was 68 residents.
1. Observation on 12/2/24 with the Housekeeping Supervisor showed:
- At 12:59 P.M., there was a buildup of cobwebs along the floor and wall area next to the refrigerator in resident room [ROOM NUMBER].
- At 1:01 P.M., there was a buildup of cobwebs in the corners of room [ROOM NUMBER].
- At 1:04 P.M., there was a buildup of dust and debris along the wall in resident room [ROOM NUMBER].
- At 1:05 P.M., there was a buildup of hair and dust along the wall in resident room [ROOM NUMBER].
- At 1:08 P.M., there was a buildup of dust under the bed in resident room [ROOM NUMBER].
- At 1:10 P.M., there was a buildup of dust and cobwebs behind the bed and long the walls at the floor level in resident room [ROOM NUMBER].
- At 1:15 P.M., there was a buildup of dust cobwebs behind the dresser in resident room [ROOM NUMBER].
- At 1:17 P.M., there were dead insects under the bed and hairs on the floor in resident room [ROOM NUMBER].
- At 1:19 P.M., there was a buildup of cobwebs behind the dresser in resident room [ROOM NUMBER].
During an interview on 12/2/24 at 1:20 P.M., the Housekeeping Supervisor said the housekeepers are not pulling furniture out from the walls so they can get behind those areas.
During an interview on 12/2/24 at 1:22 P.M., Housekeeper A said he/she cleaned the rooms daily, but sometimes it was difficult to pull the furniture out from the walls.
MO00245581.
Oct 2024
1 deficiency
1 IJ
CRITICAL
(J)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Immediate Jeopardy (IJ) - the most serious Medicare violation
Accident Prevention
(Tag F0689)
Someone could have died · This affected 1 resident
Based on observation, interview, and record review, the facility failed to ensure staff used a gait belt (a device that helps prevent falls) during transfers and ambulation for one sampled resident (R...
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Based on observation, interview, and record review, the facility failed to ensure staff used a gait belt (a device that helps prevent falls) during transfers and ambulation for one sampled resident (Resident #1) out of eight sampled residents. CNA A assisted the resident into the shower room to provide incontinence care. CNA A assisted the resident into a standing position without the use of a gait belt. The resident slid to floor, which resulted in the resident being impaled by his/her wheelchair break lever, causing a penetrating wound (trauma that occurs when a foreign object enters the body) and laceration (a wound produced by the tearing of skin and underlying soft tissue) and was hospitalized for three days. The facility census was 65 residents.
The Administrator was notified on 10/1/24 at 12:47 P.M., of the Immediate Jeopardy (IJ) which began on 9/13/24. The IJ was removed on 10/1/24 at 4:24 P.M., as confirmed by surveyor onsite verification.
Review of the facility's undated Transfer Belts/Gait Belts policy showed:
-To promote safety in transferring and ambulating residents, a gait belt is utilized when deemed appropriate by nursing staff or therapy staff.
-All Certified Nursing Assistants (CNA) and licensed nursing staff engaged in the lifting and transferring of residents will use gait belts.
-The use of gait belts and mechanical lifts is essential to reduce the risk of accident and injury to both residents and staff.
-After orientation to facility policy and training in the use of gait belts, staff who fail to use them or to use them appropriately, should be considered subject to disciplinary measures.
- GAIT BELTS ARE MANDATORY.
-CNAs will routinely have a gait belt on their person.
-Report any changes in a resident's performance during transfers to the charge nurse.
Review of the facility's undated Fall Prevention policy showed:
-Fall prevention interventions included use of a gait belt.
Review of the facility's undated Dress Code Policy showed:
-All CNAs are required to wear a gait belt at all times.
Review of the facility's Inservice Attendance titled Safe Resident Handling - Gait Belt, dated 9/10/24, showed CNA A signed the sheet indicating he/she had attended the inservice education.
1. Review of Resident #1's Face Sheet, dated 3/4/24, showed the following diagnoses:
-Stroke.
-Dementia.
-Hemiplegia (paralysis on one side of the body) and hemiparesis (weakness or inability to move one side of the body) following stroke affecting right dominant side.
-Aphasia (an impairment of language, affecting the production or comprehension of speech and the ability to read or write).
-Unsteadiness on his/her feet.
Review of the resident's quarterly Minimum Data Set (MDS - a federally mandated assessment tool required to be completed by facility staff for care planning), dated 8/9/24, showed:
-He/she had moderately impaired cognitive skills.
-He/she had unclear speech.
-He/she was sometimes understood by others.
-He/she usually understood others.
-He/she needed substantial/maximum assistance for sitting to standing.
-He/she used a wheelchair for mobility.
-He/she needed partial to moderate assistance for toileting, hygiene, and lower body dressing.
-He/she had one non-injury fall since the previous MDS (approximately 90 days).
Review of the resident's care plan, reviewed on 8/7/24, showed:
-He/she had impaired physical mobility and was at risk for falls related to right sided weakness due to a stroke.
-Staff were to observe him/her for unsteady/unsafe transfer or walking and provide stand by or balance support as needed.
-He/she had a contracture (a permanent tightening of the muscles, tendons, skin, and nearby tissues that causes the joints to shorten and become very stiff) of his/her right hand.
-He/she needed one staff persons assistance at times.
-He/she was incontinent of bladder and staff were to change his/her incontinence brief.
Review of the resident's Nurse's Notes, dated 9/13/24, showed Licensed Practical Nurse (LPN) A documented:
-At 8:15 A.M. the resident was in the shower room and a CNA was calling for help.
-LPN A went into the shower room and the CNA was holding the resident's wheelchair sideways to the resident, the resident was lying on the floor on his/her side.
-LPN A saw that the wheelchair lock was imbedded under the resident's skin up and to the left of his/her rectum.
-911 was called, the wheelchair was held in place by two staff members to keep the object under the resident's skin and the resident still until Emergency Medical Services (EMS) arrived.
-EMS staff instructed LPN A to hold the resident's wheelchair in place while EMS took the resident's wheelchair apart with tools to get him/her to the hospital.
-The wheelchair brake slid out of the resident's rectum leaving a large baseball size opening with exposed yellow and pink tissue three inches from the left of the resident's rectum.
-EMS then transported the resident to the hospital.
-The resident was alert during the entire incident.
Review of CNA A's Witness Statement, dated 9/13/24, showed:
-CNA A was toileting the resident and taped one side of the resident's brief, started to go to the other side and saw him/her sliding.
-CNA A let the resident down to the floor.
-He/she made sure the resident was safe and got help.
Review of LPN A's Witness Statement, dated 9/13/24, showed:
--CNA A had walked to the shower room door, opened it and said he/she needed help now.
-When LPN A walked into the shower room the resident was lying on the floor and no gait belt was on the resident or in the surrounding area.
-The resident's wheelchair was tipped sideways and had to be held due to the angle and the wheelchair lock having impaled the resident's rectum.
-From LPN A's angle on the ground holding the resident's wheelchair while waiting for EMS, the resident's rectum had a one to two inch tear going up his/her back.
Review of Certified Medication Technician (CMT) A's Witness Statement, dated 9/13/24, showed:
-At approximately 8:15 A.M. CMT A heard LPN A yelling out his/her name from the 500-hall shower room.
-Upon entering the shower room, he/she saw the resident on the floor and his/her wheelchair was lying behind him/her on its side; CNA A was with the resident.
-CMT A stayed with the resident until LPN A called 911 ensuring the resident did not get up due to the injury.
Review of the resident's undated facility investigation Re-enactment Summary of events as told by CNA A of the resident's fall on 9/13/24 showed:
-CNA A assisted the resident into the shower room for incontinence care, he/she positioned the resident's wheel chair facing towards the grab bar (a safety device designed to enable a person to maintain balance, lessen fatigue while standing, hold some of their weight while maneuvering, or have something to grab onto incase of a slip or fall) on the right-side wall of the room in relation to the entrance to the shower room.
-The resident used his/her stronger arm and hand (her left arm and hand) to hold onto the grab bar.
-CNA A assisted the resident into a standing position without the use of a gait belt, CNA A said that the resident's preference was to not use a gait belt and the resident would become agitated if a gait belt was used on him/her.
-CNA A then went to the resident's right side and assisted pulling down the resident's pants and unfastened the right side of the resident's soiled brief.
-CNA A walked around the back of the resident's wheelchair, took the brief off of the resident, and disposed of it in the nearby trash can.
-CNA A cleansed the resident's perineal (between the thighs extending from the pubic bone to the tail bone) area, placed a clean brief on the resident and fastened the brief on the resident's left side, using one hand to hold the brief in place and his/her other hand to pull the brief's fastening strap on the left side of the resident around the resident's left hip and used the same hand to fasten it to the front of the resident's brief.
-CNA A moved to the resident's right side by walking behind the resident's wheelchair to the resident's right side at approximately at an eight o'clock position behind the resident.
-While CNA A was relocating to the resident's right side, he/she heard the resident say, It's what it was with an inflection tone of the way in which the resident indicated to him/her that the resident was expressing fright; and appeared to be losing his/her balance and falling.
-CNA A said his/her natural instincts took over and he/she grabbed for the resident who appeared to be falling towards his/her right side, grabbing a hold of the left-shoulder portion of the resident's shirt and pulling the resident towards himself/herself.
-CNA A said his/her grabbing the resident to prevent him/her from falling or prevent the resident from falling face and head-first onto the floor resulted in the resident turning his/her position to where his/her body now was at approximately a ten o'clock' angle in relation to the grab bar, where previously the resident's body was at a two o'clock angle in relation to the grab bar.
-CNA A witnessed the resident fall backwards toward his/her wheelchair and to his/her right side, resulting in the resident being on the floor along with his/her wheelchair with the right wheel of his/her wheelchair being on the floor and the left wheelchair wheel up towards the ceiling.
-When moving to the side on which the resident fell, CNA A noticed something was wrong with the resident and the resident needed help.
-He/she asked the resident to remain as still as possible, ran to the shower room door, opened it and yelled out that he/she needed help immediately.
-LPN A ran into the shower room to assess the situation.
-LPN A noticed the resident on the floor and went to the resident's side and CNA A told LPN A not to move the resident's wheelchair, as part of it had impaled (penetration of the human body by a pointed object) the resident's rectum.
-CNA A remained with the resident and LPN A called down the hallway to CMT A he/she needed assistance immediately.
-LPN A told CMT A his/her assessment of the resident and said 911 would have to be called for EMS for the resident.
-911 was called and EMS arrived at the facility shortly afterward, bringing tools to disassemble, disconnect, or remove the object that was impaled in the resident's rectum.
-EMS started an intravenous vein (IV) access, gave medication through the IV to the resident to help him/her with his/her pain from the incident, and then the object was able to be removed from the resident's rectum.
-EMS then transported the to the hospital.
Review of the resident's EMS records, dated 9/13/24, showed:
-The Emergency Medical Technicians (EMTs) were dispatched to the scene due to a fall with impalement.
-Upon arrival, the resident was found lying on his/her left side in the shower area with staff present.
-The resident had aphagia and could not communicate verbally.
-The staff were trying to change the resident's brief and the resident slipped, fell, landing on the wheelchair pedal and brake handle.
-The brake handle inserted into the resident's rectum (the last several inches of the large intestine closest to the anus (the opening between the buttocks through which gas and feces is ejected from the body) and then tore laterally to the left.
-The was insignificant bleeding.
-The foreign body was still in the resident and he/she was yelling in distress.
-Pain medications were given through IV.
-The crew started removing bolts from the wheelchair brake, however the brake handle was wedged in place and would require hammering and jostling to remove it.
-The resident was squirming so only a small part of the foreign body was in the resident.
-A decision was made to remove the object and monitor for bleeding.
-The area was briefly irrigated with normal saline then covered and no increase in bleeding was seen.
-The resident was moved to a stretcher and began to yell in discomfort again.
-IV pain medication as administered.
-The resident was transported to the hospital.
Review of the resident's hospital records, dated 9/13/24 - 9/16/24, showed:
-He/she was seen for rectal trauma.
-He/she was in the shower area at the nursing home and fell.
-He/she had a foreign body anal penetration with laceration (a deep cut or tear in skin or flesh).
-A lever on his/her wheelchair penetrated his/her gluteal (buttock) area his/her wheelchair lever penetrated one centimeter (cm - just under 3/8 inch) into his/her gluteal (buttock) area.
-He/she received diagnostic radiology, intravenous (into a vein) antibiotics, narcotic pain medication by IV and by mouth, a tetanus vaccine (a bacterial infection caused by bacteria entering the body through cuts and punctures that can cause life-threatening muscle spasms and convulsions), and wound care.
-His/her discharge instructions included a new medication of hydrocodone/acetaminophen (narcotic pain medication), 5-325 milligrams (mg), one every four hours as needed for severe pain and wound care of wet to dry packing (WTD - a wound care technique that involves applying moist gauze dressing to a wound, allowing it to dry, and then removing it to remove dead tissue and wound drainage), daily and as needed to his/her gluteal laceration.
Review of the resident's fall facility investigation final summary, dated 9/16/24, showed:
-Upon reviewing the information regarding the resident's fall, there was mention of CNA A not using a gait belt.
-The Administrator requested immediate re-education for CNA A on the facility gait belt policy, which was completed on 9/13/24.
-The Administrator and the Director of Nursing (DON) interviewed CNA A and requested him/her to reenact and spoke with him/her, clarifying details.
-Upon reviewing the information presented, it was not believed that there was any willful abuse or deliberate negligence, but instead the need for supervisory counseling.
During an interview on 9/17/24 at 10:10 A.M., the Administrator said:
-On 9/13/24 CNA A took the resident into the shower room for incontinence care and had the resident stand and hold onto a grab bar.
-CNA A did not use a gait belt and the resident fell, resulting in him/her being injured and sent out to hospital.
-The resident was now back from the hospital.
During an interview on 9/18/24 at 10:07 A.M., CNA A said:
-On 9/13/24 he/she took the resident to a shower room to provide incontinence care for the resident.
-Without using a gait belt, he/she assisted the resident to stand by pulling on the back of the resident's pants, and had the resident take hold of the grab bar.
-He/she provided incontinence care for the resident while the resident held onto the grab bar.
-He/she fastened the resident's brief on his/her right side, moved around the resident's wheel chair, to the resident's left side.
-He/she began to fasten the resident's brief on his/her left side, heard the resident saying something with a tone as if he/she was scared.
-He/she saw the resident was beginning to fall to his/her right side.
-He/she grabbed the resident's blouse left sleeve.
-The resident continued to fall and ended up on his/her side, his/her wheelchair on its side and a part of the wheelchair was inside the resident's rectum.
-He/she saw the resident needed help and hearing a resident yelling in the area near the shower room, he/she asked the resident to not move and he/she went to the shower room door and yelled for LPN A to come to the shower room;
-LPN A came the shower room and he/she told LPN A to not move the resident because something from the wheelchair was inside the resident.
-LPN A went to the shower room door and told CMT A to come to the shower room and had him/her stay with the resident while LPN A called 911.
-When LPN A returned to the shower room, he/she had CMT A prepare the paperwork for the resident to go to the hospital.
-He/she and LPN A stayed with the resident until EMS took the resident to the hospital.
-He/she saw that EMS left with the resident.
-He/she had not used a gait belt with the resident; the resident did not like the gait belt being on him/her.
-He/she knew this because when he/she had previously tried to use the gait belt with the resident he/she said, No, no, no.
-He/she had never actually tried to put a gait belt on the resident, because the resident had said no.
-He/she did not use a gait belt on any other resident's as long as they could stand and hold onto a grab bar.
-Looking back, there was nothing different he/she would have done regarding using a gait belt with the resident.
-After the Administrator and the DON talked with him/her, he/she would get another staff person or tell the charge nurse.
-He/she had attended a recent gait belt in-service on 9/10/24 during which the DON said use of gait belts were for resident and staff safety.
-He/she asked what to do if a resident refused a gait belt and the DON said not to assist/transfer the resident without a gait belt and tell the charge nurse the resident had refused the gait belt.
-The purpose of the gait belt was for safety, if the resident was falling, to have a hold of the resident and in case of falling, he/she could in case he/she could slide the resident down to the floor.
-If a resident told me no, he/she was not going to us a gait belt on them.
-Resident's had rights, if a resident said no and he/she put a gait belt on the resident anyway, it would be abuse.
During an interview on 9/18/24 at 11:08 A.M., LPN A said:
-The resident had right sided weakness and aphasia due to having a stroke in the past.
-The resident needed one staff person assistance with a gait belt for standing and transferring.
-The resident never refused care and had never refused use of a gait belt.
-He/she had not seen CNA A not use a gait belt with the resident.
-He/she had seen CNA A not use a gait belt with two other residents.
-He/she told CNA A to use a gait belt when transferring residents and CNA A said for him/her to not tell him/her what to do.
-About one month prior, he/she told the previous Administrator that CNA A had not used a gait belt with two residents, that CNA A had said for him/her to not tell him/her what to do, talked back, wouldn't listen and was argumentative.
-When he/she entered the shower room, the resident was lying on the floor with his/her wheelchair on its side on the floor next to the resident, his/her wheelchair brake lever was in his/her anus.
-He/she went to the shower room door and called for CMT A to come to the shower room.
-When CMT A arrived in the shower room, he/she told him/her what was going on and to prevent the resident from moving.
-He/she went to the nurse's station and called, called 911 and advised that EMT's needed to bring tools to remove the resident's wheelchair break lever from the resident's wheelchair.
-He/she returned to the resident and had CMT A go and prepare the needed paperwork for the resident's transfer to the hospital and he/she and CNA A remained with the resident until EMS arrived on the unit.
-EMS started an IV and removed the resident's wheelchair lever from the resident's wheelchair.
-The lever penetrated the resident's left buttock and exited the resident's left buttock leaving a laceration on the resident's left buttock.
-EMS staff immediately packed the resident's left buttock laceration with gauze to control bleeding and then transported the resident to a trauma hospital.
-During the time EMS was removing the resident's wheelchair brake lever from the resident's wheelchair, the resident was alert and EMS administered Ketamine (a medication that can induce a state of sedation - feeling calm and relaxed, immobility - the state of not moving or inability to move, relief from pain and amnesia - no memory of events while under the influence of the drug) intravenously into a vein for pain.
-CNA A told him/her he/she had not used a gait belt during the resident's care and the resident fell.
During an interview on 10/2/24 at 10:02 A.M., EMT A said:
-On 9/13/24 when he/she arrived at the resident's location in a facility shower room, he/she saw that the resident was on his/her side, his/her wheelchair was on top of him/her.
-He/she saw the wheelchair break lever had entered into or very near the resident's rectum and had torn across the resident's mid left gluteus muscle.
-It was difficult for EMS to assess the resident's heart rate and blood pressure due to the resident's position with his/her wheelchair being on him/her.
-It was difficult to assess the resident's pain, because at his/her baseline he/she had communication difficulties due to his/her past medical history of stroke.
-The resident was squirming (made twisting/jerking movements because of pain or distress) and yelling out.
-Other EMS staff and a facility nurse were trying to keep the resident still.
-He/she started an IV line, while EMS staff worked to remove the wheelchair brake lever from the resident's wheelchair.
-He/she administered Ketamine IV which had a temporary effect of mildly reducing the resident's squirming.
-EMS staff worked to remove the wheelchair lever from the resident's wheelchair, but could not without a lot of jostling due to the position of the wheelchair and the resident.
-The resident's wheelchair brake lever slipped out of the resident from his/her already three to five-inch torn flesh on his/her rectal area to his/her left gluteus muscle.
-The resident's wound had minimal bleeding.
-He/she placed five by nine-inch trauma pad over the resident's wound to control and assess bleeding and provide a barrier to help prevent contamination of the wound.
-When placed on a wheeled stretcher, the resident began to show increased movement and began to yell out.
-He/she administered a second dose of Ketamine IV - it was typical for a first dose effect to be short in duration and for a second dose to be needed.
-He/she had concern about possible rectal perforation (a rare but serious condition that occurs when there is a hole in the rectum, most commonly caused by trauma).
During an interview on 9/18/24 at 11:48 A.M. the DON said:
-The resident had a stroke in the past and could say It is what it is. And a few other words.
-When frustrated he/she would repeatedly say no.
-He/she and the Administrator did the resident's 9/13/24 fall investigation, including interviewing CNA A and having him/her reenact the resident's fall.
-On 9/13/24 CNA A had taken the resident into a shower room to provide incontinence care.
-Without using a gait belt, CNA A had the resident stand up and hold onto a grab bar.
-CNA A moved to the resident's left side and as he/she was starting to fasten the residents brief on his/her left side and saw the resident was starting to fall and grabbed the resident's blouse left arm sleeve.
-As the resident continued to fall his/her wheelchair lock penetrated his/her rectum.
-The resident's wheelchair ended up on its side and the resident on the floor on his/her side with a wheelchair brake having punctured the resident.
-He/she saw the resident as EMS was leaving the facility with the resident and the resident appeared to be in pain by his/her voice tone when repeating words.
-Had CNA A used a belt for the resident, he/she would have had something to have assisted the resident to a sitting position in his/her wheelchair rather than falling.
-CNA A said the resident would not wear a gait belt.
-Any resident who was assisted by staff in standing/transferring was to use a gait belt.
-If any resident had refused a gait belt, CNA A should have told the charge nurse and should not have had the resident stand or transfer the resident without using a gait belt.
-He/she had not known prior to 9/13/24 that CNA A did not use a gait belt when caring for the resident and when caring for other residents.
-Staff needed to use a gait belt with any resident who needs staff assistance with standing or transferring.
Observation on 9/18/23 at 11:48 A.M., showed:
-The resident had a laceration on his/her left buttock above his/her left gluteal fold left gluteal fold (the side-to-side crease in the skin that separates the buttocks from the upper thigh) to the left of his/her gluteal cleft (the groove between the buttocks).
-The DON measured the resident's laceration with results of 1.5 centimeters (cm) (over one-half inch) by 4.1 cm (approximately one and ½ inches) and with a depth of 7.2 cm (approximately two and ¾ inches).
-DHSS staff attempted to interview the resident during this observation, the resident was not interviewable, and was only able to answer simple yes or no questions.
During an interview on 9/17/24 at 1:12 P.M., CNA B said:
-The resident was a one-person assistance with transfers.
-The resident had not refused a gait belt during care.
-He/she always used a gait belt when transferring the resident or when having the resident stand.
During an interview on 9/17/24 at 12:45 P.M., CNA C said:
-The resident was a one person assist with a gait belt for standing and transferring between surfaces.
-He/she used a gait belt when transferring the resident or when having the resident stand.
-The resident had not refused to wear a gait belt.
-All care staff were to wear a gait belt when working the floor (providing direct resident care).
Record review of the resident's Nurse Practitioner (NP-a registered nurse who has advanced clinical education and training and is qualified to perform physical exams, diagnose and treat illnesses and prescribe medications/treatments) progress note, dated 9/18/24, showed:
-He/She was seen for a readmission post hospitalization open wound on his/her left buttock.
-On 9/13/24 the resident was being assisted by a staff member in the restroom.
-He/she came down and caught his/her left buttock on his/her wheelchair brake lever which impaled his/her left buttock in the cleft area.
-He/she was sent to the hospital, received antibiotics and a colorectal (specialist in diagnosing and treating conditions that affect the lower gastrointestinal tract) surgery consultation.
-The hospital colorectal surgeon decided not to do surgery and instead to discharge the resident with instructions for loose pack wet-to dry dressing daily and as needed.
-The NP ordered empiric antibiotics asked the DON and the Assistant Director of Nursing (ADON) to reinforce to nursing staff to monitor the resident for signs and symptoms of infection due to the area of the resident's wound had a high propensity for infection.
-The NP would ask the resident's physician to see the resident that week.
-The wound care company would assume the resident's wound care the following week on 9/25/24.
During an interview on 9/18/24 at 2:16 P.M., CNA D said:
-The CNAs all knew to use a gait belt with the resident.
-The resident needed one-staff person assistance with standing and transfers.
During an interview on 9/18/24 at 2:24 P.M. CMT B said:
-He/she used a gait belt with the resident when having the resident stand and when transferring the resident.
-The resident needed one-staff person assistance with standing and transfers.
During an interview on 9/18/24 at 2:12 P.M. CNA A said:
-He/she did not use a gait belt for any of the residents when having a resident stand or transfer as long the resident could hold onto a grab bar.
During an interview on 9/18/24 at 2:29 P.M., the Director of Rehabilitation and Physical Therapist (PT) A said:
-The resident was discharged from therapy on 9/6/24.
-Rehabilitation Services determined during the resident's skilled therapy that he/she needed one person assistance with a gait belt for transfer, standing and walking.
-During therapy the resident had not been resistant to or refused use of a gait belt.
During an interview on 9/18/24 at 2:54 P.M., the ADON said:
-Unless a mechanical lift was used, direct care staff were to use gait belts when assisting residents with transfer/standing.
During an interview on 9/18/24 at 3:22 P.M., the Administrator said the fall investigation regarding the resident's 9/13/24 fall identified the root cause of the resident's fall was the lack of use of a gait belt by CNA A.
During an interview on 9/19/24 at 1:55 P.M., the resident's physician said:
-He/she did expect that if it was the facility policy, the facility staff would use a gait belt when assisting the resident to stand or when having the resident stand when receiving care and for other mobility assistance.
-The only time he would think the facility wound not us a gait belt when assisting the resident with movement was if there were an emergency that required immediate movement, such as a fire.
Record review of the resident's physician progress note, dated 9/20/24, showed:
-He/she had been seen by the physician's Nurse Practitioner who asked the physician to follow up on the resident prior to the weekend due to a fall with a wound on his/her left buttock.
-He/she had a mild amount of pain.
-He/she was empirically (based on experience and observation) observation) started on Keflex earlier in the week.
-His/her wound was clean, had no drainage (fluid that comes out of a wound) - there was a little bit of blood but no erythema (redness caused by increased blood flow).
-His/her diagnosis was puncture wound of left buttock.
Record review of the resident's NP progress note, dated 9/25/24, showed:
-The resident had a puncture wound on his/her left buttock that he/she sustained during a fall and was followed by the wound care company.
-He/she had hemiparesis affecting his/her right side and was dependent on staff for toileting assistance, transfers and most of his/her activities of daily living (ADLs - dressing, grooming, bathing, eating, and toileting) due to unsteadiness on his/her feet.
-He/she had an unsteady gait (manner of walking), used a wheelchair and required staff assistance for transfers.
Record review of the wound care company documentation, dated 9/25/24, showed:
-The resident was new to the wound care company.
-He/she was being evaluated for a trauma wound to his/her left buttock.
-He/she reportedly fell while transferring and part of his/her wheelchair went into his/her rectum and tore open his/her left medial buttock.
-The wound company ordered wound care of calcium alginate and bordered gauze daily.
-His/her left open buttock wound measured 5.5 centimeters (cm) - a little over two inches by 2.1 cm (about ¾ inch) and had a depth of 0.4 cm - less than ¼ inch.
-His/her left buttock wound was full thickness (damage extends below all the skin layers and into/ beyond the tissue under his/her skin).
- His/her left buttock wound had undermining (a wound complication that occurs when the edges of a wound separate from the surrounding healthy tissue, creating a pocket under the wound surface) within the area from 12 o'clock to 6:00 o'clock (in the area uppermost toward his/her head to the are lowest toward his/her legs).
-The origin of his/her open wound on his/her left buttock was trauma (a severe injury that occurs suddenly due to sudden onset that requires immediate medical attention).
- It was anticipated he/she would need to be under the care of an advanced wound specialist for six to nine months.
-The wound care company changed his/her wound orders to calcium alginate (a wound dressing that absorbs excess moisture but maintains a moist environment that promotes wound healing and helps prevent/treat infections in wounds) and a super absorbent non adhesive non-bordered pad daily.
During an interview on 10/2/24 at 2:08 P.M., the resident's physician said:
-The resident had a wound on h
Apr 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
Deficiency F0561
(Tag F0561)
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 promote and facilitate one sampled resident's (Resident #3) self de...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to promote and facilitate one sampled resident's (Resident #3) self determination out of four sampled residents. The facility census was 76 residents.
Review of the facility's undated Nursing Home Resident's Rights showed:
-The law requires nursing home to promote and protect the rights of resident and stresses individual dignity and self-determination.
-Right to dignified existence.
--Be treated with consideration, respect, and dignity, recognizing each resident's individuality.
--Quality of life is maintained or improved.
--Exercise rights without interference, coercion, discrimination, or reprisal.
-Right to self-determination.
--Reasonable accommodation of needs and preferences.
--Participate in developing and implementing a person-centered plan of care that incorporates person and cultural preferences.
--Choice about designating a representative to exercise his/her rights.
--Request, refuse, and/or discontinue treatment.
-Right to be fully informed of .
--The type of care to be provided, and risks and benefits of proposed treatments.
--Changes of the plan of care, or in medical or health status.
-Rights during discharge/transfer.
--Receive 30-day written notice of discharge or transfer that includes, the reason, the effective date, the location going to, appeal rights and process for filing an appeal, and the name and contact information for the long-term care ombudsman.
--Preparation and orientation to ensure safe and orderly transfer or discharge.
Review of the facility's undated admission Policy showed:
-It is the policy of the corporation to admit and/or retain only those residents whose health care needs can be met through services of the facility and staff, in cooperation with outside resources under contract with the facility.
--Involuntary transfers or discharges.
--Except for the case of late payment or nonpayment, the facility shall notify the resident and the resident family member, surrogate or representative of the transfer and the reasons for the transfer as stated in the clinical record.
1. Review of Resident #3's Face Sheet showed he/she was admitted to the facility on [DATE] with diagnoses including dementia (a serious loss of cognitive ability in a previously unimpaired person, beyond what might be expected from normal aging) and major depressive disorder (a mental disorder characterized by a feeling of profound and persistent sadness or despair and is frequently accompanied by a loss of interest in things that were once pleasurable).
Review of the Resident's Power of Attorney (POA) document showed the resident's POA had been invoked with two physician signatures.
Review of the Resident's Quarterly Minimum Data Set (MDS- a federally mandated assessment instrument completed by facility staff for care planning) dated 2/26/24 showed the resident was moderately cognitively impaired.
Review of the resident's Nurse's Notes on 4/7/24 showed:
-It was reported the resident had his/her hand in another resident's pants.
-The resident placed in line of sight.
-The resident unable to recall the alleged incident.
-The Administrator was notified.
-The resident placed on one on one.
-The resident family/POA notified.
-The POA came to facility and spoke to Administrator.
During an interview on 4/7/24 at 11:00 A.M., the Administrator said the resident had only grabbed the elastic of the another residents' pants, pulled the elastic back and let go. The resident never placed his/her hand in the pants of the other resident. The resident had no known history of touching other residents inappropriately.
Review of the Resident's Social Service Progress Note dated 4/9/24 at 10:00 A.M. showed:
-The Social Service Designee (SSD) was asked by the facility Administrator to send referral to a locked same sex facility.
-Three referrals were made for the resident.
Review of the resident's Nurse's Note dated 4/7/24 through 4/15/24 showed he/she continued on one on one observation with no behaviors.
Review of the facility Investigation Report dated 4/16/24 showed:
-On 4/7/24 at approximately 11:45 A.M. the Administrator was notified the resident had his/her hand inside the waist band of another residents' clothing by the Director of Nursing (DON).
-Interventions include a one on one facility staff presence (one staff person assigned to one resident) with the resident.
-The resident was sent to the hospital for evaluation per physician request.
-The POA was upset and was informed the resident would remain on one on one supervision during waking hours while the Administrator worked on his/her investigation.
-In conclusion, no sexual abuse had occurred.
-Per the facilities Admission, Transfer and Discharge Policy and Procedure, a transfer or discharge was necessary to meet the resident's welfare, and the resident's welfare could not met in the facility.
-The resident would remain on a one on one supervision during waking hours until a same sex unit in another facility was located.
During an interview on 4/16/24 at 10:19 A.M. the resident POA said:
-He/she spoke to SSD on 4/8/24 and was told the steps were to notify the family, then Administrator of the allegations, then the Administrator appoints the DON or someone to investigate the allegations.
-When notified of the incident, he/she came to the facility right away, spoke with the Administrator and a nurse had given him/her the Administrator's phone number.
-The Administrator said there was video of the incident but refused to allow him/her to view the video.
-No facility staff had spoken to him/her about transferring the resident to another location and the facility staff were now not communicating at all with him/her.
-When he/she contacted the Administrator for further communication, the Administrator said it was his/her personal phone number and not to call it again.
-He/she had contacted the Ombudsman.
-The Administrator informed him/her the resident would be sent to a locked same sex facility.
-He/she contacted the hospital social worker who contacted the Administrator and reminded him/her they could not transfer the resident without communication with the POA.
-The hospital social worker was helping the POA seek alternate placement for the resident.
During an interview on 4/16/24 at 11:46 A.M. the resident said all questions should go to his/her POA.
During an interview on 4/16/24 at 12:28 P.M. the SSD said:
-He/she was responsible for admissions, discharges and transfers for the residents in the facility.
-He/she was actively working on transferring the resident.
-On 4/9/24 during the morning meeting the Administrator had said the POA would not be notified of the intent to transfer.
-The POA had not been notified of the referrals made or the intent to transfer the resident or the acceptance of the referral to another facility.
-The Administrator shut down all communication about the resident.
During an interview on 4/16/24 at 2:00 P.M. the DON said:
-He/she had reviewed the video and did not see the resident have his/her hands in another resident pants. The resident had no prior inappropriate behaviors.
-The resident was sent out for medical and psychological evaluation.
-He/she was not aware of a discharge notice or any discussion with the POA.
-The one on one supervision for the resident was not necessary and could be discontinued once a final decision had been made.
During an interview on 4/17/27 at 7:30 A.M. Certified Medication Technician (CMT) A said:
-He/she witnessed the incident of alleged sexual abuse with the resident.
-He/she did see contact between the residents, but could only assume the intentions were sexual in nature so he/she reported it.
During an interview on 4/17/24 at 7:44 A.M. the POA said:
-The facility called local law enforcement on 4/8/24 related to the allegations the day after the alleged incident. The resident did not understand why the police were called.
-LPN A told the POA the resident cried when the police came and did not know why law enforcement was called.
-The staff told him/her on 4/8/24 they were not talking to him/her and then called to notify him/her they were sending the resident to the hospital.
-The resident was unable to process what had happened and he/she was concerned about the resident's overall safety.
-If the resident was in his/her right mind, he/she would feel like his/her whole world was going down.
-None of the allegations was the character of the resident and the resident would be blown away by the allegations.
-The resident was made to feel less than a person and as a criminal.
-The whole situation would negatively impact the resident dignity if he/she was in his/her right mind.
-He/she had made multiple attempts to communicate with the facility.
-He/she was concerned about the outcome of the investigation and not aware of his/her rights to locate alternate placement for the resident.
-On 4/8/24 he/she brought an advocate to the facility to speak with the Administrator, and when any questions were asked the Administrator would shut them down. The Administrator did not want to answer questions about their protocol.
-When he/she tried to get clarification as to what actually happened, the Administrator stated he/she was not going to tell the POA anything.
-The DON agreed the facility did not have to answer any of the POA's questions.
-On 4/9/24 the POA and his/her spouse went again to try to speak to the Administrator.
-They attempted to communicate their desire to relocate the resident due to the adversarial environment, but needed to know what had happened to find appropriate placement.
-The Administrator refused to give them any information and stated that he/she would have to finish the investigation. The Administrator stated he/she was going to send the resident to an same sex facility.
-The POA was afraid the Administrator was going to ship the resident somewhere without his/her permission.
-He/she felt the resident and the resident's representative should have a choice on where the resident goes.
-He/she was willing to work with the facility to transfer the resident to an appropriate facility.
During an interview on 4/17/24 at 9:14 A.M. Advocate A said:
-On 4/8/24 he/she went with the POA to mediate conversation with the facility.
-When they spoke with the SSD about protocols (steps for the investigation), the SSD told them nothing had been done at that time.
-They asked to speak with the Administrator.
-He/She reiterated to the Administrator the need for a conversation about what happened and how to work together to get the resident moved.
-The Administrator stated he/she was not obligated to speak to the POA, it was just a document and he/she didn't have to recognize it.
-He/she was upset the Administrator said the facility did not have to honor the POA and that the Administrator didn't need the POA because he/she was going to have the resident sign the discharge papers.
During an interview on 4/17/24 at 10:25 A.M. LPN A said:
-On 4/7/24 there was an allegation of sexual abuse involving the resident made by CMT A.
-He/she was called by the DON and told to put the resident on one on one supervision.
-The incident occurred in the hallway and wanted to start the investigation knowing there were cameras in that area.
-He/she was instructed to notify the resident family of the alleged sexual behavior while waiting for further instruction from the Administrator.
-He/she questioned speaking to the family before the video footage was viewed, but the Administrator wanted the family contacted anyway.
-The DON said the Administrator said not to talk to the family about anything.
-The resident continued to be on one on one supervision .
-The Administrator said he/she had five days to make decisions, it has been more than five days and the resident still has one on one supervision.
During an interview on 4/17/24 at 5:24 P.M. Officer A said there was no credibility to the allegations of sexual abuse and did not require further law enforcement investigation.
During an interview on 4/22/24 at 1:58 P.M. the ADON said:
-His/her role since the alleged incident has been to ensure there was appropriate staffing for the resident's one on one supervision.
-He/she was told the resident would be on one on one supervision until further notice by the Administrator and the DON; there was no explanation for the one on one or why it was until further notice.
-In the past when a resident has been on one on one, it is removed after 72 hours, then 15 minute checks are done, so he/she doesn't understand why the resident was still on one on one.
During an interview on 4/22/24 at 2:51 P.M. the DON said:
-The facility's escalation of the situation was due to the resident's family overreaction.
-The reason they had not been talking to the family was because they were not supposed to share opinions and the facility plan of correction.
-It was the facility's responsibility to keep the family informed; as far as he/she was concerned the family has been informed.
During an interview on 4/22/24 at 3:28 P.M. the Administrator said:
-The goal was to transfer the resident to a same sex facility.
-The reason was because if the resident's starting to change mentally, he/she questioned if the resident was safe around other residents of the opposite sex.
-He/she was not able to determine the resident's thought processes.
-His/her first thought the interaction was sexual in nature because the resident touched Resident #2's nightgown and waist band.
-The resident interaction was not sexual abuse.
-He/she was continuing the one on one, and the plan to transfer the resident to prevent behaviors with another resident.
-He/she with the Regional Director was the investigator of the allegations and would determine when the one to one was no longer needed, the situation was resolved and everyone was safe.
-One on one is someone sitting relatively close, keeping close contact with the person to make sure everyone is well protected.
-He/she was responsible to provide 30 day notice in writing when a discharge was initiated to the resident and/or resident representative when needs could no longer be met.
-He/she instructed the SSD to make referrals to alternative placement.
-He/she had not spoken to the family/POA since the alleged incident on 4/7/24 and informed them at that time the resident may go to an same sex locked facility.
-The resident enjoyed conversation with staff and the one to one had no negative outcome.
-He/she was unsure if the resident understood he/she was a safety risk and required someone with him/her at all times.
During an interview on 4/23/24 at 12:15 P.M. the Ombudsman said:
-The Administrator contacted him/her because he/she wanted to issue a discharge notice to the resident.
-The administrator was not communicating with POA.
-The facility was not respecting the rights of the resident through the discharge process or communicating with the resident legal authorized representative, the POA.
MO00234382
Aug 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
Safe Environment
(Tag F0584)
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 a comfortable environment with air temperatu...
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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 a comfortable environment with air temperatures at or below 81 ºF (degrees Fahrenheit) on 8/21/23 and 8/22/23 in the following resident use areas: the 100 Hall, 200 Hall, 300 Hall, 400 Hall, 500 Hall corridors, the South and North Dining Rooms; Resident rooms 408, 405, 406, 403, 404, 402, 507, 512, 513, 514, 204, 201, 206, 208, 206, 208, 207, 109, 108, 107, 106, 105, and 102; failed to implement its plan to monitor temperatures when the temperatures went above 81ºF; and to evacuate residents from those rooms or cease using the common spaces when the temperatures were above 81ºF. This failure affected all residents who resided in or used those areas, including 7 sampled residents (Residents #3, #5, #6, #8, #10, #13 and #16) out of 17 sampled residents. The facility census was 76 residents.
The Administrator was notified on 8/22/23 at 8:23 P.M., of the Immediate Jeopardy (IJ) which began on 8/22/23. The IJ was removed on 8/24/23, as confirmed by surveyor onsite verification.
Review of the facility's Hot Weather and Policy and Procedure dated 11/30/17, showed:
- It was the policy of the corporation to implement measures to assure the comfort and safety of resident and to prevent heat stress of residents during periods of extreme heat.
- Measures shall be implemented by departments under the overall direction of the Administrator when conditions in the living, activity or dining areas reach conditions exceeding a heat index/apparent temperature of 80 ºF (degrees Fahrenheit).
- Residents most susceptible to adverse effects of the heat shall be determined and monitored.
- All residents are to be observed by nursing staff for effects of heat related stress.
- Residents displaying such stress shall be immediately reported to the charge nurse.
- Outside temperatures may be monitored through local radio or weather television station or by a facility thermometer outside the facility.
- If the inside temperature and/or humidity exceeds a heat index apparent temperature 80 ºF, he charge nurse should take action to cool the living , dining, and activity areas of the facility.
- Nursing staff shall observe all residents for symptoms of heat stress.
- Those residents determined to be high risk shall be monitored closely.
- Regular cleaning of air conditioning filters monthly is essential.
- Maintenance personnel shall be responsible for ensuring air conditioning units are operational at all times
- No section about monitoring temperatures of resident occupied spaces including resident rooms and resident common areas.
Review of the Loss of Air Conditioning Policy section of the Facility's Emergency preparedness binder reviewed on 7/23, showed:
Overview: A high temperature/heat situation can be a true emergency, particularly, to an elderly population.
The ability to regain power, access portable air conditioning units or other mitigating efforts should be considered at the onset of the situation.
General Actions Applicable to all staff:
- Use fans and portable air conditioning units, if available. Notify staff member responsible for infection control.
- Keep blinds, curtains, drapes etc. closed in areas of building that receive direct sunlight.
Open doors and windows, as necessary, to take advantage of available breezes.
- Avoid activities that may excite residents or require physical exertion.
- Keep residents out of direct sunlight.
- Turn off lights as well as their heat producing appliances whenever possible.
- Provide plenty of liquids for residents and staff.
- Monitor vital signs of residents and staff.
Administrator/Incident Commander:
- Activate the Command Center by notify the Section Chiefs and Command center personnel by phone or pager notification indicating a Code Alert as necessary.
- Ensure all essential departments are functioning .
- Meet with Plant Operations to assess situation and develop an action plan.
- Consider relaxing the dress code and consider reduction of work time rotating staff in high heat producing areas.
Continue to monitor the situation through appropriate department heads.
-Monitor the television or radio for important heat-related announcements.
-Determine the need to report situation to local or other regulatory agency.
- Report any heat related illnesses /deaths to the Department of Public Health immediately.
Determine if any evacuation is necessary
1. Record review of data from the National Weather Service Kansas City Missouri showed:
-On 8/20/23 a high temperature of 98 ºF.
-On 8/21/23 a high temperature of 99 ºF.
-August 19-25 Historic Heatwave: Starting on 8/19/23 well-above normal temperatures impacted the central part of the United States, kicking off a heatwave that has not been experienced in the region in recent history. This stretch of hot weather was accompanied by extremely high dewpoints, with frequently reached the upper 70s to middle 80s across the entire area. The combination of the extreme heat and the excessively high dewpoints led to heat indices from August 19 through August 25 to rise to 120-130 degrees.
Observation of the facility temperatures on 8/21/23, 12:12 P.M. to 12:42 P.M., showed:
-There were 21 residents in the south dining room.
-The south dining room and hall corridors had the following temperatures:
--The south dining room was 82.6 ºF.
--The 100 hall corridor was 82.1 ºF.
--The 200 hall corridor was 82 ºF.
--The 300 hall corridor was 82.7 ºF.
--The 400 hall corridor was 83.5 ºF.
--The 500 hall corridor was 83.4 ºF.
During an interview on 6/21/23 at 2:22 P.M., the Business Office Manager (BOM) said there was no one who was monitoring air temperatures within the facility.
Review of data from the National Weather Service Local Data for Kansas City Missouri showed on 8/22/23, a high temperature of 95 ºF.
Observations of facility temperatures on 8/22/23, 12:10 P.M. to 12:37 P.M., showed:
-The south dining room and hall corridors had the following temperatures:
--The south dining room was 82.4 ºF.
-The 100 hall corridor was 82.9 ºF.
--The 400 hall corridor was 85.0 ºF.
--The 500 hall corridor was 83.8 ºF.
During an interview on 8/22/23 at 12:37 P.M., the Housekeeping Supervisor said it has been hot in the facility since, 8/18/23 and he/she has not seen anyone monitor temperatures in the corridors or the resident rooms.
During an interview on 8/22/23 at 12:42 P.M., Licensed Practical Nurse (LPN) A said:
-He/she had worked as a Charge Nurse in the facility on Friday 8/18/23, Sunday 8/20/23, and Tuesday 8/22/23, and it had felt hot in the facility during those days.
-He/she did not see anyone monitor temperatures in the back (South) Unit.
During an interview on 8/22/23 at 1:03 P.M., the Administrator said:
-Central Air conditioning was not available in any of the corridors of the facility.
-The system that was used to track the corridor temperatures, was installed before his/her time.
-He/she was not sure the system was used to keep track of the corridor temperatures in the facility was calibrated (correlate the readings of (an instrument) with those of a standard in order to check the instrument's accuracy).
-If the temperatures of the resident rooms, were comfortable for the residents as opposed to the temperatures of the corridors, than that was where the residents should be.
Review of Resident #3's quarterly Minimum Data Set (MDS-a federally mandated assessment tool completed by the facility for care planning), dated 5/10/23, showed the resident was cognitively intact with a Brief Interview for Mental Status (BIMS-an assessment tool that shows a score between 3 of 15 which shows the resident's mental status, determines the resident's attention, orientation and ability to register and recall new information) of 15 out of 15.
Observation and interview on 8/22/23 at 2:19 P.M., Resident #3 said:
-He/she was not comfortable in his/her room.
-Sometimes he/she had trouble sleeping due to the increased temperatures.
-His/her room was 86.4 ºF and the window air conditioning unit was not blowing out cool air.
Review of Resident #5's quarterly MDS dated [DATE], showed the resident had severe cognitive impairment with a BIMS of 6 out of 15, had clear comprehension of others and made himself/herself understood by others.
Observation and interview on 8/22/23 at 3:55 P.M., Resident #5 said:
-He/she had felt hot in his/her room for several days.
-His/her room was 82.5 ºF and the window air conditioning unit did not blow out cool air.
Review of Resident #6's annual MDS dated [DATE], showed the resident was cognitively intact with a BIMS of 15 out of 15, had clear comprehension of others and made himself/herself understood by others.
Observation and interview on 8/22/23 at 3:57 P.M., Resident #6 said:
-He/she had felt warm in his/her room and for the two days prior to 8/22/23, he/she had to place a cool wash cloth on his/her face to go to sleep.
-His/her room was 82.5 ºF and the window air conditioning unit did not blow out cool air.
Review of Resident #8's quarterly MDS dated [DATE] showed the resident was cognitively intact, with a BIMS of 12 out of 15, made himself/herself understood and usually understood others.
Observation and interview on 8/22/23 at 4:07 P.M., Resident #8 said:
-His/her room was always real warm any day of the week.
-His/her room was 82.9 ºF.
Review of Resident #10's quarterly MDS dated [DATE], showed the resident had severe cognitive impairment with a BIMS of 7 out of 15, usually understood others and made himself/herself understood by others.
Observation and interview on 8/22/23 at 4:13 P.M., Resident #10 said:
-He/she felt hot in his/her room for a few days.
-His/her room was 84.0 ºF and the window air conditioning unit did not blow out cool air.
Review of Resident #13's quarterly MDS dated [DATE], showed the resident was cognitively intact with a BIMS of 15 out of 15, made himself/herself understood to others and had clear comprehension of others.
Observation and interview on 8/22/23 at 4:32 P.M., Resident #13 said
-He/she felt hot in his/her room in the past few days.
-His/her room was 82.2 ºF and the window air conditioning unit in his/her room was not blowing out cool air.
Observation and interview on 8/22/23 at 4:37 P.M., Restorative Aide (RA) A said:
-room [ROOM NUMBER] was very warm.
-The resident was in the restroom.
-The room temperature was 86.1 ºF and the window air conditioning unit was not blowing out cool air.
Observation on 8/22/23 from 4:45 P.M. through 6:30 P.M., showed the absence of facility staff monitoring air temperatures throughout the facility.
Observation on 8/22/23 at 6:31 P.M., showed the Housekeeping Supervisor had just purchased two probe thermometers from a local hardware supply store.
Observation with the Housekeeping Supervisor on 8/22/23, 6:37 P.M. to 8:45 P.M., showed:
-There were 3 residents in in the south dining room.
-The south dining room and occupied resident rooms had the following temperatures:
--The south dining room was 84.0 ºF;
--Resident room [ROOM NUMBER] was 87.6 ºF;
--Resident room [ROOM NUMBER] was 88.5 ºF;
--Resident room [ROOM NUMBER] was 87.4 ºF;
--Resident room [ROOM NUMBER] was 86.7 ºF;
--Resident room [ROOM NUMBER] was 85.6 ºF;
--Resident room [ROOM NUMBER] was 84.0 ºF;
--Resident room [ROOM NUMBER] was 85.1 ºF;
--Resident room [ROOM NUMBER] was 83.8 ºF;
--Resident room [ROOM NUMBER] was 85.6 ºF;
--Resident room [ROOM NUMBER] was 86.0 ºF;
--Resident room [ROOM NUMBER] was 84.2 ºF;
--Resident room [ROOM NUMBER] was 85.6 ºF;
--Resident room [ROOM NUMBER] was 82.0 ºF;
--Resident room [ROOM NUMBER] was 82.4 ºF;
--Resident room [ROOM NUMBER] was 87.1 ºF;
--Resident room [ROOM NUMBER] was 85.6 ºF;
--Resident room [ROOM NUMBER] was 82.8 ºF;
--Resident room [ROOM NUMBER] was 81.3 ºF;
--Resident room [ROOM NUMBER] was 81.5 ºF.
Record review of data from the National Weather Service Local for Kansas City Missouri showed on 8/23/23, a high temperature of 95 ºF and on 8/24/23, a high temperature of 99 ºF.
Review of Resident #16 MDS dated [DATE] showed the resident had moderate cognitive impairment with a BIMS of 8 out of 15, had clear comprehension of others and made himself/herself understood by others.
During an interview on 8/24/23 at 1:21 P.M., Resident #16 said:
-He/she felt very uncomfortably hot in his/her room until 8/23/23 when the facility personnel placed a fan in his/her room with the air conditioning unit.
-He/she was not aware any facility staff member checked the temperature in his/her room.
During an interview on 8/24/23 at 1:47 P.M., the Regional Director of Maintenance said:
-He/she had been out of the building since 8/18/23.
-The maintenance staff at the facility should have known to monitor air temperatures.
-Several of the air conditioning units had coils (the component in the air conditioning system which absorbs the heat from the air which works with a condenser coil to complete the heat exchange process that produces cool air) which needed to be cleaned at least once per month during the summer months.
-He/she found several coils that were not cleaned.
-Air temperatures should be monitored in resident rooms if it began to feel hot within the facility.
During an interview on 8/24/23 at 11:57 A.M., the Administrator said:
-If the facility staff noticed anything above comfortable temperatures the facility staff should monitor those temperatures every shift.
-He/she would have expected facility staff to monitor air temperatures in the resident rooms even if he/she were not in the building.
NOTE: At the time of the abbreviated survey, the violation was determined to be at the immediate 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 remove the IJ 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 to be taken to address Class I violation(s).
MO 00223229
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Pharmacy Services
(Tag F0755)
Could have caused harm · This affected multiple residents
Based on interview and record review, the facility failed to establish a system of disposition of controlled drugs, when staff failed to sign their initials on the narcotic count sheet and the Medicat...
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Based on interview and record review, the facility failed to establish a system of disposition of controlled drugs, when staff failed to sign their initials on the narcotic count sheet and the Medication Administration Record (MAR) after administering narcotic (a variety of substances that dulled the senses and relieved pain) medications to four sampled residents (Residents #1, #2 #3 and #4); and the facility failed to ensure Norco (a combination of 5 milligrams of Hydrocodone and 325 milligrams of Acetaminophen used to relieve moderate to severe pain) was secured from loss; and to maintain a narcotic count sheet to show the administration of Norco doses for one sampled resident (Resident #1). The facility census was 76 residents.
Record review of the facility's Policy entitled Controlled Substances, revised on 10/07 and reviewed on 3/16/23, showed:
Policy: It was the policy of the facility that all drugs listed as schedule II drugs were subject to specified handling, storage, disposal and record keeping.
Responsibility: All Licensed Nurses.
Procedure:
-At the time a Controlled Substance was delivered, the Charge Nurse and the Delivery Person would count the controlled substance together to verify the count. If the controlled substance count of an item being delivered was in error the nurse would note the error, notify the pharmacist, refuse delivery of the substance and reorder the prescription.
-If the Controlled Substance count was correct, a control sheet for each prescription would be initiated. The control sheet would contain the following:
--Resident's name.
--Ordering physician name.
--Issuing Pharmacy.
--Name and strength of drug.
--Quantity received.
--Date and time received.
-All Schedule II drugs must be administered and recorded on a disposition sheet as follows:
--Date and time of administration.
--Signature of nurse administering drug.
--Quantity on hand/balance left.
-If a resident refused a dose of a controlled drug, or it was not given for any reason, the medication dose must be destroyed. The dose must be destroyed in the presence of two (2) Licensed Nurses and documented on the disposition sheet as destroyed.
-The drugs in Schedule II (and those in other schedules which have been restricted and stored in the Controlled Substance cabinet) would be counted and reconciled by the nurse coming on duty with the nurse that was going off duty. Those records should be retained for at least one (1) year.
-NOTE: There was no mention in the policy that the person who administered narcotics should sign the narcotic count sheet and the MAR.
Record review of the Facility's Policy, titled Missing Controlled Substance, revised on 10/07 and reviewed on 3/16/23, showed:
-It was the policy of this facility to prevent the loss of controlled substances and vigorously investigate incorrect inventory of controlled drugs, medications or pharmaceuticals reported by pharmacists, physicians or licensed nurses.
Responsibility: All Licensed Nurses monitored by the Director of Nursing (DON).
Procedure:
1. All controlled drugs would be counted by the oncoming and outgoing nurse at the change of each shift as per the Controlled Drug Policy and Procedure.
2. The count of each controlled medication would be maintained on the drug disposition sheet for each individual medication as per the controlled substance policy.
3. The oncoming and outgoing Licensed Nurse would sign the controlled substance inventory sheet each change of shift to signify the count was completed and was accurate.
4. Should the count prove to be incorrect compared to actual inventory at any time, report would be made to the Director of Nursing immediately.
5. An immediate inventory of controlled substances would be taken by the Director of Nursing and Administrator.
6. The Director of Nursing would report the discrepancy to the Pharmaceutical Consultant upon verification that the count was inaccurate.
7. The Director of Nursing would investigate the use and disposition of controlled medication to determine the nature of the discrepancy including the following parameters:
-Determine the time frame for the discrepancy by comparing doses delivered at last delivery and doses on hand.
-Compare the medication administration record with the drug disposition record to verify correct documentation of medication administration.
-Determine the number of missing doses by comparing doses administered as evidenced by drug disposition record and medication administration record compared to number at last delivery.
-When possible, verify with resident the date, time and amount of drug administered.
-Note and interview the last Licensed Nurse documented administration of the drug.
During an interview on 8/21/23 at 12:54 P.M., the Interim Director of Nursing (DON) said each time a nurse took out a narcotic medication they needed to document in two places; the controlled substance record and the as needed administration record.
1a. Review of Resident #1's Physician's Order Sheet (POS), dated July 2023, showed:
-He/she was admitted with diagnoses which included hyperlipidemia (an elevated level of lipids such as cholesterol and triglycerides - in the blood), cancer, peripheral vascular diseases (PVD--a slow and progressive circulation disorder which narrows or block blood vessels), depression (a mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life), and diabetes mellitus (a metabolic disease, involving inappropriately elevated blood glucose levels).
-A physician's Order, dated 5/26/23, to administer one tablet of morphine sulfate (schedule II medication used to help relieve moderate to severe pain) orally, every four hours as needed.
Review of the resident's Narcotic Count Sheet, dated 7/12/23 to 7/29/23, and the resident's medication administration record, dated 7/12/23 to 7/29/23, showed:
-A quantity of 42 tablets of morphine sulfate was received on 7/12/23.
-On 7/12/23 one dose was removed for administration to the resident at 8:00 P.M., without a corresponding signature on the as needed MAR.
-On 7/13/23, one dose was removed for administration to the resident at 12:00 A.M., without a corresponding signature in the as needed MAR.
-On 7/13/23, one dose was removed for administration to the resident at 9:00 P.M., without a corresponding signature in the as needed MAR.
-On 7/14/23, one dose was removed for administration to the resident at 5:00 A.M., without corresponding signature in the as needed MAR.
-On 7/15/23, one dose was removed for administration to the resident at 9:30 P.M., without a corresponding signature in the as needed MAR.
-On 7/16/23, one dose was removed for administration to the resident at 5:00 A.M., without a corresponding signature in the as needed MAR.
-On 7/17/23, two doses were removed for administration to the resident at 8:00 P.M., without a corresponding signature in the as needed MAR.
-On 7/19/23, one dose was removed for administration to the resident at 6:30 P.M., without a corresponding signature in the as needed MAR.
-On 7/19/23, one dose was removed for administration to the resident at 10:30 P.M., without a corresponding signature in the as needed MAR.
-On 7/20/23, one dose was removed for administration to the resident at 6:45 P.M., without a corresponding signature in the as needed MAR.
-On 7/20/23, one dose was removed for administration to the resident at 11:00 P.M., without a corresponding signature in the as needed MAR.
-On 7/22/23, one dose was removed for administration to the resident at 11:00 P.M., without a corresponding signature in the as needed MAR.
-On 7/23/23, one dose was removed for administration to the resident at 4:00 A.M., without a corresponding signature in the as needed MAR.
-On 7/23/23, one dose was removed for administration to the resident at 6:30 P.M., without a corresponding signature in the as needed MAR.
-On 7/23/23, one dose was removed for administration to the resident at 11:30 P.M., without a corresponding signature in the as needed MAR.
-On 7/24/23, one dose was removed for administration to the resident at 3:30 A.M., without a corresponding signature in the as needed MAR.
-On 7/24/23, one dose was removed for administration to the resident at 6:00 P.M., without a corresponding signature in the as needed MAR.
-On 7/24/23, one dose was removed for administration to the resident at 11:00 P.M., without a corresponding signature in the as needed MAR.
-On 7/25/23, one dose was removed for administration to the resident at 5:00 A.M., without a corresponding signature in the as needed MAR.
-On 7/25/23, one dose was removed for administration to the resident at 6:30 P.M., without a corresponding signature in the as needed MAR.
-On 7/25/23, one dose was removed for administration to the resident at 11:00 P.M., without a corresponding signature in the as needed MAR.
-On 7/26/23, one dose was removed for administration to the resident at 5:00 A.M., without a corresponding signature in the as needed MAR.
-On 7/26/23, one dose was removed for administration to the resident at 7:30 P.M., without a corresponding signature in the as needed MAR.
-On 7/27/23, one dose was removed for administration to the resident at 12:00 A.M., without a corresponding signature in the as needed MAR.
-On 7/27/23, one dose was removed for administration to the resident at 6:00 A.M., without a corresponding signature in the as needed MAR.
-On 7/28/23, one dose was removed for administration to the resident at 2:00 A.M., without a corresponding signature in the as needed MAR.
-On 7/28/23, one dose was removed for administration to the resident at 6:00 A.M., without a corresponding signature in the as needed MAR.
-On 7/28/23, one dose was removed for administration to the resident at 6:00 P.M., without a corresponding signature in the as needed MAR.
-On 7/29/23, one dose was removed for administration to the resident at 2:00 A.M., without a corresponding signature on the as needed MAR.
Review of the resident's Narcotic Count Sheet, dated 8/2/23 to 8/8/23, and the resident's medication administration record, dated 8/2/23 to 8/8/23, showed:
-A quantity of five tablets of morphine sulfate was received on 8/2/23.
-On 8/7/23, one dose was removed for administration to the resident at 9:10 P.M., without a corresponding signature on the as needed MAR.
-On 8/8/23, one dose was removed for administration to the resident at 1:10 A.M., without a corresponding signature on the as needed MAR.
-On 8/8/23, one dose was removed for administration to the resident at 5:10 A.M., without a corresponding signature on the as needed MAR.
-On 8/8/23, one dose was removed for administration to the resident at 4:45 P.M., without a corresponding signature on the as needed MAR.
Review of the resident's Narcotic Count Sheet, dated 8/11/23 to 8/20/23, and the resident's medication administration record, dated 8/11/23 to 8/20/23, showed:
-A quantity of 60 tablets of morphine sulfate was received on 8/11/23.
-On 8/13/23, one dose was removed for administration to the resident at 7:30 P.M., without a corresponding signature on the as needed MAR.
-On 8/14/23, one dose was removed for administration to the resident at 7:05 P.M., without a corresponding signature on the as needed MAR.
-On 8/15/23, one dose was removed for administration to the resident at 4:45 P.M., without a corresponding signature on the as needed MAR.
-On 8/16/23, one dose was removed for administration to the resident at 8:00 P.M., without a corresponding signature on the as needed MAR.
-On 8/18/23, one dose was removed for administration to the resident at 4:00 A.M., without a corresponding signature on the as needed MAR.
-On 8/20/23, one dose was removed for administration to the resident at 8:00 A.M., without a corresponding signature on the as needed MAR.
During a phone interview on 8/21/23 at 4:23 P.M., Certified Medication Technician (CMT) A, said:
-He/she passed the resident's medication and did not document his/her signature on the MAR on 8/7/23, 8/13/23, 8/14/23, 8/15/23, and 8/16/23, because he/she was hurried.
-It was only the week prior to the week of 8/21/23, that he/she was informed that he/she needed to document his/her signature on both the Narcotic Count Sheet and the as needed MAR.
During an interview on 8/24/23 at 12:27 P.M., Licensed Practical Nurse (LPN) D said he/she passed medication to the resident, but forgot to place his/her signature on the MAR on 8/20/23, because there were so many things happening at that time.
1b. Review of Resident #1's Hospice Physician's Order Sheet (POS), dated 6/1/23, showed a physicians' order, dated 5/29/23, to administer one tablet Norco 5-325 via mouth every 6 hours as needed for pain.
Review of the Patient Dispensed History from the Hospice Agency, dated 7/12/23, showed:
-56 doses of Norco were delivered to the facility on behalf of the resident.
-The medications were received by LPN D.
Review of the resident's POS, dated July 2023, showed:
-A physician's order, dated 5/27/23, to administer one Norco 5-325 tablet via mouth four times per day as needed and not to exceed a total of 3 grams of Acetaminophen within 24 hours.
Review of the resident's Medication Administration Record (MAR), dated July 2023, showed Norco was administered to the resident on 7/1/23 and 7/16/23.
Observation with LPN C on 8/21/23 at 11:13 A.M., showed:
-He/she(LPN) C did not find a pack or container with the remainder of the Norco medication for the resident.
-He/she did not find a narcotic count sheet, when he/she looked in the binder which contained the narcotic count sheets that were with that medication cart.
During an interview on 8/21/23 at 11:13 A.M., LPN C said:
-The date of the last documented dose of Norco administered to the resident, was on 7/16/23.
-He/she could not find a pack or container of the remainder of the medications for the resident in his/her medication cart.
-He/she was unable to find a narcotic count sheet for the Norco for the resident.
During an interview on 8/21/23 at 11:28 A.M., LPN B said:
-When he/she gave the dose of Norco to the resident on 7/16/23, there were multiple doses left.
-He/she was not sure exactly how many doses were left.
During an interview on 8/21/23 at 12:54 P.M., the Interim DON said each time the nurse took out a medication they needed to document that action in two places, the narcotic count sheet and the MAR. The facility staff was not aware the medications were not there until the state surveyor brought the information to them.
During an interview on 8/24/23 at 1:00 P.M., the Administrator said:
-He/she thought there would be a stop order after 14 days for the administration of the Norco to the resident.
-He/she did not see anything on the physician's order for a stop date to stop administering the Norco to the resident.
-If he/she could find out how many doses the resident had left, then he/she could find out how many doses may be missing.
-If the remainder of the resident's medications were destroyed, facility staff should fill out the section of the narcotic count sheet which pertained to disposal of medications and obtained two signatures from licensed staff to show where a medication was destroyed.
During a phone interview on 8/29/23 at 10:27 A.M., the Hospice Agency DON said:
-If hospice patients had a narcotic, the facility should inform the hospice agency the medications needed to be re-ordered at least 24-48 hours in advance.
-56 tablets of Norco were delivered to the facility on July 12 at 2:35 P.M.
-The medications are delivered in a bubble pack.
-No one from the facility informed hospice that medications were missing.
During a phone interview on 8/29/23 at 8:27 P.M., LPN E said:
-He/she looked in several places after discussing this issue of missing medications the previous week.
-He/she did not find the resident's narcotic count sheet.
-He/she did not find the verification count sheet (a sheet where an oncoming nurse verified with the outgoing nurse to ascertain how many narcotics were in the medication cart).
-He/she was not able to find the proof of delivery sheet (a document that was signed by the person at the facility who received a medication delivery from the pharmacy) for the resident's Norco.
-He/she could not find proof that any particular staff person took any of the medications.
-The DON and the Assistant Director of Nursing (ADON) were supposed to count the narcotics on a weekly basis to verify the bubble packs of medications and the narcotic count sheets were correct and matched.
-The Proof of Delivery sheet came from pharmacy during the delivery of medications to the facility, was supposed to go to medical records.
-He/she had noticed the narcotic count sheets were placed into the DON's box instead of the medical records box.
-Any kind of paperwork that was associated with a resident, should go to medical records.
-The misplacement of paperwork could explain why the paperwork regarding the medications for the resident, could not be located.
-There was a black box at the nurse's station labeled medical records that paperwork should go into.
-No one knew that any medications were missing.
-The narcotic count sheet and the verification sheet, which pertained to the resident, were both missing.
-There was no official investigation to look into any missing medications.
-No one knew that any medications were missing until the state surveyor was asking questions and wanting to see the medication cards for the resident.
During a phone interview on 8/30/23 at 2:53 P.M., LPN B said:
-At the time he/she administered the Norco to the resident medications were in a bubble pack.
-There were at least 3 days of medications left in the bubble pack.
-He/she signed out the medication on the Narcotic Count Sheet.
-He/she did not remember going to administer Norco to the resident after 7/16/23 and medication was not there.
-He/she did not know the Norco was missing.
During a phone interview on 9/5/23 at 1:51 P.M., LPN D said:
-A Narcotic Count Sheet for the Norco should have been started.
-The narcotic count sheet for the resident's Norco was missing.
-He/she did not remember receiving the medications on 7/12/23.
-He/she remembered that bubble packs of Norco for that resident were in the medication cart at one time.
2. Review of Resident #2's POS, dated August 2023, showed:
-He/she was admitted with diagnoses which included high blood pressure, Chronic Obstructive Pulmonary Disease (COPD-a group of diseases that cause airflow blockage and breathing-related problems), generalized muscle weakness, chronic respiratory failure, urine retention and unspecified chronic pain.
-A physician's Order, dated 7/22/23, to administer one tablet of oxycodone (schedule II medication an Opioid pain medication used to treat moderate to severe pain) immediate-release orally, every four hours as needed.
Review of the resident's Narcotic Count Sheet, dated 8/14/23 to 8/21/23, and the resident's medication administration record, dated 8/14/23 to 8/21/23, showed:
-A quantity of 30 tablets of oxycodone immediate-release was received on 7/12/23.
-On 8/15/23, one dose was removed for administration to the resident at 11:30 P.M., without a corresponding signature on the as needed MAR.
-On 8/17/23, one dose was removed for administration to the resident at 9:30 A.M., without a corresponding signature on the as needed MAR.
-On 8/18/23, one dose was removed for administration to the resident at 4:10 A.M., without a corresponding signature on the as needed MAR.
-On 8/18/23, one dose was removed for administration to the resident at 10:00 A.M., without a corresponding signature on the as needed MAR.
-On 8/18/23, one dose was removed for administration to the resident at 11:40 P.M., without a corresponding signature on the as needed MAR.
-On 8/19/23, one dose was removed for administration to the resident at 9:00 A.M., without a corresponding signature on the as needed MAR.
-On 8/19/23, one dose was removed for administration to the resident at 1:00 P.M., without a corresponding signature on the as needed MAR.
-On 8/20/23, one dose was removed for administration to the resident at 7:20 A.M., without a corresponding signature on the as needed MAR.
-On 8/20/23, one dose was removed for administration to the resident at 1:00 P.M., without a corresponding signature on the as needed MAR.
3. Review of Resident #3's POS, dated August 2023, showed:
-He/she was admitted with diagnoses which included acute encephalopathy (a group of disorders which affects how the brain works), COPD, Chronic Diastolic heart failure (a condition in which the heart's main pumping chamber (left ventricle) becomes stiff and unable to fill properly), high blood pressure, PVD, and hiatial hernia (occurs when part of the stomach protrudes up into the chest through the sheet of muscle called the diaphragm).
-A physician's Order dated 7/22/23 to administer one tablet Norco (schedule II medication, hydrocodone and acetaminophen combination that was used for relief of severe pain) every six hours as scheduled for pain.
Review of the resident's Narcotic Count Sheet, dated 7/16/23 to 7/28/23, and the resident's medication administration record, dated 7/16/23 to 7/28/23, showed:
-A quantity of 30 tablets of Norco was received on 7/16/23.
-On 7/18/23, one dose was removed for administration to the resident at 8:00 P.M., without a corresponding signature on the MAR.
-On 7/20/23, one dose was removed for administration to the resident at 8:00 P.M., without a corresponding signature on the MAR.
-On 7/22/23, one dose was removed for administration to the resident at 8:00 P.M., without a corresponding signature on the MAR.
-On 7/23/23, one dose was removed for administration to the resident at 8:00 P.M., without a corresponding signature on the MAR.
-On 7/25/23, one dose was removed for administration to the resident at 800 P.M., without a corresponding signature on the MAR.
-On 7/26/23, one dose was removed for administration to the resident at 12:00 P.M., without a corresponding signature on the MAR.
-On 7/26/23, one dose was removed for administration to the resident at 6:00 P.M., without a corresponding signature on the MAR.
-On 7/27/23, one dose was removed for administration to the resident at 12:00 P.M., but was documented as being removed for administration on 7/26/23 on the Narcotic Count Sheet not on 7/27/23.
-On 7/27/23, one dose was removed for administration to the resident at 6:00 P.M., but was documented as being removed for administration on 7/26/23 on the Narcotic Count Sheet not on 7/27/23.
-On 7/28/23, one dose was removed for administration to the resident at 12:00 A.M., without a corresponding signature on the MAR.
Review of the resident's Narcotic Count Sheet, dated 8/9/23 to 8/13/23, and the resident's medication administration record, dated 8/9/23 to 8/13/23, showed:
-A quantity of 15 tablets of Norco was received on 8/9/23.
-On 8/10/23, one dose removed for administration to the resident at 8:00 P.M., without a corresponding signature on the MAR
During an interview on 8/21/23 at 11:03 A.M., LPN E said:
-LPN D signed out four doses of Norco on 7/26/23 on the Narcotic Count Sheet, but only signed for 2 doses on the MAR on 7/26/23.
-LPN D actually worked on 7/27/23, but he/she did not place the correct date of 7/27/23 on the Narcotic Count Sheet for 2 of the doses.
During an interview on 8/24/23 at 12:30 P.M., LPN D said:
-He/she did not place the correct date on the Resident's Narcotic Count Sheet for the dates of 7/26/23 and 7/27/23.
-He/she had been trained that when he/she administered narcotics, that signatures were to be documented on the Narcotic Count Sheet and on the MAR.
4. Review of Resident #4's POS, dated August 2023, showed:
-He/she was admitted with diagnoses which included osteoarthritis (also called degenerative joint disease; it occurs when the cartilage within a joint begins to break down and the underlying bone begins to change), general pain, high blood pressure, PVD, cardiomyopathy (disease of the heart muscle that makes it harder for the heart to pump blood to the rest of the body) and degenerative disc lumbar spine (a disease which occurs when the spinal disks (rubbery cushions) wear down).
-A physician's Order dated 7/22/23 to administer one tablet of Norco every eight hours as needed for pain.
Review of the resident's Narcotic Count Sheet, dated 8/2/23 to 8/14/23, and the resident's medication administration record, dated 8/2/23 to 8/14/23, showed:
-A quantity of 30 tablets of Norco was received on 7/17/23.
-On 8/1/23, one dose was removed for administration to the resident at 3:30 P.M., without a corresponding signature on the MAR.
-On 8/1/23, one dose was removed for administration to the resident at 9:00 P.M., without a corresponding signature on the MAR.
-On 8/2/23, one dose was removed for administration to the resident at 7:15 A.M., without a corresponding signature on the MAR.
-On 8/2/23, one dose was removed for administration to the resident at 8:00 P.M., without a corresponding signature on the MAR.
-On 8/3/23, one dose was removed for administration to the resident at 8:30 A.M., without a corresponding signature on the MAR.
-On 8/5/23, one dose was removed for administration to the resident at 8:30 A.M., without a corresponding signature on the MAR.
-On 8/5/23, one dose was removed for administration to the resident at 5:00 P.M., without a corresponding signature on the MAR.
-On 8/6/23, one dose was removed for administration to the resident at 8:30 A.M., without a corresponding signature on the MAR.
-On 8/6/23, one dose was removed for administration to the resident at 4:30 P.M., without a corresponding signature on the MAR.
-On 8/7/23, one dose was removed for administration to the resident at 7:40 A.M., without a corresponding signature on the MAR.
-On 8/10/23, one dose was removed for administration to the resident at 2:00 P.M., without a corresponding signature on the MAR.
-On 8/10/23, one dose was removed for administration to the resident at 8:00 P.M., without a corresponding signature on the MAR.
-On 8/11/23, one dose was removed for administration to the resident at 8:00 P.M., without a corresponding signature on the MAR.
-On 8/12/23, one dose was removed for administration to the resident at 8:00 A.M., without a corresponding signature on the MAR.
-On 8/12/23, one dose was removed for administration to the resident at 2:00 P.M., without a corresponding signature on the MAR.
-On 8/12/23, one dose was removed for administration to the resident at 9:30 P.M., without a corresponding signature on the MAR.
-On 8/13/23, one dose was removed for administration to the resident at 8:00 P.M., without a corresponding signature on the MAR.
During an interview on 8/24/23 at 12:34 P.M., LPN D said he/she passed the resident's medication and did not sign the MAR for the administration of Norco to the resident on 8/5/23, 8/6/23 and 8/14/23.
5. Review of the sign in sheet for an in-service entitled signing out MARs and Treatment Administration Records (TARs) dated 7/25/22, showed:
-LPN D was the Instructor for the in-service.
-Topics covered during the in-service included:
--When giving a medication or completing a treatment, the MAR or the TAR must be signed, there were to be no holes in either the MAR or the TAR.
Review of in-services dated 7/25/22, 9/10/22, 11/10/22, 11/25/22, 1/10/23, 2/7/23, 2/10/23, 2/25/23, 2/25/23, 3/7/23, 3/10/23, 4/25/23, 5/25/23 and 6/10/23, showed:
-There was nothing that indicated any of the in-services covered proper documentation of narcotics.
-Signing the MAR, TAR and Narcotic Count Sheet was not indicated as being discussed during any of the in-services.
During an interview on 8/22/23 at 10:11 A.M., LPN E said:
-He/she knew medications were to be signed out on the narcotic count sheet and the MAR.
-He/she was not able to say why the MAR was not signed by other staff when they gave medications to the residents.
During an interview on 8/22/23 at 12:43 P.M., LPN A said:
-The administration of the narcotic should be documented in two places.
--The Narcotic Count Sheet and the As Needed MAR.
-The most current order should be on the as needed MAR.
During an interview on 8/22/23 at 1:17 P.M., the Administrator said he/she expected employees to document their signatures on both the MARs and the Narcotic Count Sheet.
MO00222831
Jul 2023
23 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0557
(Tag F0557)
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, showed the facility failed to ensure the dignity of one sampled resident (Re...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, showed the facility failed to ensure the dignity of one sampled resident (Resident #17) was protected by failing to ensure the resident's catheter (tube known as a urinary catheter is inserted into the bladder through the urethra to allow urine to drain from the bladder for collection) bag was in a privacy bag out of 18 sampled residents. The facility census was 77 residents.
1. Review of the Resident #17's Face Sheet showed he/she was admitted on [DATE], with diagnoses including spinabifida (a birth defect in which a developing baby's spinal cord fails to develop properly), high blood pressure and neurogenic bladder (to lack bladder control due to a brain, spinal cord or nerve problem).
Review of the resident's admission Minimum Data Set (MDS-a federally mandated assessment tool to be completed by facility staff for care planning) dated 6/5/23, showed the resident:
-Was alert and oriented.
-Needed extensive to total assistance with transferring, bathing, dressing, grooming, and toileting.
-Used a urinary catheter for bladder continence.
Observation and interview on 7/21/23 at 8:24 A.M., showed the resident was sitting up in his/her wheelchair in the dining room by the medication cart. His/her catheter bag was hanging below his/her bladder but it was not in a privacy bag and there was yellow fluid inside of the catheter bag. The resident said he/she did not know that his/her catheter bag was not in a privacy bag. Nursing staff looked and said that they must have forgotten to place the catheter bag in the privacy bag and he/she would take the resident to his/her room to get one.
Observation and interview on 7/21/23 at 9:30 A.M., showed the resident was sitting in his/her wheelchair in his/her room. The resident's catheter bag was in a privacy bag at the side of his/her wheelchair and was below his/her bladder. The resident said:
-When the nurse brought him/her back to his/her room, he/she took the privacy bag that was on the side of his/her bed and placed it on his/her wheelchair and put the catheter bag inside.
-He/she did not know what happened to the privacy bag that was on the side of his/her wheelchair staff usually placed his/her catheter in the privacy bag on his/her wheelchair when he/she was up.
-He/she did not know that his catheter bag was not in the privacy bag while he/she at breakfast.
-He/she did not want everyone to see the urine in his/her catheter bag and it was embarrassing.
During an interview on 7/21/23 at 9:23 A.M., Certified Medication Technician (CMT) B said:
-The resident's catheter bag should be below the bladder at all times.
-Even during transfers, it should be below the bladder and it should not ever be at or above the bladder otherwise the urine will not drain and could possibly put the resident at risk for a urinary infection.
She said the resident's catheter bag should be kept covered at all times for the resident's dignity.
During an interview on 7/21/23 at 10:05 A.M., Licensed Practical Nurse (LPN) C said:
-The resident's catheter bag should always be in a privacy bag. There should be one on the bed and one on the resident's wheelchair.
-If the privacy bag is being washed or changed, the nursing staff can obtain another clean bag from the medication room-nursing aides can ask the nurse for it.
-It was important for the resident's dignity to be maintained at all times and this resident was especially particular about it.
During an interview on 07/21/23 at 1:30 P.M., with the Administrator and Director of Nursing (DON), the DON said:
-The DON said that he/she did not know what the facility protocol was for staff regarding the placement of the catheter bag during a transfer.
-The DON and Admin said the resident's catheter should be in a dignity bag at all times and if the privacy bag is being laundered or removed, the nursing staff should get another clean privacy bag from the utility room.
-Both said they educated staff on where the bags were located.
-The resident's privacy bag was laundered.
-Staff should have obtained a new bag-they have disposable privacy bags they could use.
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 ensure a transfer notice was sent to the Ombudsman (individuals who...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure a transfer notice was sent to the Ombudsman (individuals who help residents in long-term care facilities maintain and improve their quality of life by helping ensure their rights are preserved and respected) when one sampled resident (Resident #36) was transferred to the hospital out of 18 sampled residents. The facility census was 55 residents.
A facility policy related to Ombudsman notification was requested and not received at the time of exit.
1. Review of Resident #36's face sheet showed he/she re-admitted to the facility on [DATE] with the following diagnoses:
-Unspecified Dementia (a progressive organic mental disorder characterized by chronic personality disintegration, confusion, disorientation, stupor, deterioration of intellectual capacity and function, and impairment of control of memory, judgement, and impulses) unspecified severity with behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety.
-Personal history of Cerebral Infarction (ischemic stroke- occurs as a result of disrupted blood flow and oxygen to the brain) with residual deficits.
Review of the resident's nurses notes dated 4/18/23 showed the resident was transferred to the hospital on that date.
Review of the resident's April hospital transfer notification to the Ombudsman was requested and not received.
During an interview on 7/19/23 at 9:47 A.M. the Administrator said:
-He/she did not realize that transfer notifications needed to be made to the Ombudsman.
-He/she did not think that the facility did Ombudsman notifications prior to him/her being at the facility.
During an interview on 7/21/23 at 9:08 A.M. Licensed Practical Nurse (LPN) E said he/she was unsure of who was responsible for notifying the Ombudsman of transfer and discharges.
During an interview on 7/21/23 at 9:53 A.M. LPN B said he/she was unsure of who was responsible for notifying the Ombudsman of transfer and discharges.
During an interview on 7/21/23 at 1:30 P.M. the Director of Nursing (DON) said he/she did not know what that notification was and thought it was a part of the bed hold process.
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** 2. Review of Resident #36's face sheet showed he/she re-admitted to the facility on [DATE] with the following diagnoses:
-Unspec...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Review of Resident #36's face sheet showed he/she re-admitted to the facility on [DATE] with the following diagnoses:
-Unspecified Dementia (a progressive organic mental disorder characterized by chronic personality disintegration, confusion, disorientation, stupor, deterioration of intellectual capacity and function, and impairment of control of memory, judgement, and impulses) unspecified severity with behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety.
-Personal history of Cerebral Infarction (ischemic stroke- occurs as a result of disrupted blood flow and oxygen to the brain) with residual deficits.
Review of the resident's bed-hold for the transfer to the hospital on 4/18/23 was requested and not received at the time of exit.
During an interview on 7/20/23 at 11:13 A.M. the Administrator said:
-The bed-holds were not getting sent out with each transfer out of the facility.
-There would not be a copy of the bed-hold to receive for the resident.
During an interview on 7/21/23 at 9:08 A.M. LPN E said:
-Nurses were responsible for sending bed-holds when residents transferred out of the facility.
-He/she knew that residents needed a copy of the bed-hold before leaving the facility and thought that an additional copy needed to be given to the Human Resources and the Ombudsman (individuals who help residents in long-term care facilities maintain and improve their quality of life by helping ensure their rights are preserved and respected).
-He/she was not sure if all bed-holds were getting completed.
-He/she had sent out bed-holds with residents before and would normally place a copy of it in the resident's chart.
During an interview on 7/21/23 at 9:53 A.M. LPN B said:
-The nurses were responsible for sending bed-holds when residents transferred out of the facility.
-The facility, in general, was really bad at getting the bed-holds completed.
-There was not a back-up system in place if a nurse did not complete the bed-hold prior to the resident transferring out of the facility.
-He/she thought that Social Services should also be involved in the process to ensure bed-holds were getting completed.
During an interview on 7/21/23 at 10:05 A.M., LPN C said:
-When the resident goes to the hospital, the nurse gets the bed hold form and the transfer sheet.
-They educate the resident on the bed hold and then they have the resident sign it or the responsible party sign it if they are in the building.
-The nurse was supposed to make a copy of the bed hold form, send the original with the resident, provide a copy to the Business Office Manager and put a copy in the resident's medical record.
-The Ombudsman came in monthly and they wanted to see the list of discharges during the month.
-The Business Office Manager would have that documentation to provide.
-The nurse would also have the resident or responsible party sign a bed hold if the resident was going on any long or short term visits to home/relative which happened on occasion.
During an interview on 7/21/23 at 1:30 P.M., the Director of Nursing (DON) and the Administrator said:
-The nurses knew they were supposed to complete a bed hold when residents went to the hospital.
-Whomever was sending the resident out to the hospital was supposed to complete the bed hold form and make a copy, send the original form with the resident, and place the copy in the resident's medical record.
-If they have no one to sign the bed hold form, they would speak with the responsible party and make a note in the social service section of the resident's medical record that they notified the resident's responsible party of the transfer and bed hold.
Based on interview and record review, the facility failed to ensure the resident and/or responsible party were informed of and signed a bed hold for two sampled residents (Resident #16 and Resident #36) out of 18 sampled residents. The facility census was 77 residents.
Review of the facility's Bed Hold policy and procedure dated showed:
-Upon leaving the facility for admission to a hospital or for therapeutic leave, a resident shall be guaranteed a bed in this facility upon return if the resident's condition is such that he/she is appropriate for the level of care provided by the facility and a Medicaid eligible resident was not in the hospital or on leave for more than 10 consecutive days; or the Medicaid resident or responsible party has agreed to pay the public aid rate for days in excess of the 10 days, or a private pay resident has insured a hold on a bed through reimbursement at the current private pay rate.
-The resident, resident's family or legal representative will be given the appropriate Notice of Bed Hold Policy at the time of discharge or therapeutic leave if possible, but the notice will be given no longer than 24 hours after discharge or initiation of leave.
1. Review of Resident #16's Face sheet showed he/she was admitted on [DATE], with diagnoses including arthritis, heart disease, high blood pressure, low iron, psychosis (a severe mental condition in which thought and emotions are so affected that contact is lost with external reality), and encephalopathy (a disease in which the functioning of the brain is affected by some agent or condition, such as viral infection, or toxins in the blood).
Review of the resident's admission quarterly Minimum Data Set (MDS-a federally mandated assessment tool to be completed by facility staff for care planning) dated 4/16/23, showed the resident:
-Was alert and oriented with minimal confusion.
-Needed limited assistance with transfers, grooming and toileting and needed extensive assistance with hygiene, and bathing.
-He/she used a wheelchair for mobility.
Review of the resident's Nurses Notes showed:
-4/6/23, the resident was laying in his/her bed and the nursing assistant attempted to change the resident and the resident was not responding. The nursing assistant informed the charge nurse who assessed the resident and found the resident would open his/her eyes but would not respond to any verbal commands. The nurse took the resident's vital signs (blood pressure, respirations, temperature and oxygen level) and the resident had no signs or symptoms of distress. The nurse notified the physician who gave an order to send the resident to the hospital for evaluation and treatment. The nurse attempted to notify the resident's family with no answer and no ability to leave a message. The nurse documented attempts were made to notify two additional family contacts that was unsuccessful.
-There was no documentation showing the bed hold was completed or sent with the resident to the hospital. There was no documentation stating if the nurse ever contacted the resident's family regarding his/her hospitalization or bed hold.
-4/11/23, the resident was re-admitted to the facility with new order for an antibiotic for pneumonia and a follow up chest scan due to a mass found in his/her upper left lobe. The nurse documented he/she attempted to contact the resident's family unsuccessfully. The resident was able to make his/her needs known and did not complain of any distress, pain or discomfort. His/her vital signs were within normal limits. A message was left for the resident's physician.
Review of the resident's Medical Record showed there was no documentation showing the resident or his/her responsible party had been given, educated on or signed a bed hold at anytime during the resident's hospitalization. There were no notes showing the resident's family were ever notified that the resident was in the hospital or that they were educated on the bed hold or provided the bed hold to sign and return.
During an interview on 7/20/23 at 1:22 P.M., Licensed Practical Nurse (LPN) F said:
-Usually when a resident went to the hospital, the nurse was supposed to explain and have the resident sign the bed hold form.
-Once the resident (if capable) signed the form, the nurse then was to make a copy of the form and send the form with the resident to the hospital.
-If they were sending the resident out on an emergency, they may not have the form signed, but they would always notify the resident's responsible party or family of the bed hold.
-He/she was not sure if the bed hold was sent to the responsible party or family for a signature.
-A copy of the bed hold was supposed to be placed in the resident's medical record.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Comprehensive Assessments
(Tag F0636)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility failed to ensure a Quarterly Minimum Data Set (MDS - a federally mandated as...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility failed to ensure a Quarterly Minimum Data Set (MDS - a federally mandated assessment instrument completed by facility staff for care planning) was accurate and submitted on time for one sampled resident (Resident #25) out of 18 sampled residents. The facility census was 77 residents.
Review of the facility's policy, dated 11/1/17, titled Comprehensive Assessments/MDS showed:
-Staff were to complete a Quarterly MDS on each resident within 92 days of the previous MDS.
-Staff were responsible for ensuring the MDS was accurate.
1. Review of Resident #25's face sheet showed he/she was admitted on [DATE] with a diagnoses of acute (short term) and chronic (long term) respiratory failure (a condition in which your blood doesn't have enough oxygen or has too much carbon dioxide).
Review of the resident's MDS submissions showed:
-A Quarterly MDS dated [DATE].
-No further MDS's submitted.
-NOTE: At time of exit, it had been 96 days since the last Quarterly MDS had been submitted.
Review of the resident's Quarterly MDS, dated [DATE], showed:
-The resident was severely cognitively impaired.
-The resident did not use oxygen.
-The resident had respiratory failure.
Review of the resident's Treatment Administration Record (TAR), dated April 2023, showed staff documented oxygen at 2 liters per minute was given at bedtime on 4/15/23.
Review of the resident's Physician's Orders Medications and Treatments, dated 7/31/23, showed:
-An order for oxygen at 2 liters per minute to keep oxygen saturation level greater than 90% for comfort was obtained on 10/18/22.
-An order for oxygen at 2 liters per minute at bedtime was obtained on 11/29/22.
During an interview on 7/21/23 at 1:29 P.M., the Director of Nursing (DON) said:
-The MDS was to reflect oxygen if it was used during the lookback period (7 days).
-He/she expected the MDS to be accurate and reflect the resident's care.
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** 2. Review of Resident #4's face sheet showed he/she admitted to the facility with the following diagnoses:
-Dementia (a progress...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Review of Resident #4's face sheet showed he/she admitted to the facility with the following diagnoses:
-Dementia (a progressive organic mental disorder characterized by chronic personality disintegration, confusion, disorientation, stupor, deterioration of intellectual capacity and function, and impairment of control of memory, judgement, and impulses).
-Chronic Obstructive Pulmonary Disease (COPD- a disease process that decreases the ability of the lungs to perform ventilation).
-Neuropathy (disease or dysfunction of one or more peripheral nerves, typically causing numbness or weakness).
Review of the resident's annual MDS dated [DATE] showed:
-He/she was severely cognitively impaired.
-He/she needed limited assistance (resident highly involved in activity; staff provide guided maneuvering of limbs or other non-weight bearing assistance) with dressing.
-He/she needed extensive assistance (resident involved in activity, staff provide weight-bearing support) with personal hygiene.
Review of the resident's care plan dated 6/16/23 showed he/she had a self-care deficit and needed supervision and/or assist to complete quality care to complete ADLs.
Observation on 7/17/23 at 9:40 A.M. showed the resident was wearing a red [NAME] printed top with dark red pants.
Observation on 7/18/23 at 10:00 A.M. of the resident showed:
-He/she was wearing the same shirt from 7/17/23.
-He/she was wearing brown pants with crumbs on them from breakfast.
Observation 7/19/23 at 8:52 A.M. of the resident showed the resident had wet crumbs, possibly from oatmeal on his/her face around the mouth and his/her pants.
Observation on 7/19/23 at 3:00 P.M. of the resident showed:
-He/she was in the same spot from lunch.
-He/she had cake crumbs and a dirty spoon in his/her lap.
-His/her lunch tray was still in front of him/her.
-His/her shirt had some stains on the front from lunch.
Observation on 7/20/23 at 11:23 A.M. of the resident showed:
-He/she had stains on the front of his/her shirt from breakfast.
-He/she had crumbs on his/her mouth and chin from breakfast.
During an interview on 7/21/23 at 8:51 A.M., CNA D said:
-Everyone on the unit was responsible for keeping the residents clean and groomed, but it was the aides responsibility for the most part.
-If he/she saw a resident who was dependent on care staff for grooming with crumbs on his/her face, he/she would get a wet wipe and clean them from the resident's face.
-He/She took the resident around dinner time on 7/19/23 to get cleaned up from lunch as the resident had cake all over himself/herself.
-The resident liked to maintain his/her independence at meal times and would usually get food all over himself/herself.
-He/She always tried to ensure residents were not wearing the same clothes from day-to-day, but would verify that he/she was following the resident's preferences.
During an interview on 7/21/23 at 9:30 A.M., CMT D said:
-CNAs are primarily responsible for ensuring residents were clean and groomed, but everyone in the facility could help.
-If he/she were to find a resident with crumbs or stains on them from a meal he/she would assist the resident back to their room and get them cleaned up.
-Additionally, if it were that residents shower day he/she would try to get that resident into the shower.
-He/She would ask in report if certain residents needed to be changed out of their clothes from the day before.
During an interview on 7/21/23 at 9:53 A.M. LPN B said:
-All care staff were responsible for keeping the residents clean and groomed.
-He/she would expect staff to assist residents to their rooms and help clean the resident however they needed if a resident were to have crumbs and/or stains on them after meals.
-If no care staff were available to delegate that task to, he/she would assist the residents as needed to keep them clean and groomed.
During an interview on 7/21/23 at 1:30 P.M. the DON said:
-Care staff were expected to keep all residents clean and groomed.
-He/she would expect staff to clean all residents who needed assistance after meals if they had crumbs on them and if needed, take them back to the room to get changed.
-CNAs were responsible for ensuring residents do not have on the same clothes day-to-day and if there were issues, then they would be care planned.
Based on observation interview and record review, the facility failed to ensure baths were given and documented twice weekly for one sampled resident (Resident #34) and to provide one sampled resident (Resident #4) proper Activities of Daily Living (ADL) care necessary to maintain grooming needs out of 18 sampled residents. The facility census was 77 residents.
A policy on ADL care was requested and not received at the time of exit.
1. Review of Resident #34's Face Sheet showed he/she was admitted on [DATE], with diagnoses including spondylosis (arthritis of the spine), Parkinson's Disease (a progressive disease of the nervous system marked by tremor, muscular rigidity, and slow, imprecise movement), history of stroke, diabetes, high blood pressure, history of falls and abnormal gait (balance).
Review of the resident's admission Minimum Data Set (MDS-a federally mandated assessment tool to be completed by facility staff for care planning) dated 5/11/23, showed the resident:
-Was alert and oriented.
-Needed extensive assistance with bathing, dressing, grooming, and toileting.
-Had limited mobility and range of motion on one side of his/her lower extremity.
-Used a wheelchair for mobility and did not ambulate.
Review of the resident's Care Plan dated 5/11/23, showed the resident had self-care deficits and needed supervision or assistance to complete quality care and was poorly motivated to complete activities of daily living (bathing, dressing, grooming, hygiene). This was due to muscle weakness, poor safety awareness at times, unsafe gait and verbal voicing needing assistance. Staff was to:
-Assist the resident in providing/completing cares as needed, offer supervision and verbal cues, segment tasks as needed to allow the resident to complete tasks in an efficient time safely.
-Provide sufficient time to complete tasks, avoid rushing the resident, but keep on task to avoid dignity issues.
-Provide privacy and dignity and remind resident as needed to pull curtains ads keep closed during times of undress.
-Invite to programs that enhance mobility skills, exercise group, invite to programs per previous and current interests.
-Discuss with family/resident concerns related to loss of independence, encourage the resident to vent feelings.
-NOTE: The care plan did not show that the resident refused bathing or had any behaviors around taking a bath or shower.
Review of the resident's bathing sheets that were requested for June 2023 and July 2023, showed the facility was unable to provide bath sheets for June 2023. Bath sheets provided for July 2023 showed the resident received a bath on 7/4/23 and 7/7/23.
Oobservation and interview on 7/17/23 at 1:32 P.M., showed the resident was sitting in his/her wheelchair and had just come out of the bathroom. He/she said:
-He/she did need assistance from staff for bathing, but he/she could do some things for himself/herself.
-He/she was supposed to receive a shower on Tuesdays and Fridays of every week, but he/she had not received a shower in six days (he/she did not know why).
-Last Tuesday was when he/she last had a shower.
-He/she wanted a shower because he/she sweated a lot and needed to take one.
-The nursing staff did not try to re-schedule a shower for him/her during the week or in the evening or weekend to make it up.
-He/she did not refuse showers.
-He/she did not always get a shower twice weekly, but they were supposed to receive showers twice weekly.
Observation and interview on 7/18/23 at 8:54 A.M., showed the resident was sitting in his/her electric wheelchair in his/her room watching television. He/she was wearing different clothes and said he/she was doing fine-had a good breakfast and was having a good day so far today. He/she said he/she did not have a shower yesterday or today, he/she just changed his/her clothes (today was his/her shower day).
Observation and interview on 7/19/23 at 8:18 A.M., showed the resident was sitting in his/her wheelchair with the same clothes on as on Tuesday (yesterday), but he/she was not odorous and the resident said:
-He/she did not receive his/her shower yesterday.
-He/she wanted a shower and it was not right that he/she has not had one in over a week.
-He/she did not know why he/she did not get his/her shower yesterday.
-No one offered to give it today or at another time.
Observation and interview on 7/19/23 at 3:00 P.M., showed the resident was sitting in the dining area in his/her wheelchair with other peers eating ice cream. He/She was dressed in a different shirt and pants. He/She said that he/she finally received a shower that afternoon and he/she was happy.
During an interview on 7/20/23 a 1:22 P.M., Licensed Practical Nurse (LPN) F said:
-Residents were supposed to receive baths/showers twice weekly.
-They had a bath/shower aide that gave baths/showers to residents.
-If the bath/shower aide was unavailable, the Certified Nursing Assistants (CNAs) were supposed to give the baths/showers.
-Once the residents received their bath/shower, the CNA was supposed to complete the resident's bath/shower sheet and document what they did on it and any skin issues they may find on it. They then give the bath sheet to the nurse for their signature and it was turned into the Director of Nursing (DON).
-Residents had scheduled bath days and they (the nurses) had a list so they knew who was supposed to receive a bath/shower.
-If a bath/shower was not given, they should try to schedule it for the following day.
-Usually when he/she was working, the residents who were supposed to receive bath/shower on that day do receive them.
During an interview on 7/21/23 at 9:23 A.M., Certified Medication Technician (CMT) B said:
-The residents were supposed to get two baths/showers per week.
-Sometimes they had a bath aide and sometimes they didn't, but on days they don't have one, the aides were supposed to complete their own showers.
-Whatever the day shift did not get done, they were supposed to finish on the night shift.
-They don't have showers scheduled on the night shift.
-If they miss the resident's scheduled bath day, they were supposed to receive it the following day or on another day that week.
-Some residents would refuse baths.
-Some of the residents who were on hospice would only accept baths/shower from the hospice staff.
-They would complete bed baths for some residents who refused to get up for showers.
-Resident #34 was not on Hospice and usually did not refuse bathing. if offered a bath he/she would accept it.
During an interview on 7/21/23 at 1:30 P.M., the DON said:
-Nursing staff were responsible for ensuring residents needs were met, and they were clean.
-Residents were offered showers twice weekly. If they do not get their shower the following shift should offer and try to get the shower completed.
-The nurse aide was supposed to complete the bath sheet and give it to the charge nurse.
-The charge nurse had a daily sheet showing who got showers and they knew who was supposed to receive a shower daily.
-The charge nurse should be monitoring to ensure the residents had received a bath/shower.
-If a resident refused a bath/shower, the nurse aide was supposed to still complete the bath sheet showing the shower was refused.
-Whether the resident took a shower or not, they should still turn in a bath sheet showing the bath/shower was attempted and why it was not given.
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 observation, interview and record review, the facility failed to ensure to complete and document a comprehensive Weekly...
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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 to complete and document a comprehensive Weekly Skin Assessment for two sampled residents (Resident #62 and Resident #64) who were high risk and had current treatments for skin breakdown, out of 18 sampled residents. The facility resident census of 77 residents.
Review of the facility Policy and Procedure Skin Condition Monitoring revised 3/16/23 showed:
-Licensed nursing staff were responsible for providing monitoring, treatment and documentation of any resident with skin abnormalities.
-Documentation of the skin abnormality must occur upon identification and at least weekly thereafter until the area were healed. The documentation must include the following: size, shape, depth, odor, color and condition of the tissue.
-Treatment and response to treatment. Observe and measure pressure ulcers (localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction) at regular intervals.
-Prevention techniques that were used for the resident.
1. Review of Resident #62 admission Face Sheet showed he/she had diagnosis of Osteomyelitis (a serious infection of the bone that can be either acute or chronic) of the right heel and foot.
Review of the the resident's admission nursing assessment dated [DATE] showed:
-The resident had a scabbed area on the right heel.
-Had no pressure wounds (injuries to skin and underlying tissue resulting from prolonged pressure).
-He/she was unable to stand.
Review of the resident's admission Minimum Data Set (MDS-a federally mandated assessment instrument completed by facility staff for care planning) dated 4/10/23, showed he/she:
-Had a Brief Interview of Mental Status (BIMS) score of 15 indicating no cognitive impairment.
-Was at risk for skin breakdown.
-Had no unhealed pressure wounds.
Review of the resident Braden Scale (a pressure sore/wound risk assessment instrument) for predicting pressure ulcers risk dated 4/26/23 showed the resident had a score of 14 (score 16 or less indicated the resident was at high risk for developing pressure ulcers).
Review of the resident's Treatment Administration Record (TAR) dated 6/1/23 to 6/31/23 showed the resident:
-Had a physician's order for skin protocol, chart skin condition on back of the TAR weekly on Monday's (order date of 4/3/23).
-Had no documentation on the back of the TAR and no nursing initials that the resident's skin had been assessed on 6/5/23, 6/11/23 and 6/19/23.
Review of the resident's Physician Order Sheet (POS) dated 7/1/23 to 7/31/23 showed the resident had physician order dated 4/3/23 for nursing staff to following skin protocol and chart skin condition on back of the resident's TAR weekly on Mondays.
Review of the resident's wound Evaluation & Management Summary dated 7/6/23 showed the resident:
-Had a recommendation for intravenous (IV) antibiotic after a discussion with the resident and Director of Nursing (DON) due to wound infection.
-Had a right heel Stage IV pressure wound (Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed. Often includes undermining and tunneling.).
-On 7/5/23 lab work confirmed the resident had Osteomyelitis (a serious infection of the bone that can be either acute or chronic) at his/her wound site.
-The wound measurement was length (L) of 2.9 centimeter (cm) by width (W) of 2.4 cm by depth (D) of 0.1 cm.
-The wound progress had deteriorated due to Osteomyelitis and the resident was nutritionally compromised.
Review of the resident's TAR weekly skin monitoring dated 7/2023 showed:
-Nursing to follow the facility's skin protocol chart skin condition on back of resident's TAR weekly on Monday's.
-On 7/9/23, the resident had no documentation on the back of the TAR for skin assessment that day and had no nursing initials indicating the resident's skin had been assessed that day.
Review the resident's medical record dated 5/1/23 to 7/18/23 showed:
-He/she had no nursing documentation of detailed weekly skin assessments.
-He/she had no nursing documentation of weekly wound assessments.
-He/she had no nursing documentation of detailed description of the right heel pressure ulcer.
Review of the resident Shower/Abnormal Skin Report showed:
-On 7/4/23, the resident had a wound and circled the body part on the report (left foot area) being treated noted by Certified Nursing Assistant (CNA) who provided shower.
-On 7/11/23 no changes noted by the CNA.
-Noted: Both shower sheets were signed off by the nurse and had no detailed skin assessment documented.
Review of the resident's Discharge MDS dated [DATE], showed he/she:
-Had a BIMS score of 15 indicating he/she had no cognitive impairment.
-Was at risk for skin breakdown.
-Was discharged with a Stage IV pressure ulcer.
The resident's wound care was not observed due to he/she was admitted to the hospital on [DATE] for abnormal labs findings.
2. Review of Resident #64's admission Face Sheet showed he/she had a diagnosis of Osteomyelitis fn the buttocks area.
Review of the resident's admission MDS dated [DATE], showed he/she was:
-Cognitively Intact.
-Totally dependent of facility staff for all cares.
-At risk for skin breakdown, had one Stage IV pressure wound upon admission.
Review of the resident's Significant Change MDS dated [DATE], showed he/she:
-Had a right below knee amputation.
-Was at risk for pressure wounds and had three Stage IV pressure wounds.
Review of the resident's TAR dated 7/1/23 to 7/31/23, showed
-Physician's order for skin protocol, chart skin condition on back of the TAR weekly on Friday's.
-Documentation on back of the TAR dated 7/7/23 showed: the resident continued with wounds to his/her sacrum (large, triangular bone at the base of the spine and at the upper and back part of the pelvic cavity) area and a bunch of small open areas along the buttocks, with a tunneled wound on the right buttocks. Wound to genital area related to Foley catheter (a tube with retaining balloon passed through the urethra into the bladder to drain urine) usage. The resident had treatment in place for all the wounds.
-The resident had no documentation for 7/14/23 on the front of the TAR indicated by nursing initials as completed or on back of TAR with a nursing assessment note.
Review of the resident's POS dated 7/1/23 to 7/31/23 showed:
-Physician's order for skin protocol, chart skin condition on back of the TAR weekly on Friday's.
-Minocycline 100 milligrams (mg) (antibiotic) by mouth two times a day for 90 days due to diagnosis of Osteomyelitis (ordered 7/18/23).
Review of the resident's Shower/Abnormal Skin Report showed on 7/4/23, the resident had a wound and circled the body part on the report (bottom area) by the CNA who provided showers. It was signed off by the nurse and had no detailed skin assessment documented.
Review of the resident's wound Management & Summary Report dated 7/6/23 showed the resident:
-On 6/14/23, had a confirmed diagnosis of Osteomyelitis, wound progress deteriorated due to infection, and the resident being nutritionally compromised.
-On his/her right buttock had a Stage IV pressure wound.
-The wound measurement was (L) of 3.9 cm by (W) of 2.0 cm by (D) of 2.0 cm.
-The sacrum wound was a stage III (a full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle is not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining or tunneling) with measurements of (L) of 9.5 cm by (W) of 10.5 cm by (D) of 0.2 cm
-Pressure wound to genital area was healing and then reopened on 6/29/23. The wound measurements were the (L) of 1.0 cm by (W) of 0.8 cm by (D) of 0.1 cm and undermining (Tunneling occurs) of 3.1 cm at one o'clock (placement of around wound)
Review of the resident's Shower/Abnormal Skin Report showed on 7/11/23 showed: no changes noted by the CNA. It was signed off by the nurse and had no detailed skin assessment documented.
Review of the resident's Shower/Abnormal Skin Report dated 7/14/23 showed:
-Handwritten documentation showing the wound had opened back up and new wounds near the old ones on the resident's left and right side of his/her buttocks, the nurse was notified. (Written by the CNA who provided care).
-No detailed nursing assessment of the findings were completed or documented on the Skin Report or in the residents nursing notes.
-The CNA and nursing staff signature documented and dated the Skin Report sheet.
-No Charge nurse response documented on the skin report.
During an interview on 7/17/23 at 1:07 P.M., the resident said:
-He/she was currently getting treatment for and infection of the wound on his/her bottom area and had been on several antibiotics for wound infections.
-He/she recently had a right below knee amputation, due to a diabetic infection of the right lower leg.
-He/she did see the wound physician at least weekly.
During interview on 7/20/23 at 1:40 P.M., the Wound Physician said:
-The resident had potential of having a [NAME] wound (wound seen last stage of life) but after further assessment and tunneling it was not.
-The resident had comorbidities that increased his/her risk for skin break down and came to facility with wounds.
-The resident had lost his/her right leg due to a diabetic infection about a month ago.
-The resident now had Osteomyelitis in his/her sacrum wound.
-The genital wound was much better, it was split prior to admission.
-The resident's poor protein intake and poor wound healing, ongoing diarrhea contributed to his/her poor wound healing and risk for infections.
He/she documented findings on form and then transcribed notes and would send a summary of the comprehensive assessment and visit to the facility for the resident's medical record.
Observation on 7/20/23 at 1:45 P.M., of the resident's wound showed:
-Wound physician present and Licensed Practical Nurse (LPN) D.
-Observed the genital area had a split (prior) and area was healing. Foley catheter tubing in place no redness or drainage noted at site.
-Observed sacrum area butterfly shape area, had dark discolored edges and bright red discharge noted. Had a small tunneling area toward the left buttock.
-No odor noted at that time.
During an interview on 7/21/23 at 12:03 P.M., LPN E said:
-Residents who were high risk for pressure wounds would have a physician's order for daily and weekly skin assessments on his/her TAR.
-The resident's Weekly Skin Assessment would be documented on the back of the TAR.
-The nursing staff were responsible for reviewing and signing off on the resident's Shower/Abnormal Skin Reports forms, which were completed by CNA's during showers, and were part of the resident's skin assessment.
-The resident had Shower/Abnormal Skin Report Sheet dated 7/14/23 that showed the nurse had signed off documentation from the CNA showing the resident's wound had opened back up. The nursing staff did not document any findings or interventions put in place for the resident.
-The nurse should have documented on the resident's TAR with nursing initials and documented findings on the back of TAR and/or in nursing notes the nursing assessment and any orders obtained.
-The CNA's would assess the resident's skin during showers and document any changes in the resident skin on the shower sheet, then shower reports would be reviewed and signed off by the licensed nursing staff on duty that day.
3. During an interview on 7/20/23 at 10:53 A.M., Certified Medication Technician (CMT) D said:
-CNA's and CMT's were to report any changes in the resident's skin to the resident's charge nurse.
-The charge nurse would assess the resident and document in the resident's medical record.
During an interview on 7/20/23 at 11:19 A.M., CNA E said:
-If he/she found any changes in the resident's skin, he/she would notify the resident's charge nurse, the LPN would assess and document in the resident's medical record.
-If he/she noticed a skin issue, he/she would document on the resident's shower sheet, let nurse know, or pull the call light if the resident needed immediate attention.
During an interview on 7/21/23 at 9:15 A.M., LPN F said:
-Nurse's assigned that day, would be responsible for completing the resident's weekly skin assessment and document findings on the resident TAR. The Director of Nursing (DON) would be responsible for the residents weekly wound assessment.
-Nursing staff would complete daily wound treatment and document wound treatment in the the resident TAR.
-He/She would sign off by nursing initial on front of the TAR and document findings on back of the TAR.
-During the morning and weekly meetings discuss any resident skin changes and update care plan at that time.
During an interview on 7/21/23 at 11:42 A.M., the DON said:
-He/she was responsible for tracking and documentation of the residents with wounds and normally would round with wound doctor.
-He/she would take a paper form to document the wound measurements obtained by the wound physician.
-The facility Weekly Wound Tracking Report sheet was a Quality Assurance document and he/she was not able to share the facility wound tracking document, was shown June 2023 which had documentation of the resident's wound measurement, type of wound and when it started.
-He/she did not document any weekly wound assessments in the resident medical record. The facility relied on wound clinic documentation for the resident's monitoring and weekly wound assessment reports.
-The facility placed the weekly wound clinic summary notes in the resident medical records which include detail comprehensive wound assessment for the resident wound and wound progress weekly.
During an interview on 7/21/23 at 1:30 P.M., the DON and Administrator said:
-The licensed nurses were responsible for the resident's weekly skin assessments and should be documented as completed on the resident's TAR by the nurses initials and document any findings on the back of the resident's TAR.
-CNA's complete a visual assessment and would document on the resident's Shower/Abnormal Skin Report Sheet (CNAs could write anything about a skin issue).
-CNAs were responsible for turning in the shower sheets to the charge nurse, the charge nurse would be responsible for signing off and monitoring the resident's skin for abnormal findings, and completing any follow up assessment.
-Any additional documentation would be completed by nursing in the resident's nursing notes/ or on the back of the TAR.
-The DON would be responsible for rounding with the wound physician and documenting the findings on the facility weekly Quality Assurance wound Report.
-The facility nursing staff did not document a detailed weekly wound assessment in the resident's medical record.
-If there were any new changes in the residents skin he/she would expect nursing staff to document detailed findings on the back of the TAR or in a nursing note and notify the resident's physician.
-The DON was responsible for documentation, monitoring and tracking all resident's with wounds
-The facility did not have an auditing system in place to ensure facility nursing staff have completed resident's weekly skin assessments.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Accident Prevention
(Tag F0689)
Could have caused harm · This affected 1 resident
Based on observation, interview and record review, the facility failed to ensure safe secure storage of cleaning chemicals by leaving the housekeeping keys unsupervised in the door located on memory c...
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Based on observation, interview and record review, the facility failed to ensure safe secure storage of cleaning chemicals by leaving the housekeeping keys unsupervised in the door located on memory care unit for over 30 minutes. The facility census was 77 residents.
A policy for storage of housekeeping chemical cleaning supplies was requested and not received at the time of exit.
1. Review of Resident #53's Quarterly Minimum Data Set (MDS - a federally mandated assessment instrument completed by facility staff for care planning) dated 2/18/23 showed:
-The resident was severely cognitively impaired.
-He/she had wandering behaviors.
Observation on 7/19/23 at 11:00 A.M. showed the resident was walking up and down the hallway with his/her head down and would enter the conference room when the door was open.
2. Observation on 7/19/23 at 11:45 A.M. to 12:12 P.M. of the Memory Care Unit housekeeping cleaning supplies storage room (located on the 500 hall) showed:
-The lock/unlock of the doorknob had a set keys hanging from the doorknob lock.
-With the set of keys in the key hole, was able to turn the key and open the storage door.
-The housekeeping storage area had open boxes and bottles of potential hazardous cleaning chemicals including bleach disinfectant sprays, bleach disinfectant wipes and multiple jugs of disinfectant liquids cleaners.
-At 11:55 A.M., Resident #53 wandered pass the storage closet with keys hanging from the door lock.
-At 11:57 A.M. to 12:02 P.M., two unknown staff member walked past the storage door and did not notice or address the keys in the door.
-At 12:08 P.M., Resident #53 had wandered past the storage closet with the keys in the door lock. (Resident #53 has a history and was observed of wandering into unlocked rooms or in rooms with the doors left opened)
-At 12:10 P.M., a two unknown residents had looked at the storage door with keys hanging and did not attempt to open door.
-12:12 P.M., an unknown staff member entered the 500 unit hallway and walked past the keys hanging from the door lock.
Observation on 7/19/23 at 12:13 P.M., showed:
-Housekeeping staff had returned to the unit to find the keys in the storage door.
-He/she entered the room and took the keys from the door.
During an interview on 7/19/23 at 12:16 P.M., Housekeeper B said:
-He/she had found the keys in storage room door.
-Another housekeeper had left his/her keys in the door.
-Name tag on the key ring was for Housekeeper A, who works on the front hallway.
-Housekeeper set of keys should be secure at all time with the assigned housekeeper.
-The keys should not been left in the housekeeping storage room door lock.
-Would be a potential resident safety concern, especially on memory care unit.
-Most of the residents on the unit were at risk for wandering into unlocked room or try turning doorknobs.
During an interview on 7/19/23 at 3:13 P.M., Housekeeper A said:
-He/she said this was not first time he/she had left his/her housekeeping keys in the door lock.
-The housekeeper keys should not be left in door lock, due to safety risk of a wandering resident trying to enter the cleaning supplies storage room.
During an interview on 7/21/23 at 12:18 P.M., Housekeeping Supervisor said:
-He/she would expected housekeeping staff to take their keys with them at all times and not to be left in storage door lock.
-Housekeeping keys left unattended in a lock for 30 minutes, would be to long of time frame and not be acceptable.
During an interview on 7/21/23 at 1:29 P.M., Director of Nursing (DON) and Administrator said:
-Housekeeping storage doors should be secured, if keys are left in them.
-He/She would expect staff to take them out of the door after door opened or as soon as found left in door.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Incontinence Care
(Tag F0690)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Review of Resident #11's Significant Change MDS, dated [DATE], showed staff documented the resident:
-Had severe cognitive i...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Review of Resident #11's Significant Change MDS, dated [DATE], showed staff documented the resident:
-Had severe cognitive impairment.
-Had an indwelling catheter.
-Was totally dependent on staff for bed mobility.
-Required extensive assistance for personal hygiene.
-Was totally dependent on staff for bathing.
Review of the resident's POS dated May 2023 showed on 5/7/23, the physician ordered the resident's catheter site to be cleansed and covered with gauze daily.
Review of the resident's undated care plan showed:
-Staff were to provide moderate to maximum assistance to the resident for activities of daily living (ADL).
-Staff were to keep the drainage bag below the bladder to prevent backflow of urine.
-Catheter care was to be provided twice a day with soap and water.
Review of the resident's Office Visit Encounter, dated 5/11/23, showed:
-The resident was hospitalized on [DATE] with a UTI.
-The physician documented the resident had a history of UTIs.
Review of the resident's Treatment Administration Record (TAR), dated June 2023, showed staff did not document catheter care completed for 14 out of 30 days in the month.
Review of the resident's TAR, dated July 2023, showed staff did not document catheter care completed for one out of 19 days in the month.
Observation on 7/20/23 at 6:49 A.M. showed the resident was in bed with his/her catheter drainage bag hanging from the bed in contact with the floor without a barrier.
Observation on 7/20/23 at 7:07 A.M. showed:
-Certified Medication Technician (CMT) A and CNA B entered the resident's room, washed their hands, put on gloves, and prepared supplies.
-CMT A was speaking with the resident and stepped on the drainage bag that was on the floor.
-CNA B tried to remove the resident's pants but could not as the catheter tubing extended from the resident's insertion site (lower belly), through the pant leg, and into a drainage bag that hung on the resident's bed.
-CNA B removed the drainage bag from the bed and held it above the resident's head for approximately 10 seconds, then laid the drainage bag on the bed and was able to successfully remove the resident's pants.
-CMT A exposed the resident's catheter insertion site which had a dressing on with the date 7/19/23, stated it was clean, and did not remove the dressing or clean the site.
-CMT A and CNA B continued with cleaning the resident's genitals and buttocks, placed a new brief, applied new pants, and began transferring the resident with a mechanical lift.
-During the transfer, CMT A again lifted the urine drainage bag above the resident's head.
-Urine, with sediment, in the tubing flowed toward the resident and the tubing was then empty.
-CMT A and CNA B completed the transfer with a mechanical lift, moved the resident out of the room, and moved the mechanical lift to the hallway outside the resident's room.
-CNA B returned, got the mechanical lift, and moved it directly into another resident's room without cleaning it.
During an interview on 7/20/23 at 7:42 A.M., CMT A said:
-Urine drainage bags should always be below the bladder.
-He/she realized he/she shouldn't have picked the drainage bag up over the resident after he/she had done it.
3. During an interview on 7/20/23 at 10:18 A.M., CMT A said:
-Urine drainage bags were always to remain below the level of the bladder.
-Urine drainage bags were to be kept at the resident's side, if possible.
-Sometimes he/she put the drainage bag in the resident's lap if the bag wasn't full.
-If the drainage bag was full, he/she would empty if first so urine did not go back up into the resident's bladder.
-It was never okay to lift a drainage bag over a resident's head as it would drain the urine back into the resident.
-The drainage bag was never to be on the floor; it was always to have a privacy bag around it so it didn't directly touch the floor.
During an interview on 7/20/23 at 10:43 A.M., Licensed Practical Nurse (LPN) A said:
-Urine drainage bags were not to be placed in the resident's lap while transferring.
-Urine drainage bags were never to be held above a resident's head.
-Any missing signatures on the TAR meant that care was not provided.
-The TAR should never have blank spots, if there was a reason the care was not provided, the date should be circled and staff were to write why it was not completed.
During an interview on 7/21/23 at 9:23 A.M., CMT B said:
-The resident's catheter bag should be below the bladder at all times.
-Even during transfers, it should be below the bladder and it should not ever be at or above the bladder otherwise the urine will not drain and could possibly put the resident at risk for a urinary infection.
During an interview on 7/21/23 at 9:29 A.M., LPN B said:
-Urine drainage bags were not to be lifted above the bladder, placed in a resident's lap when being transferred, or lifted above a resident's head.
-Any missing signatures on the resident's TAR indicated that treatment wasn't provided.
During an interview on 7/21/23 at 10:05 A.M., LPN C said:
-The catheter bag should be below the level of the bladder at all times so it can drain properly and not back up so it won't contribute to the resident getting a urinary tract infection.
-The resident had recently been treated for a urinary tract infection and not having the catheter bag below the bladder may have contributed to it.
During an interview on 7/21/23 at 1:29 P.M., the Director of Nursing (DON) said:
-Urine drainage bags could not be sat in a resident's lap during a transfer.
-Urine drainage bags were always to be held below the bladder so the old urine doesn't get back into the resident and cause an infection.
-A urine drainage bag should never be held above a resident's head.
-Catheter care was to be completed per the physician's order.
-Missing signatures on the TAR indicated the care was not provided.
During an interview on 7/21/23 at 1:29 P.M., the Administrator said he/she believed it was appropriate to place a urine drainage bag in the resident's lap when performing a transfer so it didn't touch the ground.
Based on observation, interview and record review, the facility failed to maintain the resident's catheter (a tube is inserted into the bladder through the urethra to allow urine to drain from the bladder for collection) below the bladder for two sampled residents (Resident #17 and #11) with a history of urinary tract infections (UTI - an infection of one or more structures in the urinary system); failed to provide catheter care as ordered by the resident's physician and to prevent the catheter drainage bag from coming in contact with the floor without a barrier for one sampled resident (Resident #11) out of 18 sampled residents. The facility census was 77 residents.
Review of the resident's Catheter Care policy and procedure dated 3/15/23, showed catheter care is provided daily and as needed to all residents who have an indwelling catheter to reduce the incidence of infection. The policy did not show where the catheter bag placement should be.
1. Review of the Resident 17's Face Sheet showed he/she was admitted on [DATE], with diagnoses including spinabifida (a birth defect in which a developing baby's spinal cord fails to develop properly), high blood pressure and neurogenic bladder (to lack bladder control due to a brain, spinal cord or nerve problem).
Review of the resident's admission Minimum Data Set (MDS-a federally mandated assessment tool to be completed by facility staff for care planning) dated 6/5/23, showed the resident:
-Was alert and oriented.
-Needed extensive to total assistance with transferring, bathing, dressing, grooming, and toileting.
-Used a urinary catheter for bladder continence.
Review of the resident's Physician's Order Sheet (POS) dated 7/2023, showed physician's orders for:
-Catheter care every shift.
-Flush catheter with 200 milliliter (ml) sodium chloride every other day.
-Change catheter bag and dignity bag every two weeks.
Review of the resident's Nursing Notes showed on 6/12/23 the resident received the results of his/her culture and sensitivity report for a urinalysis (a panel of medical tests that includes physical examination of the urine, chemical evaluation using urine test strips, and microscopic examination) was completed on 6/7/23. It showed growth greater than 100,000. They physician was notified and gave new orders for Vancomycin (an antibiotic) 1000 milligrams (mg), intravenously (to receive medication through a needle or tube inserted into the vein) for 12 hours a day for 7 days for a urinary tract infection; Probiotic twice daily for 7 days for gastrointestinal health. The nurse documented he/she notified the resident's responsible party.
Review of the resident's Physician's Notes dated 6/14/23, showed the resident was recently receiving Vancomycin for a urinary tract infection that was effective.
Review of the resident's Medication Administration Record dated 6/2023 showed the resident received Vancomycin 1000 mg as ordered from 6/12/23 to 6/21/23.
Review of Physician's Telephone Order dated 6/21/23 showed a physician's order for the resident's Vancomycin antibiotic to be discontinued.
Observation on 7/17/09 at 9:05 A.M., showed the resident was sitting in his/her wheelchair, dressed for the weather. It was noted the resident's catheter was in a privacy bag hanging at the side of his/her electric wheelchair, at the level of his/her bladder, not below. There was yellow fluid in his/her catheter tube.
Observation on 7/17/23 at 1:13 P.M., showed the resident was sitting in the dining room in his/her electric wheelchair. The resident's wheelchair was tilted back. The resident's catheter bag was in a privacy bag that was slightly below his/her bladder. There was cloudy yellow fluid in the catheter tubing that was hanging at the side of his/her wheelchair.
Observation on 7/18/23 at 9:00 A.M., showed the resident was sitting up in his/her wheelchair dressed for the weather, groomed with glasses on. His/Her catheter bag was in a privacy bag that was sitting at the level of his/her bladder, not below. There was yellow fluid in the catheter tubing.
Observation on 7/20/23 at 7:16 A.M., showed the resident was laying down in his/her bed with Certified Nursing Assistant (CNA) J assisting the resident to get dressed. The resident's catheter bag was hanging in a privacy bag below the resident's bladder at the side of his/her bed. CNA F took the catheter bag out of the privacy bag and emptied it into the catch container and placed the catheter bag back into the privacy bag. CNA F and CNA J transferred the resident using the full body mechanical lift. They hung the resident's catheter bag on the side of the sling (below the resident's bladder) during the transfer. Once they lowered the resident into his/her wheelchair, CNA F placed the resident's catheter bag in the privacy bag that was on his/her wheelchair. The catheter bag was not below the resident's bladder while the resident was sitting upright in his/her wheelchair.
During an interview on 7/20/23 at 7:32 A.M., CNA F and CNA J said the resident's catheter was supposed to be below the resident's bladder at all times. They also said the resident had a recent urinary tract infection. CNA F said:
-He/She thought that the resident's catheter bag should be lower because it seemed to sit at the level of the resident's bladder when he/she was sitting in his/her wheelchair.
-The resident's catheter privacy bag should be lowered on the resident's wheelchair (and then CNA F began looking at how they could reposition the catheter privacy bag so that the catheter bag would be lower than the resident's bladder).
-CNA F readjusted the resident's privacy bag so that it hung lower on the resident's wheelchair and the catheter bag was below the resident's bladder.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0800
(Tag F0800)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Review of Resident #53's face sheet showed he/she admitted to the facility with the following diagnoses:
-Alzheimer's Disease...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Review of Resident #53's face sheet showed he/she admitted to the facility with the following diagnoses:
-Alzheimer's Disease (a progressive disease that destroys memory and other important mental functions).
-Diabetes Mellitus (DM II- a complex disorder of carbohydrate, fat, and protein metabolism that is primarily a result of a deficiency or complete lack of insulin secretion in the pancreas or resistance to insulin).
Review of the resident's significant change MDS assessment dated [DATE] showed:
-The resident had a severe cognitive impairment.
-The resident only needed supervision and set-up help only when eating.
-The resident had the ability to use suitable utensils to bring food to the mouth and swallow food once the meal was presented on a tray/table with supervision or touching assistance.
Review of the resident's care plan, last updated 5/18/23, showed:
-The absence of any section that the resident ever received finger foods.
-The absence of any section on how the resident was to be assisted with feeding.
Record review of the resident's nutritional assessment dated [DATE] showed:
-The resident was on a regular diet.
-The resident's feeding ability was to feed him/herself with tray setup and verbal assist (cueing).
-If the resident was on finger foods, the nutritional assessment did not mention the resident received finger foods.
Observation on 7/17/23 at 12:37 P.M., showed:
-CNA B assisted the resident with feeding in the dining room.
-The resident's dietary card listed his/her diet as finger foods, but no finger foods were received during this meal.
Observation on 7/19/23 at 12:54 P.M. showed:
-Staff were sitting with the resident while the resident ate lunch.
-The resident was feeding him/herself lunch with a spoon.
-The resident was able to get all the food on the spoon into his/her mouth.
-The resident ate approximately 75% of his/her meal.
Observation on 7/20/23 at 7:24 A.M. showed staff did not provide the resident with finger foods during the breakfast meal, which consisted of scrambled eggs and hot cereal.
During an interview on 7/20/23 at 8:46 A.M., the DM said:
-The dietary card for this resident needed to be changed because the resident required assistance with feeding.
-The resident did eat finger foods at one time, from around December 2022 through about February 2023.
During an interview on 7/20/23 at 10:32 A.M., CNA H said:
-The resident received full assist with feeding around the time he/she started employment in May 2023.
-The resident did not receive finger foods at that time.
During an interview on 7/20/23 at 11:49 A.M., LPN B said the resident required the assistance of facility staff for feeding.
During a phone interview on 7/24/23 at 3:55 P.M., MDS Coordinator A said:
-He/she asked LPN B about the resident,
-LPN B said Resident #53 ate independently until about 2-3 weeks ago.
-LPN B knew that at one time the resident ate independently
-He/she would address the absence of a section within the existing care plan which referred to how the resident should be assisted with feeding.
3. During an interview on 7/21/23 at 1:32 P.M. the Director of Nursing (DON) said:
-Resident #36 did require assistance at meal times.
-Some of the food the residents received throughout the week could have been turned into finger foods.
-He/she had not seen Resident #53 eat recently as he/she had only been to the locked unit's dining room when the resident was throwing his/her tray.
-He/she would have expected the staff to only assist Resident #36 when needed during meal times and not fully assist the resident.
-Resident #36's and Resident #53's care plans needed to be updated to reflect current dietary needs and preferences.
-The nurses perform monthly assessments that should accurately reflect the resident's current status.
-The dietary department should be completing quarterly assessments to ensure residents are receiving the appropriate diet and types of food at meal times.
-Resident #36 should have been receiving finger foods.
Based on observation, interview, and record review, the facility failed to ensure ongoing communication of dietary needs related to assistance while eating; to update the dietary cards; and to include the assistance needed for eating within the care plan for two sampled residents (Resident #36 and Resident #53) out of 18 sampled residents. The facility census was 77 residents.
1. Review of Resident #36's face sheet showed he/she admitted to the facility with the following diagnoses:
-Unspecified Dementia (a progressive organic mental disorder characterized by chronic personality disintegration, confusion, disorientation, stupor, deterioration of intellectual capacity and function, and impairment of control of memory, judgement, and impulses) unspecified severity with behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety.
-Personal history of Cerebral Infarction (ischemic stroke- occurs as a result of disrupted blood flow and oxygen to the brain) with residual deficits.
Review of the resident's care plan dated 5/11/23, showed:
-The resident was at risk for weight loss with a goal of maintaining a healthy weight.
-The Dietician had been consulted at that time.
-No section within the care plan that addressed the resident's dietary needs or preferences.
Review of the resident's quarterly Minimum Data Set (MDS- a federally mandated assessment tool completed by facility staff for care planning) dated 6/1/23 showed:
-The resident was severely cognitively impaired.
-The resident only needed supervision (oversight, encouragement, or cueing) and set-up help only when eating (how the resident eats and drinks, regardless of skill).
-The resident had the ability to use suitable utensils to bring food to mouth and swallow food once the meal was presented on a table/tray with supervision or touching assistance (helper provides verbal cues or touching/steadying assistance as resident completes activity).
Review of the resident's quarterly dietary assessment dated [DATE], showed the resident only required tray set-up for feeding ability.
Review of the resident's Nursing Summary completed on 6/17/23 showed:
-The resident needed limited assistance while eating.
-The resident needed a one person physical assist when eating.
Review of the resident's Physician Order Sheet (POS) dated July 2023 showed the resident had a regular diet order with thin liquids (no additives, includes all liquids and was considered non-restrictive).
Observation on 7/17/23 at 12:34 P.M. showed Certified Nursing Assistant (CNA) E assisted the resident with feeding during the lunch meal and the food was not in a form that the resident could eat with his/her fingers.
Observation on 7/17/23 at 12:42 P.M. of the resident's dietary card showed the resident was supposed to be served finger foods at all meals.
Observation on 7/18/23 at 12:26 P.M. of the lunch meal showed:
-The resident was receiving full assistance with eating from care staff.
-The resident was served:
--A piece of bread.
--A slice of watermelon.
--Salisbury steak with brown gravy.
--Mashed potatoes.
--A mixed vegetable blend.
--A glass of water.
--A nutritional shake.
During an interview on 7/20/23 at 8:46 A.M. the Dietary Manager (DM) said:
-The dietary card for the resident needed to be changed because the resident required assistance with eating.
-The resident had eaten finger foods at one time from around December 2022 to around February 2023.
During an interview on 7/20/23 at 10:24 A.M. CNA B
said:
-The resident used to eat finger foods about four months ago.
-The resident used to spill food on him/herself.
-About three months ago, sometime after the Easter holiday, he/she realized the resident was not receiving finger foods anymore and that was around the time care staff started to assist him/her with eating.
During an interview on 7/20/23 at 10:29 A.M., Licensed Practical Nurse (LPN) A said:
-He/She had been caring for the resident around the beginning of June and he/she was being fully assisted at each meal.
-He/She thought the diet card needed to be changed to reflect the resident's current status.
-The MDS assessment was incorrect and needed to be updated to reflect the resident's current status.
-He/She felt the resident's functional abilities had declined.
During an interview on 7/20/23 at 10:35 A.M. CNA J said the resident had required assistance with feeding for at least two months.
During an interview on 7/20/23 at 10:40 A.M. Certified Medication Technician (CMT) A and CNA B said:
-If the resident was served finger foods he/she would be able to eat by himself/herself.
-The food the resident had been provided throughout the week had not been finger foods.
-CMT A had fed the resident breakfast which included eggs, toast, and cream of wheat.
-The resident had not tried to feed himself/herself during that meal.
During an interview on 7/20/23 at 11:57 A.M. LPN B said there was not a section of the care plan that addressed the resident's eating and dietary needs.
During an interview on 7/21/23 at 8:51 A.M. CNA D said:
-He/she thought the resident started receiving full assistance at meal times somewhere in between March and April.
-The resident was able to feed himself/herself sometimes and was able to grab and reach for his/her drinks and utensils.
-He/she had not really seen the resident eat finger foods.
During an interview on 7/21/23 at 9:53 A.M. LPN B said:
-He/she had been back on the unit for about one month and the resident was able to feed himself/herself when finger foods were served.
-The care staff had gotten into a bad habit of fully assisting the resident with eating.
-He/she would think the resident at baseline would only need supervision when eating with the potential for assistance when served the appropriate foods.
During a phone interview on 7/24/23 at 4:00 P.M. the MDS Coordinator A said:
-The resident had not always been receptive to the facility staff assisting him/her with Activities of Daily Living (ADLs) care.
-He/she believed that the resident had not been receiving finger foods around march or April.
-There should have been a section within the care plan related to the resident's dietary needs and preferences.
-He/she had not communicated with the MDS Coordinator B about the development of a dietary care plan for the resident. **there is only one MDS coordinator listed on the staff roster please add the second MDS coordinator and then identify them as MDS Coordinator A and B
During a phone interview on 7/28/23 at 9:57 A.M., the DM said:
-He/she did not write the care plans.
-If he/she noticed something with a resident(s), such as a resident not receiving finger foods anymore, that change should be included within the care plan.
-He/she expected the portion of the care plan which pertained to how a resident was assisted with feeding, should be within the care plan.
During a phone interview on 7/28/23 at 9:57 A.M., LPN A said:
-Either the MDS/Care Plan Coordinator, LPNs, or Department heads could write updates in the care plan if one of those positions noticed something.
-If he/she noticed something with a resident, he/she would discuss that potential issue with his/her Director of Nursing (DON).
-The care plan should have had a section on it, regarding how residents were assisted with feeding.
-The care plans should reflect the status of the resident on how that resident received assistance with feeding.
During a phone interview on 7/31/23 at 12:32 P.M., CNA J said:
-He/she had access to the care plans because it is behind the desk.
-The Resident's care plan should include assistance with feeding. and The resident has required more assistance with feeding over the last two months.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0883
(Tag F0883)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure pneumococcal (a name for any infection caused by bacteria ca...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure pneumococcal (a name for any infection caused by bacteria called Streptococcus pneumonia) vaccinations were offered for four sampled residents (Resident #64, #179, #25, and #26) out of 18 sampled residents. The facility census was 77 residents.
Review of the facility's policy, dated 1/23/20, titled Immunization of Residents showed:
-Staff were to offer all residents vaccinations to aid in the prevention of infectious diseases.
-Staff were to obtain proof of pneumococcal vaccinations upon admission.
-Staff were to offer the pneumococcal vaccine within 30 days of admission.
-Staff were to document all vaccinations on the Immunization Record.
1. Review of Resident #64's admission Minimum Data Set (MDS-a federally mandated assessment instrument completed by facility staff for care planning), dated 5/27/22 showed:
-The resident was not up to date on the pneumococcal vaccine.
-Staff did not offer the resident a pneumococcal vaccine.
Review of the resident's Significant Change MDS, dated [DATE], showed:
-The resident was not up to date on the pneumococcal vaccine.
-Staff did not offer the resident a pneumococcal vaccine.
Review of the resident's undated Immunization Record showed the pneumococcal vaccine section was blank.
2. Review of Resident #179's admission MDS, dated [DATE], showed the resident was up to date on the pneumococcal vaccine.
Review of the resident's undated Immunization Record showed the pneumococcal vaccine section was blank.
3. Review of Resident #25's admission MDS, dated [DATE], showed:
-The resident was not up to date on the pneumococcal vaccine.
-The resident had declined the pneumococcal vaccine.
Review of the resident's Quarterly MDS, dated [DATE], showed the resident was up to date on the pneumococcal vaccine.
Review of the resident's undated Immunization Record showed the pneumococcal vaccine section was blank.
4. Review of Resident #26's admission MDS, dated [DATE], showed:
-The resident was not up to date on the pneumococcal vaccine.
-The resident was offered and declined the pneumococcal vaccine.
Review of the resident's Annual MDS, dated [DATE], showed the resident was up to date on the pneumococcal vaccine.
Review of the resident's undated Immunization Record showed the pneumococcal vaccine section was blank.
5. During an interview on 7/20/23 at 8:39 A.M., Certified Medication Technician (CMT) B said nurses were responsible for giving vaccines.
During an interview on 7/20/23 at 8:54 A.M., Licensed Practical Nurse (LPN) D said he/she believed the Infection Control Preventionist (ICP) monitored the resident's vaccinations.
During an interview on 7/20/23 at 8:57 A.M., the Administrator said:
-He/she was the ICP for the facility.
-He/she knew Resident #179 had not received the pneumococcal vaccine but did not know why.
-All the residents had been at the facility for a long time and he/she needed to get the names together and run a report to see what residents needed what vaccines.
-The facility did not request vaccination records prior to admission.
-He/she could not find documentation that any vaccine had been offered and declined for any of the residents.
During an interview on 7/21/23 at 1:29 P.M., the DON said: all residents need to be offered the pneumococcal vaccine.
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 and interview, the facility failed to maintain the ceiling fans in the south dining room free form a buildu...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, the facility failed to maintain the ceiling fans in the south dining room free form a buildup of dust; to maintain restroom ceiling vents free of dust inside the vents in resident rooms 401, 507, 308, 306 and 302; to maintain resident use fans free of a heavy buildup of dust in resident room [ROOM NUMBER]; to maintain the ceiling fan in the therapy office free from a heavy buildup of dust; and to maintain the commode seat in the restrooms of 208, 104 and 102. This practice potentially affected at least 50 residents who resided in or used those areas. The facility census was 77 residents.
1. Observation on 7/17/23 at from 12:33 P.M. through 12:52 P.M., showed a heavy buildup of dust on the blades of the ceiling fans over the south dining room where 24 residents ate their lunch meal.
During an interview on 7/17/23 at 12:55 P.M., the Housekeeping Supervisor said the fans are cleaned every two days, but the cleaning cloth may not get the dust from the fan blades like it should.
2. Observations with the Maintenance Director on 7/19/23, showed:
-At 9:01 A.M., a heavy buildup of dust was present inside the restroom ceiling vent of resident room [ROOM NUMBER].
-At 9:40 A.M., a heavy buildup of dust was present inside the restroom ceiling vent of resident room [ROOM NUMBER].
-At 10:52 A.M., a heavy buildup of dust was present inside the restroom ceiling vent of resident room [ROOM NUMBER].
-At 10:54 A.M., a heavy buildup of dust was present inside the restroom ceiling vent of resident room [ROOM NUMBER].
-At 11:00 A.M., a heavy buildup of dust was present inside the restroom ceiling vent of resident room [ROOM NUMBER].
During an interview on 7/19/23 at 9:41 A.M. the Maintenance Director (MD)acknowledged that there were several vents which needed to be cleaned.
3. Observation with the MD on 7/19/23 at 10:44 A.M., showed a heavy buildup of dust on the resident use fan in resident room [ROOM NUMBER].
During a phone interview on 7/26/23 at 3:35 P.M., the Housekeeping Supervisor said:
- The resident use fans are supposed to be cleaned every three days with the cleaning device that the housekeepers use to get to the blades of the fans.
-The housekeepers did not take the apart to clean the motors at the risk of breaking the fans.
4. Observation with the MD on 7/19/23 at 10:13 A.M., showed a heavy buildup of dust on the ceiling fan of the therapy director's office.
During an interview on 7/19/23 at 10:15 A.M., the Housekeeping Supervisor said the fan is supposed to be cleaned every other, but by the look of that fan, it has been longer than every other day.
5. Observations with the MD on 7/19/23, showed:
-At 12:45 P.M., several areas on the commode seat, which were not easily cleanable in the restroom of resident room [ROOM NUMBER].
-At 1:26 P.M., there were areas on the commode seat which were not easily cleanable in the restroom of resident room [ROOM NUMBER].
-At 1:36 P.M., there were areas on the commode seat which were not easily cleanable in the restroom of resident room [ROOM NUMBER].
During an interview on 7/19/23 at 12:46 P.M., the MD acknowledged that the some commode seats may need to be changed because there were areas on that commode seat which were not easily cleanable.
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** 5. Review of Resident #4's face sheet showed he/she admitted to the facility on [DATE] with the following diagnoses:
-Dementia (...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 5. Review of Resident #4's face sheet showed he/she admitted to the facility on [DATE] with the following diagnoses:
-Dementia (a progressive organic mental disorder characterized by chronic personality disintegration, confusion, disorientation, stupor, deterioration of intellectual capacity and function, and impairment of control of memory, judgement, and impulses).
-Chronic Obstructive Pulmonary Disease (COPD- a disease process that decreases the ability of the lungs to perform ventilation).
Review of the resident's hospice (end of life) book showed the resident admitted to hospice on 3/11/22 prior to being admitted to the facility.
Review of the resident's annual MDS dated [DATE] showed the resident received hospice care.
Review of the resident's care plan dated 6/16/23 showed the resident did not have a specific care plan need related to being on hospice services.
During an interview on 7/20/23 at 10:40 A.M. CNA A and CNA B said:
-Care plans needed to reflect the resident's current status.
-They were unsure where the facility kept the care plans and had not looked at them before.
During an interview on 7/21/23 at 8:51 A.M. CNA D said:
-He/she did not look at resident care plans and did not know where they were located at the facility.
-Care plans should address resident preferences, goals, dietary needs, and anything pertinent to the specific resident's care.
-Care plans needed to be individualized and if a resident were on hospice that it needed to be in the care plan.
During an interview on 7/21/23 at 9:08 A.M. LPN E said:
-The MDS Coordinator was responsible for all care planning.
-The nurses were able to make changes to the care plans as needed.
-Care plans needed to be individualized and reflect the resident's current status.
-Hospice care plans were in the resident's hospice book and were updated by hospice nurses.
During an interview on 7/21/23 at 1:29 P.M., the Administrator said:
-Care plans were the responsibility of the MDS Coordinator.
-Any staff member could update the care plans.
-Care plans were to reflect the residents' current status.
6. During an interview on 7/21/23 at 1:30 P.M., Director of Nursing (DON) said:
-The care plan in the resident medical record would be most up to date plan of care.
-Any nurse can update the resident's care plan, but it was the responsibility of the MDS Coordinator to ensure the care plans were up-to-date.
-He/she did not have a system in place for auditing the resident's care plan,
-He/she would expect the resident to have an up-to-date comprehensive care plan for his/her feeding tube.
-He/she would expect the resident to have an up-to-date comprehensive care plan for his/her oxygen usage.
-He/she would expect the resident to have an up-to-date comprehensive care plan for his/her receiving hospice services.
'
2. Review of Resident #25's Quarterly MDS dated [DATE], showed:
-The resident was severely cognitively impaired.
-The resident did not use oxygen.
-The resident had respiratory failure.
Review of the resident's Treatment Administration Record (TAR), dated April 2023, showed staff documented oxygen at 2 liters per minute was given at bedtime on 4/15/23.
Review of the resident's POS dated July 2023, showed:
-An order for oxygen at 2 liters per minute to keep oxygen saturation level greater than 90% for comfort was obtained on 10/18/22.
-An order for oxygen at 2 liters per minute at bedtime was obtained on 11/29/22.
Observation on 7/17/23 at 8:28 A.M. showed an oxygen tank with a nasal cannula (a device that consists of a lightweight tube which on one end splits into two prongs which are placed in the nostrils and from which a mixture of air and oxygen flows) was in the resident's room.
Observation on 7/18/23 at 10:02 A.M. showed the resident was receiving oxygen via nasal cannula at 1.5 liters per minute.
Observation on 7/19/23 at 11:10 A.M. showed:
-The resident had an oxygen tank on his/her wheelchair set at 2 liters per minute with the attached nasal cannula under the resident's buttocks.
-LPN A requested another staff member place the nasal cannula on the resident.
3. Review of Resident #11's Significant Change MDS, dated [DATE], showed:
-The resident was severely cognitively impaired.
-The resident did not use oxygen.
Review of the resident's POS, dated July 2023, showed no physician order for oxygen.
Observation on 7/17/23 at 8:28 A.M. showed an oxygen nasal cannula was lying on the resident's floor.
During an interview on 7/17/23 at 1:20 P.M., the resident's family member said he/she was aware the resident used oxygen.
Observation on 7/19/23 at 8:46 A.M. showed the resident was receiving oxygen via nasal cannula at 2 liters per minute.
4. During an interview on 7/20/23 at 10:18 A.M., Certified Medication Technician (CMT) A said:
-All residents that used oxygen should have an order for oxygen.
-All residents that used oxygen, even if only on occasion, should have it listed on their care plan.
During an interview on 7/20/23 at 10:30 A.M., Certified Nursing Assistant (CNA) A said:
-Any resident that used oxygen were to have it listed on their care plan.
-He/she used care plans to care for his/her assigned residents so he/she needed the care plans to be accurate.
-He/she had no involvement with the MDS process or care planning.
During an interview on 7/20/23 at 10:43 A.M., LPN A said:
-All residents that used oxygen were to have an order.
-All residents that used oxygen were to have that reflected on their care plan.
During an interview on 7/21/23 at 9:29 A.M., LPN B said:
-Any resident who used oxygen was to have an order.
-Any resident who used oxygen was to have that on their care plan.
-Care plans were made by the MDS Coordinator but nurses did provide input.
Based on observation, interview, and record review, the facility failed to ensure care plans were up to date and reflected the resident's current status for four sampled residents (Resident's #6, #25, #11 and #4) out of 18 sampled residents. The facility census was 77 residents.
The facility's policy titled Comprehensive Care Planning dated 7/20/22 showed:
-It is the policy to comprehensively assess and periodically re-asses each Resident admitted to the facility.
-The results of the resident assessment shall serve as the basis for determining each resident's strengths, needs, goals, life history, and preferences to develop a person centered comprehensive care plan.
-Care plans were to include the resident's medical, nursing, physical, mental, and psychological needs.
-Each resident's comprehensive care plan will describe the services that are furnished to attain or maintaining the resident's highest practicable physical, mental, and psychosocial well-being.
-The care plan shall be revised as necessary when the needs/problems and care services specified in the plan of care no longer reflect those of the resident.
1. Review of Resident #6's Face Sheet showed he/she had a diagnosis of difficulty swallowing, aspiration precautions.
Review of the resident's hand written care plan last updated on 3/22/23 showed:
-On 3/22/23 the resident returned from hospital with a Percutaneous Endoscopic Gastrostomy (PEG, surgical produce place a tube that allows you to receive nutrition directly through your stomach) tube.
--Had no comprehensive care plan to include what interventions were put in place.
Review of the resident's hand written care plan last updated on 4/7/23 showed:
-The resident was to have nothing by mouth (NPO).
-Tube feeding formula was Jevity (fiber-fortified therapeutic nutrition that provides complete, balanced nutrition for long- or short-term tube feeding) 60 milliliters (ml) per hour via pump, and the pump was to be off for two hours for cares, nursing staff were to flush the PEG tube per physician orders, and all medication were to be given through the PEG tube.
--No other updates or changes noted. The care plan did not have detailed individualized interventions for the resident's peg tube related to ongoing care.
Review of the resident's Significant Change Minimum Data Set (MDS-a federally mandated assessment tool completed by facility staff for care planning) dated 4/14/23, showed the resident:
-Was alert and oriented.
-Needed extensive to total assistance with transferring, bathing, dressing, grooming, and toileting.
-Required feeding tube for nutritional needs.
Review of the resident's Physician Order Sheet (POS) dated 7/1/23 to 7/31/23 showed:
-The resident's current physician order for tube feeding:
--Jevity 1.2 cal at 80 ml per tube feeding every eight hours from 10:00 P.M. to 6:00 A.M. and then bolus tube feeding of Jevity 1.2 cal three times a day via PEG tube.
--Flush tube with 200 ml of water every four hours.
--Check PEG tube site every shift for drainage.
--Check residual prior to each medication and flushes, hold and notify physician if residual 200 ml or greater.
--Head of bed elevated 30 degrees at all times.
--Give all medication via PEG tube .
--Check proper place of PEG tube prior to medications and flushes.
--Measure external length of PEG tube every shift.
--Change feeding irrigation set every night.
--Split dressing to PEG tube site daily .
Observation on 7/18/23 at 2:05 P.M. of the resident's PEG tube feeding by Licensed Practical Nurse (LPN) E showed:
-LPN E had provided bolus feeding for resident per physician orders.
--Checked residual and length of the tube prior to feeding (set at 4 inches).
--Flushed with water prior to bolus feeding without difficulty.
--Completed bolus feeding and with a final flush of tube with 200 cc water total.
During an interview on 7/19/23 at 8:56 A.M., LPN A said:
-The resident's current care plans were located in the resident medical record.
-The MDS Coordinator would be responsible for updates to the resident's care plans.
-He/she would expect to have a comprehensive tube feeding care plan for the resident.
During an Interview on 7/20/23 at 12:21 P.M., LPN D said:
-The MDS Coordinator would be responsible for care plan updates and to ensure most up to date care plans were placed in resident medical records.
-The LPNs would update the resident care plan only if had a fall.
During an interview on 7/21/23 at 9:15 A.M., LPN F said:
-The resident's care plans were located in residents medical record.
-The MDS Coordinator would be responsible for initiation of the care plans and any updates.
-The resident's tube feeding care plan should be a comprehensive plan of care.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Respiratory Care
(Tag F0695)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Review of Resident #11's Significant Change MDS, dated [DATE], showed:
-The resident was severely cognitively impaired.
-The ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Review of Resident #11's Significant Change MDS, dated [DATE], showed:
-The resident was severely cognitively impaired.
-The resident did not use oxygen.
Review of the resident's POS dated July 2023, showed no order for oxygen.
Observation on 7/17/23 at 8:28 A.M. showed an oxygen nasal cannula was lying on the resident's floor.
During an interview on 7/17/23 at 1:20 P.M., the resident's family member said he/she was aware the resident used oxygen.
Observation on 7/18/23 at 8:39 A.M. showed a nasal cannula attached to an oxygen tank was lying on the floor uncovered and not bagged.
Observation on 7/19/23 at 8:46 A.M. showed the resident was receiving oxygen via nasal cannula at 2 liters per minute.
Observation on 7/20/23 at 7:07 A.M. showed:
-Certified Medication Technician (CMT) A and CNA B entered the resident's room to provide cares.
-CMT A removed the resident's oxygen nasal cannula and laid it on the resident's bed and tucked it under the resident's hair.
-CMT A, while assisting the resident in dressing, stepped on the nasal cannula tubing.
-Once the resident had been moved to his/her wheelchair, CNA B turned off the oxygen concentrator (a type of medical device used for delivering oxygen to individuals with breathing-related disorders), picked up the nasal cannula from behind the resident's pillow, and placed it in a plastic bag.
-CNA B attached a new nasal cannula to the resident's oxygen tank and placed the oxygen cannula on the resident.
4. Review of Resident #25's Quarterly MDS dated [DATE], showed:
-The resident was severely cognitively impaired.
-The resident did not use oxygen.
-The resident had respiratory failure.
Review of the resident's Physician's Orders Medications and Treatments, dated July 2023, showed:
-An order for oxygen at 2 liters per minute to keep oxygen saturation level greater than 90% for comfort was obtained on 10/18/22.
-An order for oxygen at 2 liters per minute at bedtime was obtained on 11/29/22.
Review of the resident's Treatment Administration Record (TAR), dated July 2023, showed staff documented the resident received oxygen at 2 liters per minute via nasal cannula at bedtime on the following dates:
-7/3/23.
-7/4/23.
-7/6/23.
-7/7/23.
-7/8/23.
-7/10/23 through 7/16/23.
Observation on 7/17/23 at 8:28 A.M. showed an oxygen tank with a nasal cannula attached was in the resident's room with the nasal cannula uncovered and undated, wrapped around the tank.
Observation on 7/18/23 at 10:02 A.M. showed the resident was receiving oxygen via nasal cannula at 1.5 liters per minute.
Observation on 7/19/23 at 11:10 A.M. showed:
-The resident had an oxygen tank on his/her wheelchair set at 2 liters per minute with the attached nasal cannula under the resident's buttocks.
-Licensed Practical Nurse (LPN) A pulled the nasal cannula out from under the resident and draped over the back of his/her wheelchair.
-LPN A then requested another staff member place the nasal cannula on the resident.
5. During an interview on 7/20/23 at 10:18 A.M., CMT A said:
-All residents that use oxygen should have an order for oxygen.
-All oxygen supplies were to be placed in bags as soon as they were removed from the resident.
-The nasal cannula was not clean and no longer usable if it had touched a resident's bed or hair.
During an interview on 7/20/23 at 10:30 A.M., CNA A said:
-Oxygen supplies were to be stored in a bag so it would remain sanitary.
-Oxygen supplies were to be placed in a bag as soon it was removed from the resident to keep it clean.
During an interview on 7/20/23 at 10:43 A.M., LPN A said:
-All residents that used oxygen were to have an order.
-All oxygen supplies were to be stored in a labeled, plastic bag.
-When staff removed a nasal cannula from a resident, the nasal cannula was to go directly in the bag and was not to be laid under the resident or on the bed prior to bagging.
During an interview on 7/21/23 at 9:29 A.M., LPN B said:
-Any resident who used oxygen were to have an order.
-All oxygen supplies were to be stored in a plastic bag when not in use.
-Once staff removed a nasal cannula from a resident, they were to immediately place oxygen equipment in a plastic bag and that equipment should not be laid down prior to bagging.
During an interview on 7/21/23 at 1:29 P.M., the DON said:
-Any resident who used oxygen was to have an order entered within 24 hours.
-All oxygen supplies were to be stored in a dated bag when not in use.
-Nasal cannulas were to be bagged immediately after removal from the resident.
-Nasal cannulas not found in a bag were to be discarded and replaced; this included in or on a resident's bed, on the floor, and underneath a resident.
Based on observation interview and record review, the facility failed to ensure physician's orders for oxygen were transcribed to the physician's order sheet for two sampled residents (Resident #179 and #11) and to ensure oxygen equipment such as nasal cannulas (a lightweight tube which on one end splits into two prongs which are placed in the nostrils and from which a mixture of air and oxygen flows), tubing and respiratory suction equipment was stored in a sanitary condition for four sampled residents (Resident #17, #179, #11, and #25) out of 18 sampled residents and seven supplemental residents. The facility census was 77 residents.
Review of the facility's Oxygen Storage and Assembly policy and procedure dated 01/2002, showed:
-The purpose was to properly store and assemble oxygen tanks and accessories in a safe and correct manner.
-It showed the equipment included the nasal cannula, face mask and tubing and a plastic or cloth bag for the cannula or mask.
-The policy did not show how the nasal cannula, face mask were to be stored when not in use.
Review of the facility's Oxygen Therapy policy and procedure dated 03/2019, showed:
-Oxygen therapy may be used provided there is a written order by a physician.
-The order must state liter flow per minute, nasal cannula or face mask, and timeframe.
-Change oxygen cannula, tubing, mask or tracheostomy mask on a weekly basis.
Review of the facility's Tracheostomy (surgical opening into the wind pipe into which a tube is inserted to allow passage of air and removal of secretions) Care policy and procedure dated 08/2003, showed the purpose was to maintain airway patency and to reduce the incidence of infection. The policy showed tracheostomy suctioning is done to clear the trachs of secretions. The policy described the procedure for caring for the tracheostomy and use of the suctioning equipment, but did not show how the suctioning equipment was to be stored.
--The policy did not include tracheostomy suctioning was a sterile procedure or that sterile gloves were to be used during tracheostomy care.
1. Review of Resident #17's Face Sheet showed he/she was admitted on [DATE], with diagnoses including spinabifida (a birth defect in which a developing baby's spinal cord fails to develop properly), and had a tracheostomy.
Review of the resident's admission (MDS a federally mandated assessment tool to be completed by facility staff for care planning) dated 6/5/23, showed the resident:
-Was alert and oriented.
-Needed extensive to total assistance with transferring, bathing, dressing, grooming, and toileting.
-Received tracheostomy care.
Observation on 7/17/09 at 9:05 A.M., showed the resident was sitting in his/her wheelchair dressed for the weather. His/she tracheostomy suction machine was sitting on the resident's tray table by the window. It was uncovered, there was a clear fluid in the collection cup that was attached to the machine and the suction tube was attached to the suction machine and hanging down with the opening touching the floor.
Observation on 7/17/23 at 10:12 A.M., showed the resident was not in his/her room. The resident's suction machine was still sitting on his/her tray table uncovered, and the end of the suction tubing was still on the floor. There was still water in the collection cup that was attached to the suction machine.
Observation on 7/19/23 at 8:46 A.M., showed the resident was not in his/her room. The resident's suction machine and tubing were partially covered with a plastic bag and the sterile supplies were also sitting on the tray table in a plastic bag-sealed. The suction machine tubing was laying on the machine, still attached to the suction machine and there was a clear fluid inside the collection cup.
Observation on 7/20/23 at 9:27 A.M., showed the resident's suction machine was sitting on the resident's tray table and the supplies for his/her tracheostomy were sitting on the tray table and the suction machine was partially covered. The suction collection cup had water inside of it and the suction tubing (also partially covered) had water in the tube. The open end of the tube was resting on the machine. The resident was not in his/her room.
Observation on 7/20/23 at 10:33 A.M., showed the resident's suction machine was partially covered. The collection cup that was attached to the suction machine was empty and looked to have been cleaned. There was a new tube that was connected to the machine.
-Licensed Practical Nurse (LPN) D placed all sterile supplies in a basket on a tray table, then washed his/her hands.
-LPN F washed his/her hands, gloved, and a filled a container with water.
-LPN D filled a separate container with 50 milliliters (ml) of peroxide and 50 ml normal saline. LPN D then sanitized her hands, donned (put on) sterile gloves and began providing the resident's tracheostomy care.
-LPN D removed his/her gloves, sanitized his/her hands, donned sterile gloves, opened the sterile suctioning tube container and connected it to the suction machine. He/She then used the tube to suction the resident.
-When done, LPN D de-gloved, sanitized his/her hands, donned sterile gloves, then completed the tracheostomy care and placed the cap back on the resident's tracheostomy.
- He/She then de-gloved, washed his/her hands and began to clean up the used supplies, discarding them, to include the suction tubing.
-LPN F emptied the containers of liquid, rinsed them out and placed them on the tray table to air dry.
-Both LPN D and LPN F then washed their hands.
During an interview on 7/20/23 at 10:53 A.M., LPN D and LPN F said:
-The resident was given tracheostomy care twice daily, once in the morning and again at night, but he/she received suctioning as needed.
-LPN F said they needed to get another plastic bag to put the resident's suction tubing in because it should not sit on the tray table or machine.
-LPN D said that he/she noticed that there was water left in the container on the suction machine and in the tubing this morning and he/she changed it out this morning before completing the resident's tracheostomy care.
-Both LPN D and LPN F said after they complete the resident's tracheostomy care, they should empty all of the containers, rinse them out, and place them on the tray table to air dry. They should also discard the tubing they used to suction, not leave it on the suction machine with fluid in the tubing.
-LPN D said the suction machine should not be left uncovered and the tubing should not be on the floor at any time.
-Both LPN D and LPN F said they are supposed to place new suction tubing on the suction machine before they suction the resident to prevent contamination.
During an interview on 7/21/23 at 1:30 P.M., the Director of Nursing (DON) said:
-With tracheostomy care, it was a sterile procedure, so the nurse should remove the used suction tubing, throw it away, and clean the canister
-There should not be water left in the canister or the tubing, and the tubing should not be on the floor.
-The tubing should be in a plastic bag and not resting on the suction machine or tray table.
-If staff saw the tubing on the floor, they should notify the nurse so that it could be discarded immediately.
2. Record review of Resident #179's Face Sheet showed he/she was admitted on [DATE] with diagnoses including arthritis,and heart failure, Chronic Obstructive Pulmonary Disease (COPD- a progressive disease that is characterized by shortness of breath and difficulty breathing), history of stroke, and high blood pressure.
Review of the resident's Physician's Order Sheet (POS) dated 6/2023, showed a physician's order for oxygen at 2 liters per minute per nasal cannula as needed for shortness of air, ordered 3/11/23.
Review of the resident's POS dated 7/2023, showed physician's orders for:
-Spiriva inhaler inhale 1 capsule by mouth daily, ordered 6/18/23.
-Wixela 250-50 milligrams (mg), inhale one puff by mouth twice daily rinse mouth after each use for COPD, ordered 6/18/23.
-Albuterol 90 micrograms (mcg) inhaler inhale two puffs by mouth every 6 hours as needed for COPD, ordered 6/18/23.
-Albuterol 3 ml vial, use one vial per nebulizer every four hours as needed for COPD, ordered 6/18/23.
-Change oxygen tubing and clean air filter weekly on Wednesday, ordered 6/16/23.
-Check oxygen saturation levels every shift.
-There were no physician's orders for oxygen transcribed to the current POS.
Observation on 7/17/23 at 9:59 A.M., showed the resident was in his/her room the bathroom. There was a very long oxygen tube that was attached to the resident's oxygen concentrator. There was a portable oxygen tank in a stand with the oxygen nasal cannula and tubing coiled around the oxygen tank open to air and not in a bag or covering.
Observation on 7/17/23 at 1:20 P.M., showed the resident was sitting up in his/her recliner with oxygen on, glasses on eating lunch in his/her room while watching television. The resident's portable oxygen tank was in a stand with the tubing and nasal cannula coiled around the canister, uncovered. There was no bag or covering observed to put the nasal cannula and tubing in.
Observation on 7/18/23 at 9:13 A.M., showed the resident was sitting in his/her recliner with oxygen on dressed for the weather. The resident's portable oxygen tank was on the back of his/her wheelchair. The nasal cannula and tubing was coiled around the oxygen tank, uncovered. There was no bag or covering observed to place the tubing and cannula in and the oxygen tank was turned off.
Observation on 7/19/23 at 11:17 A.M., showed the resident was sitting in his/her recliner with his/her feet up. He/She was using the oxygen from his/her oxygen concentrator. The resident's portable oxygen tank was on the back of his/her wheelchair and was not on. The nasal cannula and oxygen tubing were coiled around the canister and were uncovered. There was no plastic bag or covering observed to place the tubing in.
Observation on 7/20/23 at 10:04 A.M., showed the resident was not in his/her room. His/Her oxygen concentrator was beside his/her bed and was not on. The oxygen tubing was placed in a plastic bag that was attached to the concentrator. The portable oxygen tank in his/her room was in a stand and there was a plastic bag attached to the tank without anything in the bag (there was no tubing).
During an interview on 7/20/23 at 11:12 A.M., Certified Nursing Assistant (CNA) J said all oxygen supplies, nasal cannulas, oxygen tubing and face masks should be in a plastic bag and dated when not in use.
During an interview on 7/20/23 at 1:22 P.M., LPN F said:
-Any oxygen tubing, nasal cannulas, nebulizer mouthpiece, and face masks should all be in a plastic bag when not in use.
-All nursing staff can get the plastic bags from dietary and they are accessible to all staff.
-The night shift nursing staff were supposed to change the resident oxygen supplies out weekly.
-Nasal cannulas and tubing should not be wrapped around the oxygen tanks or uncovered.
During an interview on 7/21/23 at 1:30 P.M., the DON said:
-Oxygen equipment should be stored in a bag and dated when not in use.
-Nebulizers should be rinsed and air dried before placing in the plastic bag.
-Nasal cannulas and tubing should be placed immediately in the bag if staff removed them from the resident.
-Oxygen cannulas should be replaced if found on the floor.
-Residents who have oxygen should have a physician's order.
-Nurses, the DON and Administrator are responsible for ensuring the physician's oxygen orders are transcribed to the POS month to month.
-In an emergent situation, the nurse can use nursing judgement to place oxygen on a resident and notify the physician so they can obtain the order.
-The MDS and the care plan should reflect the resident's use of oxygen.
-The extra oxygen supplies are in central supply and are accessible to the nursing staff.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Drug Regimen Review
(Tag F0756)
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 ensure the pharmacist's monthly medication recommendations were ad...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility failed to ensure the pharmacist's monthly medication recommendations were addressed in a timely manner for one sampled resident (Resident #25) out of 18 sampled residents. The facility census was 77 residents.
Review of the facility's policy, dated 11/28/16, titled Medication Regimen Review (MRR) showed:
-Facility staff were to ensure the attending physician, Medical Director, and Director of Nursing (DON) were provided with copies of each residents' MRR.
-The attending physician was to document in the resident's chart that the identified irregularity had been reviewed and what, if any action, had been taken.
-If the attending physician decided not to make changes per the pharmacist's recommendations, the rationale was to be documented in the resident's chart.
-The facility was to alert to attending physician when MRRs were not addressed in a timely manner.
-The physician was to address all recommendations no later than 30-60 days after the recommendations were made.
-The facility was to maintain copies of the MRR as part of the resident's permanent record.
1. Review of Resident #25's face sheet showed he/she was admitted on [DATE] with a diagnoses of acute (short term) and chronic (long term) respiratory failure (a condition in which your blood doesn't have enough oxygen or has too much carbon dioxide).
Review of the resident's Medication Regimen Review-12 Months, dated from June 2022 to June 2023, showed:
-The pharmacists reviewed the resident's medications each month in the 12 months.
-The pharmacists marked See report for noted irregularities and recommendations for July 2022, September 2022, December 2022, February 2023, March 2023, April 2023, and June 2023.
Review of the MRR for months listed with recommendations were requested in writing on 7/19/23 at 11:50 A.M. to the DON and were not received at time of exit.
During an interview on 7/21/23 at 9:29 A.M., Licensed Practical Nurse (LPN) B said:
-The pharmacist's recommendations were received via fax.
-All the faxed recommendations were given to the DON who placed them in the physician's folders for review.
-Once the recommendations were signed, they were given to the nurses to enter the orders.
-The DON was responsible for putting them in the physician's folders for review.
-The physicians were responsible for going through their folder and ensuring all paperwork had been reviewed.
During an interview on 7/21/23 at 8:31 A.M., the DON said:
-He/she had difficulty finding the MRR for several residents.
-He/she had found some MRRs from June 2023 the previous night and had placed them in the physicians' folders.
-Several of the recommendations were missed and the physicians had not received them for the month of June 2023.
-He/she found several recommendations that had not been responded to prior to May 2023.
-All the facility's physicians had been in the facility that week and none had responded to the recommendations because the recommendations had been misplaced.
During an interview on 7/21/23 at 1:29 P.M., the DON said:
-The pharmacist emailed the recommendations at least monthly.
-He/she placed the recommendations in the appropriate physician's folder for them to see the next time they came in.
-He/she hadn't read the policy on MRR yet.
-The physicians knew they were to check their folders.
-After the physicians signed the orders, they gave them to the nurses and the nurses would enter the orders.
-He/she didn't have a process to ensure the orders had all been reviewed or that new orders had been entered into the residents' charts.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0761
(Tag F0761)
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 a refrigerator was double locked which had nar...
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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 a refrigerator was double locked which had narcotics (controlled substances) stored in it; and to ensure a crash cart (a cart used for medical emergencies) was locked. The facility census was 77 residents.
Review of the facility's policy titled Controlled Substances dated [DATE] showed schedule II drugs (drugs with a high potential for abuse, with use potentially leading to severe psychological or physical dependence) were to be kept under two separate locks requiring two separate keys.
A policy related to crash carts was requested and not received at time of exit.
1. Observation of the locked unit's medication room on [DATE] at 2:00 P.M. showed:
-The medication refrigerator door was unlocked.
-The medication refrigerator contained three vials of Lorazepam (Ativan- a medication used to treat anxiety) two milligrams (mg)/ milliliters (ml).
-The medication refrigerator contained three boxes of Lorazepam Oral Concentrate two mg/ml.
During an interview on [DATE] at 2:03 P.M. Licensed Practical Nurse (LPN) A said:
-He/she had just been in the fridge and that was why it was unlocked.
-He/she knew the fridge needed to be locked due to the controlled substances within the fridge.
During an interview on [DATE] at 9:08 A.M. LPN E said:
-Controlled substances needed to be stored behind two separate locks.
-Any refrigerator or box where controlled substances were kept needed to be locked when not in use.
-If he/she were to find a refrigerator with controlled substances unlocked he/she would verify what all was supposed to be in the refrigerator and make sure nothing was taken.
During an interview on [DATE] at 9:53 A.M. LPN B said:
-Controlled substances needed to be stored behind two separate locks.
-There would not be any reason to leave a refrigerator or box unlocked which held controlled substances such as Ativan.
-If he/she were to find a refrigerator or box with controlled substances unlocked he/she would notify the Director of Nursing (DON) and recount all of the controlled substances to ensure nothing was missing.
During an interview on [DATE] at 1:30 P.M. the DON said:
-Narcotics should always be kept behind two locks.
-There would be no reason a refrigerator or box that contained narcotics would be unlocked.
-He/She would have expected staff to verify that was nothing was taken and lock the refrigerator.
2. Review of a crash cart checklist dated [DATE] showed:
-There was no specific crash cart labeled to the checklist.
-The crash carts were to be checked on a weekly basis on Sundays.
-A list of supplies that were to be in the crash cart.
-The crash cart was not checked on the following dates:
--[DATE].
--[DATE].
--[DATE].
Observation on [DATE] at 8:19 A.M. showed the crash cart in the 100/300 resident/dining area was unlocked.
Observation on [DATE] at 9:57 A.M. showed the crash cart in the 100/300 resident/dining area was unlocked.
Observation on [DATE] at 10:22 A.M. of the crash cart in the 100/300 resident/dining area showed:
-It was unlocked.
-There were various supplies kept within the crash cart such as sterile water, gloves, and other sterile supplies.
Observation on [DATE] at 10:58 A.M. of the crash cart in the 100/300 resident/dining area showed:
-It was unlocked.
-A container of sterile water 250 ml had expired with an expiration date of [DATE].
Observation on [DATE] at 12:09 P.M. of the crash cart in the 100/300 resident/dining area showed it was unlocked.
Observation on [DATE] at 12:52 P.M. showed the crash cart in the 100/300 resident/dining area was unlocked.
Observation on [DATE] at 3:19 P.M. showed the crash cart in the 100/300 resident/dining area was unlocked.
Observation on [DATE] at 12:22 P.M. showed the crash cart in the 100/300 resident/dining area was unlocked.
Observation on [DATE] at 3:19 P.M. showed the crash cart in the 100/300 resident/dining area was unlocked.
Observation on [DATE] at 8:04 A.M. showed the crash cart in the 100/300 resident/dining area was unlocked.
Observation on [DATE] at 11:29 A.M. showed the crash cart in the 100/300 resident/dining area was unlocked.
During an interview on [DATE] at 1:33 A.M. CNA B said:
-He/she was unsure what supplies were supposed to be in the crash cart.
-He/she was unsure of which cart in the 100/300 hall was the crash cart.
During an interview on [DATE] at 11:38 A.M. LPN D said:
-Supplies needed in the crash cart included:
--A stethoscope.
--Oxygen tubing.
--A glucometer (a device for measuring the amount of glucose (sugar) in the blood).
--Other miscellaneous supplies that he/she could not think of at the time.
-He/she had never used the crash cart before, so he/she would not know if any supplies were missing.
-He/she did not think the crash cart needed to be kept locked in case of an emergency.
-The reason why he/she thought it needed to be unlocked was everyone needed to be able to have access to the crash cart.
Observation on [DATE] at 11:40 A.M. of the crash cart in the 100/300 dining area showed LPN D could not lock the crash cart due to a hole being drilled into the crash cart lock.
During an interview on [DATE] at 11:41 A.M. LPN D said he/she thought the lock to the 100/300 hall crash cart had been drilled through because the key may have been lost before.
During an interview on [DATE] at 1:32 P.M. LPN D said:
-He/she was unsure where the checklist for the 100/300 hall crash cart was kept.
-He/she knew that there had been a checklist for the crash cart.
-He/she would not know if the crash cart was fully stocked without a checklist being in place.
-There were labels on the top of each drawer that indicated were supplies needed to go which could be used as a guide for what was needed in the crash cart.
-If he/she were to use any supplies in the crash cart he/she would replace them immediately.
-He/she did not think any resident on the unit would get into the crash cart.
-No resident in the past to his/her knowledge had gotten into the crash cart.
-There were not any residents on the 100/300 unit that expressed any behaviors to indicate malice of any supplies on the crash cart.
During an interview on [DATE] at 8:51 A.M. CNA D said:
-There should be a checklist for all crash carts in the facility.
-He/she was unsure of where the checklists would be found.
-He/she thought crash carts did not need to remain locked.
During an interview on [DATE] at 9:08 A.M. LPN E said:
-There was not a current checklist for the supplies needed in the crash cart.
-Only basic supplies needed to be kept in the crash carts.
-The DON was responsible for stocking the crash carts.
-He/she thought the crash carts needed to remain unlocked, but it would depend on what was in the cart and where it was kept in the facility.
During an interview on [DATE] at 9:53 A.M. LPN B said:
-Crash carts should always be locked and unlocked at emergencies only.
-He/She could not think of a reason why the crash carts needed to remain unlocked.
During an interview on [DATE] at 1:30 P.M. the DON said:
-Crash carts could be unlocked so everyone had access to them.
-The crash cart in the locked unit should be locked due to the resident population.
-The crash carts were checked weekly to ensure all supplies needed were in the carts.
-There had not been any issues with residents trying to get into the crash carts.
-He/she was aware that the crash cart in the 100/300 hall could not be locked.
-The night nurses were the ones that checked the crash carts for any needed supplies.
-The checklist for the crash cart was located at the nurse's station with all of the other night shift nurse duties.
-The nurse's would know if there were any supplies missing in the crash carts.
-There were not any residents on the 100/300 hall that would get into the crash cart.
-He/she did not think there were any dangerous supplies in the crash cart, except maybe scissors and oxygen tubing.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0804
(Tag F0804)
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 temperatures of hot foods on room tray meals, w...
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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 temperatures of hot foods on room tray meals, were maintained at or close to 120 ºF (degrees Fahrenheit) and the facility failed to ensure that seasonings and condiments were available for residents who want to use them. This practice potentially affected five residents on the 200 Hall and at least 12 residents who resided on on the 400 and 500 Hall. The facility census was 77 residents.
1. Review of Resident #27's quarterly Minimum Data Set (MDS-a federally mandated assessment tool completed by the facility for care planning) dated 5/15/23 identified the resident as cognitively intact with a Brief Interview for Mental Status (BIMS-an assessment tool that shows a score between 3 of 15 which shows the resident's mental status, which helped to determine the resident's attention, orientation and ability to register and recall new information and these items are crucial factors in care planning decisions) score of 15 of 15.
During an interview on 7/17/23 at 9:53 A.M.,the resident said the food is cold when he/she received his/her room tray.
During an interview on 7/19/23 at 2:45 P.M., the resident said the food was always cold.
2. Review of Resident #63's quarterly MDS dated [DATE] identified the resident's cognitively intact with a BIMS score of 14 of 15.
During an interview on 7/19/23 at 3:54 P.M., the resident said the food was cold most of the time.
3. Observations during the breakfast meal preparation and service on 7/20/23 from 7:14 A.M. through 8:35 A.M., showed the following:
-At 7:19 A.M., scrambled eggs and hot cereal were placed into plates and the plates were placed in a dietary cart, there were no covers on the plates and that cart was not heated.
-At 7:32 A.M., the cart was delivered to the south kitchenette which served residents who resided on the 400 and 500 Halls.
-At 7:57 A.M., the temperature of the hot foods on one of the plates were measured in front of the Dietary Manager (DM); the temperature of the eggs were 95.3 ºF and the temperature of the cereal was 101.2 ºF
During an interview on 7/20/23 at 7:59 A.M., the DM said:
-There were not enough dietary staff that morning, for a dedicated staff member to serve plates from the steam table in the south kitchenette.
-There were 13 residents left to be served and he/she would have to get new plates for those residents.
Observations on 7/20/23 from 8:06 A.M. through 8:23 A.M., showed the delivery of room trays in the 300, 100, and 200 Halls:
-Certified Nurse's Assistant (CNA) E delivered room trays starting with 300 Hall then delivered room trays to residents in the 100 Hall, then the 200 Hall.
-At 8:20 A.M., CNA E delivered a room tray to resident room [ROOM NUMBER] where he/she had to wake the resident up and had to set the bed up to an angle that the resident in that room could eat properly.
-At 8:23 A.M., the temperatures of three plates of eggs were recorded as 95.9 ºF, 94.2 ºF, and 111.6° respectively.
During an interview on 7/20/23 at 8:25 A.M., CNA E said he/she did not usually deliver room trays, but he/she delivered room trays that day, because there was not anyone else to do it.
During an interview on 7/20/23 at 8:35 A.M., CNA E said normally the dietary department would communicate with the nursing staff to say that the room trays were ready for delivery.
During an interview on 7/20/23 at 8:39 A.M. Licensed Practical Nurse (LPN) G said:
-Facility staff try to get as many residents to eat in the dining room as possible, but several residents choose to eat in their rooms.
-The nursing department communicated with the dietary department about the residents who want to eat in their rooms.
-For them most part they try to get the positioning of the residents completed and the cleaning of the over bed tables done, depending on how the morning goes.
During an interview on 7/20/23 at 8:44 A.M., the DM said the dietary department expected the person who is supposed to deliver room trays to let the dietary department, that that particular hall or section of the facility was ready for the room trays to be plated and delivered.
4. During an interview on 7/17/23 at 9:53 A.M., Resident #27 said the facility did not provide any condiments to make the food taste better.
During an interview on 7/19/23 at 2:45 P.M., Resident #27 said the food should taste the way it was made at home and there was not much flavor.
During an interview on 7/19/23 at 3:54 P.M., Resident #63 said:
-About 50% of the food taste good.
-Sometimes the facility provided condiments and sometimes they did not.
-At times, they give the residents packets which are hard to open and he/she would prefer if the condiments were in a bottle.
During an interview on 7/20/23 at 9:31 A.M., the DM said:
-Condiments such as seasoned salt, onion powder, sodium free spice blends and others could be made available.
-The residents did not know about the seasonings that could be available.
-The activity director can place information about the availability of seasonings and condiments in the daily bulletin.
-For those residents who have trouble reading, he/she would have to speak with those residents to let them know that seasonings and condiments were available upon request.
-The dietary department has bottles of ketchup and mustard that they can provide.
-The dietary department has the seasonings and condiments available, but the residents may not have known the items were available.
5. Record review of Resident #75's quarterly MDS dated [DATE] identified the resident as cognitively intact with a BIMS score of 13 of 15.
During an interview on 7/21/23 at 9:49 A.M., the resident said:
-The food is cold every other day.
-He/she would like seasonings such as sodium free spice blends, garlic powder, onion powder etc.
-Those seasonings were not generally available, as far as he/she knew.
-The resident said he/she had trouble opening the condiment packets at times.
-Ketchup was one of his/her favorites.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Food Safety
(Tag F0812)
Could have caused harm · This affected multiple residents
Based on observation and interview, the facility failed to maintain the fan vent covers of the freezer free from a dust buildup, to ensure there was not chipping paint on the range hood; to prevent a ...
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Based on observation and interview, the facility failed to maintain the fan vent covers of the freezer free from a dust buildup, to ensure there was not chipping paint on the range hood; to prevent a buildup of dust and grease on the light fixtures over the food preparation area; to maintain the ceiling vents in the south kitchenette and in the main kitchen free of a heavy dust buildup inside the vents; to maintain the outflow vents of the air conditioner free of a heavy dust buildup and to maintain the floor of the south kitchenette free from food crumbs and debris. This practice potentially affected all residents who ate food from the kitchen. The facility census was 77 residents.
1. Observation of the main kitchen on 7/17/23 from 8:58 A.M. through 12:30 P.M., showed:
-A buildup of dust on the fan vent covers in the walk-in refrigerator.
-A buildup of dust and grease on the light fixtures over the food preparation area.
-The presence of chipping paint on the range hood.
-A buildup of dust on the outflow vent of the window unit air conditioner.
Observation of the South Unit kitchenette on 7/17/23 from 11:30 A.M. through 12:30 P.M., showed:
-A buildup of dust and food debris on the floor behind the steam table in the South.
-A heavy buildup of dust in ceiling vents over food service area of the South Unit kitchenette.
-A non-illuminated light bulb from the ceiling.
During an interview on 7/17/23 at 9:09 A.M., the Dietary Manager (DM) said he/she notified the Maintenance department about cleaning the light fixtures as far back as January 2023.
During an interview about the South Kitchenette on 7/17/23 at 12:46 P.M., the DM said:
-The housekeeping department is supposed to clean the floors of the south kitchenette.
-He/she did not serve food from the South kitchenette very often, so he/she did not notice the food debris on the floor and the buildup of dust inside the ceiling vents of the south kitchenette.
-He/she did not notice the non-working light bulb in the ceiling.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Safe Environment
(Tag F0921)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, the facility failed to maintain the 400 Hall, 500 Hall and 100 Hall shower rooms in good rep...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, the facility failed to maintain the 400 Hall, 500 Hall and 100 Hall shower rooms in good repair to prevent water from flowing into the room adjacent to the 500 Hall shower room; to maintain the following non-resident areas in a sanitary manner: the floor technician's office and under the vending machines; and to maintain the 3 compartment sink in the kitchen in good repair. This practice potentially affected at 50 residents who resided in or used those areas. The facility census was 77 residents.
1. Observation on 7/18/23 at 2:46 P.M., showed a pool of water flowed from the 500 Hall shower room which was the adjoining room to the room (room [ROOM NUMBER]). The water created a standing pool of water around the chairs closest to the 500 Hall shower room.
During an interview on 7/18/23 at 3:14 P.M., Certified Nurse's Assistant (CNA) K said the water has flowed from the shower room to room [ROOM NUMBER], with that much capacity at least three times within the last two months when he/she assisted with showering residents.
During an interview on 7/18/23 at 3:19 P.M., CNA D said:
-There was an instance where there was a big flood from the 500 Hall shower room to room [ROOM NUMBER] and the Maintenance Director (MD) was notified.
-Around the middle of June, there was an instance in which he/she gave a shower and the water flowed with the capacity with which it flowed with on 6/18/23.
-In the last 2 months, he/she has cleaned up water which lowed from the 500 Hall shower room to room [ROOM NUMBER] at least 3-4 times .
During an interview on 7/18/23 at 3:23 P.M., the Housekeeping Supervisor said:
-His/her department has been called to clean up water that flowed into room [ROOM NUMBER] from shower room.
-The water flow has not always been like it was on 7/18/23.
Observation on 7/19/23 at 9:48 A.M., showed a 2 inch (in.) holes in the tile in the area where the wall met the floor on the side of the shower stall which was closest to room [ROOM NUMBER].
During an interview on 7/19/23 at 9:49 A.M., the MD said the caulk needed to be replaced and the tiles needed to be removed from that shower stall and replaced to repair that shower stall adequately.
2. Observation with the MD on 7/19/23 at 9:09 A.M., showed damage such as peeling and cracked tiles on a 4 feet (ft.) 3 in high section of one of the shower stalls in the 400 Hall shower room.
3. Observation with the MD of the Floor Technician's office on 7/19/23 at 8:39 A.M., showed a plate of old food, a bucket with liquid inside of it with two discarded soda cans, one discarded plastic cup, old napkins and open ketchup packets on the floor or the Floor Technician's office.
During an interview on 7/19/23 at 8:40 A.M., the MD said the Floor Technician was a night shift person and he/she would ask him/her to clean up his/her office.
4. Observation with the MD on 7/19/23 at 11:09 A.M., showed a heavy buildup of dust under two vending machines in the room across from the assist dining room in the 300 Hall.
During an interview on 7/19/23 at 11:11 A.M., the MD said that situation required the facility to notify the owners of the vending machines to move them so the housekeepers could properly clean the floor under those machines.
5. Observation on 7/20/23 at 6:58 A.M., showed a water leak from under two sinks of the three compartment sink in the main kitchen.
During an interview on 7/20/23 at 7:11 A.M., Dietary [NAME] (DC) B said he/she noticed a leak on the previous day, but he/she thought it was sitting water in the floor, but on the morning of 7/20/23, he/she really noticed the leaks.
During an interview on 7/20/23 at 9:30 A.M., the Dietary Manager (DM) said:
-He/she was told about the leak just that morning.
-He/she was not sure how long the sink has been leaking.
-He/she has not noticed it being wet under the sink prior to the morning of 7/20/23.
During a phone interview on 7/20/23 at 2:05 P.M., the MD said:
-The sink has been repaired before with a professional strength, versatile filler for repairing interior and exterior surfaces around the home.
-The filler had broken off and created a drip from underneath the sink.
-The high temperature of the water which came from the faucet and the chemicals used for sanitizing, combine to potentially break down the filler over time.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0923
(Tag F0923)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, the facility failed to maintain adequate ventilation to remove excess heat from the kitchen,...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, the facility failed to maintain adequate ventilation to remove excess heat from the kitchen, and to have ventilation which included negative air flow in the 400 Hall shower room, the 400 Hall medication room, the south hall soiled utility room the 500 Hall shower room, the 300 Hall shower room, the 100 Hall shower room, and the restroom of resident room [ROOM NUMBER] This practice potentially affected 61 residents who resided close to or use those area. The facility census was 77 residents.
1. Observation on 7/17/23 at 11:19 A.M., showed the temperature of the kitchen was 83 ºF (degrees Fahrenheit).
During an interview on 7/17/23 at 11:21 A.M., Dietary [NAME] (DC) A said the kitchen felt hot to him/her.
During an interview on 7/17/23 at 11:24 A.M., the Dietary Manager (DM) said sometimes, it got stuffy in the kitchen and he/she would notify the Maintenance Director (MD).
Observation on 7/17/23 at 11:35 A.M., showed the MD checked on the vent that was supposed to remove the air from the kitchen and he/she saw that the vent for removing the air was closed.
During an interview on 7/17/23 at 11:40 A.M., the MD said he/she was not sure why the vent was closed, but he/she needed to look into that situation a little bit more.
2. Observation with the MD on 7/19/23 at 9:04 A.M., showed weak negative air flow and the presence of a pungent odor of fecal matter in the 400 Hall shower room. There was no fecal matter in the commode or within shower room at that time.
3. Observation with the MD on 7/19/23 at 9:14 A.M., showed the lack of ventilation in the 40 Hall medication room.
4. Observation with the MD on 7/19/23 at 9:18 A.M., showed the absence of a vent from the south soiled utility room.
During an interview on 7/19/23 at 9:19 A.M., the MD said the ventilation in some areas were not working and the ventilation in some areas only activate when the attic areas in those area get to 80 ºF or higher.
5. Observation with the MD on 7/19/23 at 9:48 A.M., showed the absence of negative air flow in the 500 Hall shower room with a musty ( damp, stale smell).
6. Observation with the MD on 7/19/23 at 10:30 A.M., showed the absence of negative air flow and a heavy buildup of dust inside the outflow vent in the 300 Hall shower room.
During an interview on 7/19/23 at 10:31 A.M., the MD said the vents in the 300 Hall shower room were cleaned more than 6 months ago.
7. Observation with the MD on 7/19/23 at 12:59 P.M., showed the absence of negative air flow from the 100 Hall shower room.
8. Observation with the MD on 7/19/23 at 1:36 P.M., showed the absence of negative air flow from the restroom of resident room [ROOM NUMBER].
During an interview on 7/21/23 at 11: 44 A.M., Certified Nursing Assistant (CNA) J said the 400 Hall Shower Room got hot sometimes hot and the ventilation may not be sufficient to remove the odors.
During an interview on 7/21/23 at 12:05 P.M., the Housekeeping Supervisor said the musty smell in the 500 Hall Shower Room emanated from the drainage area and there was not enough ventilation in 500 Hall shower room.
9. Observation on 7/21/23 at 12:11 P.M. showed a musty smell in the 500 Hall shower room.
10. Observation on 7/21/23 at 12:12 showed a fecal odor smell in the 400 Hall shower room.
11. During a phone interview on 7/28/23 from 12:21 P.M. though 12:26 P.M., the MD said:
-For the vent over the kitchen area, the duct tubing came off which caused the vent not to draw out the heat at that time.
-The negative air flow vent over the soiled utility room, was just dirty and the maintenance staff had to clean that vent. and
-For the 500 and 400 Hall shower rooms the vents needed to be cleaned because the additional exhaust vents which were within those shower rooms were not working and he/she would have to do a little more exploration to find out why the additional vents were not working.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0947
(Tag F0947)
Could have caused harm · This affected multiple residents
Based on interview and record review, the facility failed to ensure a system was in place for tracking the Certified Nursing Assistant's (CNAs) 12 hours of Continuing Education Units (CEU); and to pro...
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Based on interview and record review, the facility failed to ensure a system was in place for tracking the Certified Nursing Assistant's (CNAs) 12 hours of Continuing Education Units (CEU); and to provide documentation of staff training records and annual dementia care training for 2022 for five sampled staff. The facility census was 77 residents.
The facility did not provide a policy related to ongoing staff training by the time of exit.
1. Review of all facility staff in-services attendance sheets showed the following in-services topics were completed from 7/25/22 to 4/25/23:
-On 7/25/22 heat safety and signing Medication Administration Records (MAR)/Treatment Administration Record (TAR).
-On 10/25/22, fire drills are serious.
-On 11/10/22, safe resident handling.
-On 11/25/22, abuse.
-On 2/25/23, resident rights and use of mechanical lifts.
-On 3/7/23, door alarms.
-On 3/10/23 smoking policy.
-On 3/10/23 Nurses & Certified Medication Technician (CMT) Antibiotic use.
-On 4/25/23 isolation.
-NOTE: Did not include dementia care training sign in sheets or documentation of dementia training was provided to all staff, including CNA's.
Review on 7/20/23 at 9:00 A.M., of the requested documentation for CEU's for five sampled CNA's showed the facility administration was not able to provide any documentation of the CEU's for CMT D, CMT B, CNA E, CNA D, and CNA H.
During an interview on 7/20/23 at 10:53 A.M., CMT D said the facility provided training every pay day that would go toward CEU's, to include dementia care, abuse and neglect, resident rights and infection control.
During an interview on 7/20/23 at 11:19 A.M., CNA E said:
-He/she received in-services or training on pay days.
-The training included dementia care, abuse & neglect, resident rights, and infection control.
-The facility kept track of the CEU's for the CNA's.
During an interview on 7/21/23 at 11:30 A.M., the Administrator and Director of Nursing (DON) said:
-He/she would be responsible for tracking CNA's staff training's and ensuring the completion of 12 hours of CEU's.
-The CNA 12 hours of CEU's training were completed during the payday inservices.
-The sampled employees had not been at the facility long enough to have received all the training.
-The facility had not completed this years dementia training.
-He/she was unable to obtain last years documentation for dementia care training due to illness of the past DON.
-At this time the facility administration was not tracking CNA's 12 hours of CEU's.
-He/she or assigned staff were providing clock hours, but he/she did not have formal documentation for the tracking of the CNA's required 12 hours CEU's.
-The facility could not provide copies of training reports and could not provide proof of any CEU hours for the five sampled staff members.
During an interview on 7/21/23 at 1:30 P.M., the DON said:
-He/she and the Administrator would be responsible for providing staff in-services and tracking the training hours for all staff including CNA's.
-He/she did not have documentation for tracking of the CNA's clock hours.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected most or all residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 9. Review of Resident #71's face sheet showed he/she admitted to the facility with the following diagnoses:
-Acute Kidney Failur...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 9. Review of Resident #71's face sheet showed he/she admitted to the facility with the following diagnoses:
-Acute Kidney Failure (AKF- a condition in which the kidneys suddenly can not filter waste from the blood).
-Diabetes Mellitus (DMII- a complex disorder of carbohydrate, fat, and protein metabolism that is primarily a result of a deficiency or complete lack of insulin secretion in the pancreas or resistance to insulin).
Observation on 7/19/23 at 9:16 A.M. of a medication pass for the resident completed by LPN A showed:
-He/she grabbed the wrist blood pressure machine and attached it to the resident's wrist without washing/sanitizing his/her hands.
-When the blood pressure appeared on the screen, he/she took off the cuff from the resident's wrist and placed it back on top of the medication cart without washing/sanitizing his/her hands.
-He/she then started preparing the resident's medication without washing/sanitizing his/her hands.
-After placing all medications in the medication cup he/she gave the cup to the resident.
-The resident took his/her medications and gave the cup back to LPN A.
-LPN A threw the empty cup away and sanitized his/her hands.
During an interview on 7/19/23 at 9:27 A.M., LPN A said:
-He/she thought that the medication pass went fine.
-He/she would not have done anything differently.
-He/she would normally sanitize his/her hands after each medication pass and wash his/her hands between every few medication passes.
-He/she could not remember when he/she sanitized his/her hands throughout the medication pass process.
During an interview on 7/20/23 at 7:04 A.M., LPN G said:
-Between every two or so residents was when hand hygiene needed to be completed.
-When a blood pressure check is performed before a medication pass the CMT or nurse would need to sanitize his/her hands before and after.
During an interview on 7/20/23 at 7:11 A.M., CMT B said:
-Hand washing should be completed between every three residents during a medication pass.
-When a blood pressure check is completed whoever is performing the check would need to sanitize his/her hands before and after getting the blood pressure.
During an interview on 7/21/23 at 9:08 A.M., LPN E said:
-He/she would expect hand sanitization to be performed before and after each resident during medication pass.
-He/she would have expect LPN A to perform hand sanitization before and after taking the resident's blood pressure.
During an interview on 7/21/23 at 1:30 P.M., the DON said:
-He/she would expect hand sanitization to be performed between each resident during medication pass.
-He/she would have expected care staff to perform hand hygiene before a blood pressure was taken and after it was taken.
Based on observation, interview, and record review, the facility failed to have an adequate Infection Surveillance Program for all residents; to perform a yearly tuberculosis (TB-a potentially serious infectious bacterial disease that mainly affects the lungs and is spread by coughing and/or sneezing) test and/or screening for two sampled residents (Resident #26 and #32); to provide care in a manner to prevent infection by using soiled gloves to perform clean tasks during incontinence care for two sampled residents (Residents #25 and #48) and one supplemental resident (Resident #47), to ensure a mechanical lift (used for transferring residents that are not able to assist in their own transfer) was cleaned after being contaminated for one supplemental resident (Resident #47); and to ensure proper hand hygiene was completed during a medication pass for one supplemental resident (Resident #71). There were 18 sampled residents and 7 supplemental residents. The facility census was 77 residents.
Review of the facility's policy, dated 12/7/18, titled Surveillance For Nosocomial (originating from the hospital) Infections Suggested Definitions did not address the facility's Infection Surveillance Program.
The facility's TB screening and testing policy was requested and not received at time of exit.
Review of the facility's policy, dated 4/3/23, titled Hand Hygiene showed:
-All staff were to wash their hands after resident contact or contact with blood and body fluids, as well as equipment contaminated by blood or body fluids, as an important component of the infection control precautions
-NOTE: The facility's policy did not include hand hygiene before resident contact or before putting on or after taking off gloves.
Review of the facility's policy, dated 3/15/23, titled Catheter Care showed:
-Staff were to provide catheter care daily to reduce the chances of infection.
-NOTE: The facility's policy did not include when staff were to wash hands or change gloves.
A policy related to cleaning equipment, including mechanical lifts, was requested but not received at the time of exit.
1. Review of the facility's Resident Infection Control and Antimicrobial (an agent that kills microorganisms or stops their growth) Log, dated May 2023, showed:
-A map of the facility with no coloring or writing for any resident room.
-The total number of infections was not filled out.
-The types of infection were not filled out.
-19 resident infections were listed.
-Zero residents had a date the infection was resolved.
-Zero residents had culture and sensitivity results listed.
-The column labeled as clinical documentation supporting the use of antibiotics was blank for all 19 entries.
-The form contained an area for staff to identify a pattern or trend of infections, which was blank.
Review of the facility's Resident Infection Control and Antimicrobial Log, dated June 2023, showed:
-A map of the facility with seven rooms colored in.
-The total number of infections was not filled out.
-The types of infection were not filled out.
-19 resident infections were listed.
-17 of the 19 resident infections did not have culture and sensitivity results.
-The form contained an area for staff to identify a pattern or trend of infections, which was blank.
Review of the facility's Resident Infection Control and Antimicrobial Log, dated July 2023, showed:
-A map of the facility with four rooms colored in.
-The total number of infections was not filled out.
-15 resident infections were listed.
-Zero residents had a culture and sensitivity result listed.
Observation on 7/20/23 at 8:57 A.M. showed the Administrator and Director of Nursing (DON) were copying information from small, yellow slips of paper onto another form.
During an interview on 7/20/23 at 8:57 A.M., the Administrator said:
-He/she was responsible for the infection surveillance program.
-He/she was the Infection Control Preventionist (ICP) for the facility.
-The infection surveillance book had not been updated for months because he/she was behind.
-He/she and the DON were copying orders from the small, yellow slips of paper onto the infection surveillance worksheet to get the book up to date.
During an interview on 7/21/23 at 8:48 A.M., the Administrator said:
-If a resident had health complaints, he/she notified the doctor and would request a culture and sensitivity (a culture is a test to find germs, such as bacteria or a fungus, that can cause an infection; a sensitivity test checks to see what kind of medicine will work best to treat the infection) if necessary.
-If the type of infection would not require the resident to be put on isolation precautions (different types of isolation precautions are used to prevent contaminating others), he/she would just request antibiotics from the physician.
-He/she knew of a resident that had a Urinary Tract Infection (UTI) but none of the doctors had given an order to retest and he/she had not requested any such order from the physician.
-The facility employed a Wound Physician that would order a culture and sensitivity on wounds that he/she believed were infected.
-Staff were to use the McGeer Criteria (a form that provides guidance for infection surveillance) but sometimes they did not.
-He/she believed many of the nurses wouldn't attempt to argue with a physician and would give any medication the physician ordered, regardless of whether the criteria for the medication was met or not.
-He/she did not request a culture and sensitivity on all suspected infections because the physicians would order medication and he/she expected the staff to give the ordered medication.
-Sometimes the physicians did not want a culture and sensitivity.
-Any culture and sensitivity results that were not filled in on the surveillance form were because he/she couldn't find the results or the test was never ordered.
-He/she hadn't been keeping the infection surveillance book up to date because he/she didn't have time.
-On the infection surveillance form, any missing medications or residents known to have an infection but were not listed, were due to him/her missing them when trying to update the book.
During an interview on 7/21/23 at 9:29 A.M., Licensed Practical Nurse (LPN) B said:
-Staff did not always run a culture and sensitivity before prescribing antibiotics.
-The staff would run testing to check for inflammation and then will jump to giving antibiotics.
-Staff did not always have a culture and sensitivity so they didn't know if the medication they were using was effective.
-He/she had requested a culture and sensitivity for a resident returning from the hospital but never received the results.
During an interview on 7/21/23 at 1:29 P.M., the Administrator said:
-He/She expected all infections to be logged on the infection log.
-Sometimes he/she wasn't informed of any signs or symptoms of infections, he/she was just given an order for medication.
-If an infection was suspected, there should be a culture and sensitivity performed.
-The culture and sensitivity is important so he/she and the doctor would know if they were using the correct medication to treat the infection.
-He/she used a different color highlighter for different types of infection on the facility maps that accompanied the Resident Infection Control and Antimicrobial Log so he/she could have a visual of where the infections were to know what type of in-services to offer to staff.
-If a map had no coloring, that would indicate there was no infections that month.
2. Review of Resident #26's undated Immunization Record showed:
-The pneumococcal vaccine section was blank.
-The last entry for TB testing was dated 7/22/19.
3. Review of Resident #32's Quarterly Minimum Data Set (MDS a federally mandated assess tool to be completed by facility staff for care planning), dated 5/5/23, showed the resident had severe cognitive impairment.
Review of the resident's undated Immunization Record showed the last entry for TB testing was dated 4/24/20.
4. During an interview on 7/20/23 at 8:39 A.M., Certified Medication Technician (CMT) B said nurses were responsible for giving TB tests.
During an interview on 7/20/23 at 8:54 A.M., LPN D said he/she believed the ICP monitored the resident's TB screenings.
During an interview on 7/20/23 at 8:57 A.M., the Administrator said:
-He/she was the ICP for the facility.
-He/she believed the facility was to give a TB test to every resident every year.
-The facility did not do TB screening in place of TB tests.
During an interview on 7/20/23 at 8:57 A.M., the DON said:
-He/she could not find any documentation showing a TB screening had been performed on Resident #26.
-None of the residents had symptoms of TB but he/she had not documented that information anywhere.
During an interview on 7/21/23 at 1:29 P.M. the DON all residents were to be tested or screened for TB yearly.
5. Review of Resident #25's Quarterly MDS dated [DATE], showed staff documented the resident:
-Was always incontinent of bladder.
-Was frequently incontinent of bowel.
-Was totally dependent on staff for turning in bed.
-Required extensive assistance for toileting, dressing, and personal hygiene.
During an observation on 7/18/23 at 9:18 A.M., LPN B and Certified Nursing Assistant (CNA) C:
-Entered the resident's room and put on gloves without performing hand hygiene.
-Transferred the resident to his/her bed.
-LPN B removed the resident's pants and placed them in a bag, removed the resident's brief, then used one gloved hand to position and expose all creases of the resident's genitals while using the other gloved hand to clean with wet wipes.
-LPN B, without removing gloves used for positioning and cleaning the resident's genitals, touched the resident's skin and clothing while rolling the resident to the resident's right side.
-CNA C, with his/her gloved hands, wiped feces from the resident.
-CNA C then, without removing or changing gloves, placed his/her right hand on the resident bare back to prevent the resident from rolling while LPN B obtained more supplies.
-CNA C used his/her contaminated, gloved, left hand to place a new, clean brief, under the resident while keeping his/her contaminated, gloved, right hand on the resident's back.
-CNA C placed his/her contaminated, gloved, left hand on the resident's back and removed his/her contaminated, gloved, right hand from the resident.
-CNA C patted the resident on the arm with his/her contaminated, gloved, right hand.
-CNA C released the resident, removed his/her gloves, and without performing hand hygiene, went through the resident's bedside table drawers.
-LPN B returned and he/she and CNA C completed the process.
During an interview on 7/18/23 at 9:46 A.M., LPN B said nothing he/she would have done differently.
6. Review of Resident #47's Significant Change MDS, dated [DATE], showed the staff documented the resident:
-Was always incontinent of bowel and bladder.
-Required one staff member to assist with positioning in the bed.
-Required extensive assistance for dressing and personal hygiene.
Observation on 7/19/23 at 3:12 P.M. showed:
-CMT A and CNA D entered the resident's room, sanitized hands, gloved, prepared the resident's supplies, and transferred the resident to the bed.
-CNA D used gloved hands to remove the resident's brief which had a strong odor of urine.
-CNA D then used the same gloved hands to clean the resident's genitals.
-After cleaning the resident's genitals, CNA D rubbed the resident's bare right arm with the same gloves used to clean the resident.
-CNA D, with same gloves used to clean the resident's genitals, placed his/her hands on the resident's shirt and skin to reposition the resident.
-CMT A, with clean gloves, began cleaning the resident's buttocks.
-CNA D, with same gloves used to clean the resident's genitals, opened the resident's drawers and got out more supplies.
-CNA D and CMT A, both with contaminated gloves, placed a new brief and placed their hands on the resident's back to reposition the resident and finished placing the brief.
-CNA D, with soiled gloves, used the remote control to raise the head of the bed, opened the resident's closet, moved the mechanical lift by the handles, and removed clothing from the resident's closet.
-CNA D, with same soiled gloves, placed the resident's arms in the shirt, touched the resident's bare back, and placed his/her hand on the resident's head to finish putting the shirt on.
-CNA D, with same soiled gloves, patted the resident on the head and touched the left cheek with his/her right hand.
-CMT A and CNA D, both with soiled gloves used to clean the resident, rolled the resident from one side to the other to adjust clothing.
-CMT A removed his/her gloves and, without washing or sanitizing his/her hands, grabbed the mechanical lift by the handles and moved it away from the sink.
-CNA D removed his/her gloves and both staff washed their hands.
-CNA D, ungloved, then grabbed the mechanical lift by the handles (which had been touched with contaminated gloves after cleaning stool from the resident and was not sanitized afterwards) and moved it to the other side of the room and exited the room.
-CNA D washed/sanitized his/her hands.
-CNA D returned with bleach wipes, both CNA D and CMT A put on gloves, and cleaned the resident's wheelchair, sling for mechanical lift, and remote control for the bed.
-CMT A removed his/her gloves, did not perform hand hygiene, and left the room.
-CNA D removed his/her gloves and performed hand hygiene, placed bare hands on handles of mechanical lift, moved the lift to the shower room, and exited the shower room without cleaning the lift or performing hand hygiene.
During an interview on 7/19/23 at 3:34 P.M., CNA D and CMT D said neither knew if they were to change gloves before touching clean items after cleaning a resident's genitals and buttocks.
7. During an interview on 7/20/23 at 10:18 A.M., CMT A said:
-Gloves were to be changed after wiping a resident's genitals and/or buttocks, even if the gloves were not visibly dirty, before touching a resident's skin/clothes/environment.
-The mechanical lift was to be cleaned between each resident with bleach wipes.
During an interview on 7/20/23 at 10:30 A.M., CNA A said:
-Gloves were to be changed after wiping a resident's genitals and/or buttocks, whether visibly dirty or not, before touching the resident or any items in their environment.
-Mechanical lifts were to be cleaned every night with bleach wipes.
During an interview on 7/20/23 at 10:43 A.M., LPN A said:
-Gloves were to be changed after wiping a resident's genitals and/or buttocks, even if not visibly dirty.
-Gloves were to be changed after a resident's brief was checked, whether anything was cleaned or not, before touching the resident or their environment.
-He/she believed the mechanical lift was to be cleaned after each use but was unsure.
During an interview on 7/21/23 at 9:29 A.M., LPN B said:
-Gloves were to be changed after changing or checking a resident's brief, even if not visibly dirty, before touching anything clean.
-Staff were not to touch a resident after checking their brief without removing gloves and performing hand hygiene.
-He/she was not sure how often the mechanical lift needed cleaned; during the COVID-19 (a new disease caused by a novel (new) coronavirus) years, staff were required to clean the lift between each resident but he/she wasn't sure if that was still the rule.
During an interview on 7/21/23 at 1:29 P.M., the DON said:
-Gloves were to be changed after checking a resident's brief, even if not visibly dirty, and before touching any clean items.
-Staff were to perform hand hygiene between dirty and clean tasks, and between each resident when passing medications.
-Once staff had wiped a resident's genitals and/or buttocks, they could not touch the resident or anything in the room until they had removed their gloves and washed their hands.
-Staff were to clean the mechanical lift at least daily but were to clean it after using it on a resident's that wasn't exactly clean before using it on the next resident.
-If the lift was touched with gloves that had been used to provide cares, it was to be cleaned before moving it into another resident's room.
-He/she would not know if there was a trend in infections if the infection surveillance log wasn't complete or accurate.
-The coloring on each map of the facility indicated rooms with infections so he/she could provide in-services on those topics.
-He/she hadn't seen any trend in infections.
8. Record review of Resident #48's Face Sheet showed he/she was admitted on [DATE], with diagnoses including failure to thrive, arthritis, pain and vitamin D deficiency.
Record review of the resident's quarterly MDS dated [DATE], showed the resident:
-Was alert and oriented
-Was dependent on staff extensively for bathing, dressing, grooming and toileting.
Observation on 7/19/23 at 8:55 A.M., showed the resident was sitting up in his/her specialized wheelchair, dressed for the weather. At this time CNA E and CNA F came into the resident's room and without washing or sanitizing their hands, both CNA's put on gloves. The following occurred:
-CNA E and CNA F began to attach the sling to the full body lift. CNA E operated the lift while CNA F monitored the resident and positioned the resident in his/her bed.
-CNA E then removed his/her gloves, washed his/her hands then removed the lift from the room.
-CNA F removed the sling from under the resident, obtained briefs from the residents drawer, pulled the resident's brief down and removed them, began providing incontinence care to the resident then without discarding his/her gloves, washing/sanitizing her hands, and re-gloving, he/she put a clean brief on the resident.
-CNA F then changed his/her gloves, fastened the brief, pulled up the resident's pants then discarded his/her gloves.
-CNA F then pulled the sheet up over the resident, lowered his/her bed, placed the call light within reach, put the wipes up then washed his/her hands us to turn off the faucet.
During an interview on 7/19/23 at 9:16 A.M., CNA F said:
-He/she was nervous, but he/she should have probably changed his,her gloves and washed her hands after transferring the resident.
-He/she should have washed his/her hands and changed his/her gloves after he/she cleaned the resident and before he/she put the new brief on the resident.
-They were supposed to wash their hands upon entering the resident's room, before gloving.
During an interview on 7/21/23 at 10:05 A.M., LPN C said:
-The nursing staff should wash their hands when they enter the resident's room before starting care, after changing their gloves, between clean and dirty tasks and before leaving the resident's room.
-They can use sanitizer if their hands are not soiled.
During an interview on 7/21/23 at 1:30 P.M., the DON said all nursing staff should wash their hands as soon as they enter the resident's room, when going from a dirty to clean task, after gloving, after completing resident care and before leaving the resident's room.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Antibiotic Stewardship
(Tag F0881)
Could have caused harm · This affected most or all residents
Based on observation, interview and record review, the facility failed to have a process to ensure the antibiotic (an antimicrobial [an agent that kills microorganisms or stops their growth] medicatio...
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Based on observation, interview and record review, the facility failed to have a process to ensure the antibiotic (an antimicrobial [an agent that kills microorganisms or stops their growth] medication) ordered for each resident was appropriate for the treatment of the infection, that excessive antibiotics were not used, and to monitor antibiotic use trends. This had the potential to affect all residents at the facility. The facility census was 77 residents.
Review of the facility's policy, dated 3/20/23, titled Assessment of Infections and Antimicrobial Usage showed:
-Assessing antimicrobial use was essential for determining antimicrobial trends.
-Staff were to perform a monthly review of antibiotics ordered and the clinical documentation for why the medication was ordered.
-Staff were to review clinical documentation for documented signs and symptoms of infection for each resident prescribed an antibiotic.
-Staff were to document whether testing was performed and the results.
-After completing the above for all residents on an antibiotic, staff were to summarize the information and look for trends.
-Staff were to thoroughly document a resident's signs and symptoms of infection.
-Staff were to determine if the resident's signs and symptoms aligned with the criteria for starting antibiotics.
-Staff were to determine if the infection met the Center for Disease Control's (CDC) definition for infection in long-term care facilities using the McGeer Criteria (a form that provides guidance for infection surveillance) or a similar form.
1. Review of the facility's Resident Infection Control and Antimicrobial Log, dated May 2023, showed:
-A map of the facility with no coloring or writing for any resident room.
-The total number of infections was not filled out.
-The types of infection were not filled out.
-19 resident infections were listed.
-Zero residents had a date the infection was resolved.
-Zero residents had culture and sensitivity (a culture is a test to find germs, such as bacteria or a fungus, that can cause an infection; a sensitivity test checks to see what kind of medicine will work best to treat the infection) results listed.
-The column labeled as clinical documentation supporting the use of antibiotics was blank for all 19 entries.
-The form contained an area for staff to identify a pattern or trend of infections, which was blank.
-Resident #11 was listed twice, once on 5/3/23 for a urinary tract infection (UTI-an infection in any part of the urinary system) with an order for Augmentin (an antibiotic) 875 milligrams (mg) and again on 5/7/23 for a UTI with an order for Cipro 500 (an antibiotic) mg; no culture and sensitivity results were listed.
Review of the facility's Resident Infection Control and Antimicrobial Log, dated June 2023, showed:
-A map of the facility with seven rooms colored in.
-The total number of infections was not filled out.
-The types of infection were not filled out.
-19 resident infections were listed.
-17 of the 19 resident infections did not have culture and sensitivity results.
-The form contained an area for staff to identify a pattern or trend of infections, which was blank.
Review of the facility's Resident Infection Control and Antimicrobial Log, dated July 2023, showed:
-A map of the facility with four rooms colored in.
-The total number of infections was not filled out.
-15 resident infections were listed.
-Zero residents had a culture and sensitivity result listed.
Observation on 7/20/23 at 8:57 A.M. showed the Administrator and Director of Nursing (DON) were copying information from small, yellow slips of paper onto another form.
During an interview on 7/20/23 at 8:57 A.M., the Administrator said:
-He/she was responsible for the infection surveillance program.
-He/she was the Infection Control Preventionist (ICP) for the facility.
-The infection surveillance book had not been updated for months because he/she was behind.
-He/she and the DON were copying orders from the small, yellow slips of paper onto the infection surveillance worksheet to get the book up to date.
During an interview on 7/21/23 at 8:48 A.M., the Administrator said:
-If a resident had health complaints, he/she notified the doctor and would request a culture and sensitivity (a culture is a test to find germs, such as bacteria or a fungus, that can cause an infection; a sensitivity test checks to see what kind of medicine will work best to treat the infection) if necessary.
-If the type of infection would not require the resident to be put on isolation precautions (different types of isolation precautions are used to prevent contaminating others), he/she would just request antibiotics from the physician.
-He/she knew of a resident that had a UTI but none of the doctors had given an order to retest and he/she had not requested any such order.
-Staff were to use the McGeer Criteria but sometimes they did not.
-He/she believed many of the nurses wouldn't attempt to argue with a physician and would give any medication the physician ordered, regardless of whether the criteria for the medication was met or not.
-He/she did not request a culture and sensitivity on all suspected infections because the physicians would order medication and he/she expected the staff to give the ordered medication.
-Sometimes the physicians did not want a culture and sensitivity.
-Any culture and sensitivity results that were not filled in on the surveillance form were because he/she couldn't find the results or the test was never ordered.
-He/she hadn't been keeping the infection surveillance book up to date because he/she didn't have time.
-On the infection surveillance form, any missing medications or residents known to have an infection but were not listed, were due to him/her missing them when trying to update the book.
During an interview on 7/21/23 at 1:29 P.M., the Administrator said:
-He/she did not always know a resident's signs and symptoms of infection, but if the physician gave an order for an antibiotic, he/she would give the antibiotic without investigating further.
-If an infection was suspected, he/she expected staff to obtain a culture and sensitivity test.
-A culture and sensitivity test was important to ensure the facility was using the right antibiotic for the infection.
-He/she expected the antibiotic log to be accurate and up to date.
-He/she expected a culture and sensitivity result before a second antibiotic was ordered for the same infection because the antibiotic used didn't work.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0925
(Tag F0925)
Could have caused harm · This affected most or all residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, the facility failed to maintain the main kitchen area free from roaches and to maintain the ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, the facility failed to maintain the main kitchen area free from roaches and to maintain the facility free from numerous flies, which were present throughout the facility. This practice potentially affected all residents. The facility census was 77 residents.
1. Observations on 7/17/23 at 9:27 A.M., showed roaches in the chemical storage room and a roach which crawled on the ceiling over the corridor to back exit door from the kitchen.
Observations on 7/20/23, showed:
-At 6:51 A.M., showed one roach crawling on wall at the lower level of steam table.
-At 7:01 A.M., showed another roach which crawled on the door jamb of door between kitchen and assist dining room.
-At 7:05 A.M., one roach crawled on wall next to ice tea making machine.
-At 7:07 A.M., four roaches crawled on wall behind ice tea machine.
During an interview on 7/20/23 at 7:08 A.M., Dietary [NAME] (DC) B said the facility is old and there have been and were roaches in the kitchen.
During an interview on 7/20/23 at 9:26 A.M., the Dietary Manager (DM) said:
-The roaches were an ongoing issue.
-The exterminator has sprayed all the baseboards in the kitchen including within the chemical storage room of the kitchen.
2. Observations on 7/19/23, from 8:37 A.M. through 1:36 P.M., showed numerous flies throughout the facility.
-At 9:17 A.M., there were numerous flies flew around inside the 500 Hall soiled utility room.
-At 9:47 A.M. there were numerous flies in resident room [ROOM NUMBER].
-At 12:47 P.M., numerous flies were present in resident room [ROOM NUMBER].
-At 1:17 P.M., numerous flies were present in Resident #16's room and on Resident #16's leg; further observation showed Resident #16 had a fly swatter in his/her hand.
Record review of Resident #16's quarterly Minimum Data Set (MDS- a federally mandated assessment tool completed by the facility for care planning) dated 4/16/23 identified the resident as cognitively intact with a Brief Interview for Mental Status (BIMS-an assessment tool that shows a score between 3 of 15 which shows the resident's mental status, which helped to determine the resident's attention, orientation and ability to register and recall new information and these items are crucial factors in care planning decisions) score of 13 of 15.
During an interview on 7/19/23 at 2:49 P.M., Resident #16 said:
-He/she grew up on a farm, but the amount of flies in the facility was ridiculous.
-The flies bothered him/her, because they were nasty.
Observation on 7/19/23 at 2:50 P.M., showed where Resident #16 killed three flies which were on the floor of his/her room.
Observations on 7/20/23 from 7:13 A.M. through 8:35 A.M., showed numerous flies in the south dining room and facility staff and residents swatted at the flies during the breakfast meal.
During a phone interview on 7/26/23 at 3:39 P.M., the Maintenance Director said:
-He/she wanted install one more Halo (a device which uses blue wavelength of light to attract insects into it) close to the south kitchen to get additional flies.
-At times they can contact their pest control company to get additional sprays and traps that they can lay down to catch additional insects.
Mar 2023
2 deficiencies
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0602
(Tag F0602)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to prevent the misappropriation of a resident's Scheduled II controlle...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to prevent the misappropriation of a resident's Scheduled II controlled medications (a medication with a higher potential of dependency and abuse) for one sampled resident (Resident #1) when Licensed Practical Nurse (LPN A) took the resident's control medication for his/her own personal use out of three sampled residents. The facility census was 77 residents.
On 3/28/22 the Administrator was notified of the past noncompliance which occurred on 2/18/23. On 3/14/23 the facility administration was notified of the incident and the investigation was started. LPN A was terminated. No employees were allowed to work prior to reeducation. The deficiency was corrected on 3/16/23.
Record review of the undated facility Abuse Prevention Program Policy showed:
-Policy:
--This facility affirms the right of our residents to be free from abuse, neglect, misappropriation of resident property, corporal punishment and involuntary seclusion.
-Definitions:
--Misappropriation of resident property is the deliberate misplacement, exploitation, or wrongful, temporary or permanent, use of a resident's belongings or money with the resident's consent.
1. Record review of Resident #1's Face Sheet showed he/she was admitted on [DATE] with the diagnosis of vascular dementia (a general term for the loss of thinking, remembering, and reasoning so severe that it interferes with an individual's daily functioning, and may cause symptoms that include changes in personality, mood, and behavior, anxiety and heart failure).
Record review of the resident's Physician's Order Sheet (POS) dated 2/1/23 through 2/28/23 showed a physician order for Alprazolam 0.5 milligram (mg), take one tablet by mouth three times daily for anxiety.
Record review of the facility Controlled Substance Manifest for the facility dated 2/18/23 showed:
-Three cards of Alprazolam 0.5 mg, quantity of 30 tablets for each card, packaged by the pharmacy for delivery.
-A line drawn through the receipt of one full card.
-LPN A signed the receipt of two full cards for the resident, totaling 60 tablets, of Alprazolam 0.5 mg on 2/18/23 at 3:30 P.M.
Record review of the facility Controlled Substance Manifest for the pharmacy dated 2/18/23 showed:
-The manifest for the driver that was returned to the pharmacy showed three cards of Alprazolam 0.5 mg, quantity of 30 tablets for each card, packaged by the pharmacy for delivery.
- The pharmacy manifest showed all three cards signed for as delivered to the facility for the resident signed by LPN A on 2/18/23 at 3:30 P.M.
During an interview on 03/22/23 2:15 P.M. the LPN A said:
-He/she was working the evening of 2/18/23 and was the person in charge of receiving the resident's Alprazolam.
-He/she took one card of the resident's Alprazolam home with him/her.
-He/she knew it was wrong but only took the medication for his/her spouse.
During an interview on 3/28/23 at 10:10 A.M. the Administrator said:
-He/she conducted an investigation about the missing controlled substance.
-LPN A admitted to taking the controlled substance prescribed to a resident in the facility.
-Due to only two cards of the Alprazolam being signed into the narcotic log, the count did not appear to be incorrect.
-The discrepancy was not found until the resident's medication was reordered and the pharmacy alerted the facility that the refill was too soon.
-Law enforcement was contacted to report the theft of the controlled substance.
-Pharmacy had been contacted in reference to the discrepancy.
-He/she provided copies of the facility's completed investigation.
During an interview on 3/28/23 at 12:26 P.M. the Interim Director of Nursing (DON) said:
-He/she was contacted by the Administrator about the concern of the missing controlled substance.
-The Administrator and Assistant Director of Nursing (ADON) have been responsible for monitoring controlled substances in the facility.
During an interview on 3/28/23 at 12:53 P.M., LPN A said:
-He/she said the bottom line was he/she did take the medications.
-He/she took the medications because his/her spouse was distraught about his/her diagnosis.
-He/she took four or five of the pills for him/herself and gave some to his/her spouse.
-He/she folded the card of medication and stuck them in his/her bag to take home.
-There was nobody around.
-He/she was in the medication room next to the nurse's station with the door open.
Record review of the Police Report dated 3/29/23 showed:
-Stealing of a controlled substance was reported on 3/14/23.
-An investigation was completed by law enforcement.
-The alleged perpetrator (AP) was identified as LPN A.
-The AP was interviewed on 3/22/23 at which time he/she admitted to taking the controlled substance from the facility to be consumed by the AP's spouse.
-The report was being reviewed by the prosecutor pending prosecution.
During an interview on 3/29/23 at 11:32 A.M. the Law Enforcement Officer said:
-An investigation had been completed.
-The case was under review by the prosecutor for consideration of prosecution of LPN A.
During an interview on 3/30/23 at 9:03 A.M., the General Manager for the Pharmacy said:
-Controlled substances are packaged and sealed with tamper resistant tape.
-There were three copies of the manifest for controlled substances.
-One copy was signed by the driver at the pharmacy.
-Two copies were sent with the driver, one to be kept by the facility and one as returned to the pharmacy with the receiving nurse's signature.
-It was expected the receiving nurse would break the seal and count the narcotics upon delivery and sign the two copies of the manifest.
-If there was anything missing it was expected to be documented on the manifest and the pharmacy to be contacted.
-The Alprazolam was reported as missing from the delivery.
-The facility would be billed for the replacement of the missing medication.
Record review of LPN A facility file on 4/10/23 showed:
-He/she was disservice on abuse and neglect 7/13/22.
-He/she was terminated from the facility on 3/21/23.
MO00215414
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
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility failed to ensure there was a full time Director of Nursing (DON), for at lea...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility failed to ensure there was a full time Director of Nursing (DON), for at least 40 hours a week since November 2022. This deficient practice had the potential to affect all residents residing in the facility. The facility census was 77 residents.
1. Record review of the Facility assessment dated [DATE] showed the total resident census was 78 residents.
Record review of the undated facility DON job description showed:
-Job Summary to plan, organize, develop, and direct the overall operation of the nursing service department in accordance with current federal, state and local standards, guidelines, and regulations that govern the facility and as may directed by the administrator and the medical director to ensure that the highest degree of quality care is maintained at all times.
Record review of the facility staffing sheets dated 3/1/23 through 3/27/23 showed:
-The Registered Nurse (RN) B was scheduled to work for eight hours on 3/3/23.
-The RN B was scheduled to work as a charge nurse for the south hall on 3/4/23.
-The RN B was scheduled to work as a charge nurse for the south hall on 3/5/23.
-RN B was not in the building or scheduled for any other days.
During an interview on 3/28/23 at 11:45 A.M., the Administrator said:
-The facility did not have a full time DON.
-RN B was the Interim DON, but he/she would not be in facility until 3/31/23.
During an interview on 3/28/23 at 12:26 P.M., RN B said:
-He/she was the Interim DON.
-He/she had just been helping out as needed since November 2022.
-He/she had been coming to the facility about one to two days per week.
-He/she had not been on assignment with his/her full time job out of state.
-He/she was out of the state at the time of the interview.
-He/she had primarily signed off on Minimum Data Set (MDS- a federally mandated assessment instrument completed by facility staff for care planning) and addressed issues and complaints as they have come to the attention of the administration.
During an interview on 3/28/23 at 12:53 P.M., Licensed Practical Nurse (LPN) A said:
-The DON was recently hired.
-He/she had always talked to the Administrator about concerns in the facility.
During an interview on 3/28/23 at 1:51 P.M., Administrator said the department heads for morning meeting Monday through Friday consisted of two MDS nurses, the Assistant Director of Nursing (ADON) and the Administrator to handle the DON duties, unless the Interim DON was at the facility that day.
During an interview on 3/28/23 at 1:56 P.M., Certified Nursing Assistant (CNA) A said:
-He/she was not sure who the DON was, but thought it was RN B.
-Has not seen RN B for a few weeks.
-He/she went to the Administrator or LPN B with his/her concerns.
During an interview on 3/28/23 at 1:58 P.M. the CNA B said:
-He/she thought the DON was RN B, but was not for sure.
-He/she was not sure when RN B was last in the facility.
-He/she went to the charge nurse, or Administrator for any concerns.
During an interview on 3/28/23 at 2:01 P.M., LPN E said:
-He/she thought the Acting DON was RN B.
-RN B has been in the facility maybe once a week.
-He/she went to the Administrator or the Infection Preventionist with any concerns.
During an interview on 3/28/23 at 2:05 P.M., MDS Nurse A said:
-The DON was technically RN B.
-RN B had been in facility about once a week.
-He/she does not know who had been handling the DON responsibilities on a daily basis.
-He/she had went to the Administrator for any of his/her concerns.
During an interview on 3/28/23 at 2:13 P.M., Physical Therapy Assistant said:
-The DON was the Infection Preventionist.
-He/she usually saw the Infection Preventionist in his/her office.
During an interview on 3/28/23 at 2:26 P.M., RN A said:
-He/she thought the Acting DON was RN B.
-He/she saw RN B possibly last week, but was not certain.
-If he/she needed to talk to the DON and RN B was not in the facility, he/she would contact the ADON, Social Services or the Administrator.
During an interview on 3/29/23 at 8:45 A.M., RN B said:
-His/her duties have been to basically to help out with MDS's and whatever the Administrator gives him/her to handle when in facility.
-The Administrator usually had a list ready for when he/she gets to the facility.
-He/she had been in the facility one to two days a week.
-There were some weeks he/she was not there at all.
-He/she lived locally and traveled out of town/state for his/her full time job with a travel nursing agency.
-He/she had never gotten a job description for the DON position.
During an interview on 3/29/23 at 2:58 P.M. the ADON said:
-He/she clarified with corporate his/her titles are Infection Preventionist and ADON.
-The DON was RN B and he/she was Interim.
-The DON responsibilities were to oversee the nursing department.
-When RN B was here, he/she checked on everything, helped on the floor and does paperwork.
-The DON was supposed to review referrals for resident admissions.
-The DON was usually in the facility a couple of days per week.
-When RN B was not in the facility there is RN coverage through an agency.
-RN B was in facility maybe 20 hours per week, depends on how much he/she was working on another contract job.
-The facility had advertised for a DON for full time employment without success.
-DON responsibilities were taken care by him/her or the Administrator.
-They try to tag team things so they are not just waiting on the DON when he/she gets in the facility.
-Was not sure how much the DON was required to be in the facility.
During an interview on 3/29/23 at 3:11 P.M. the Administrator said:
-The Interim DON was RN B.
-The DON responsibilities include:
--Help with discipline problems.
--When RN B was in the building he/she did all DON responsibilities.
-RN B was available by phone to answer questions.
-RN B began as the full time Interim DON in November 2022.
-Corporate and RN B could not come to a salary agreement.
-In February RN B said he/she would only be able to help when he/she could.
-Ideally the DON should be in the facility 40 hours per week or more.
-RN B had been paid for 60 hours for the last pay period.
-The pay schedule was bi-monthly.
-When RN B was not in the facility, anything that did not require an RN either he/she or the ADON handled.
-The RN B handled all the MDS's, everyone else tries to pick up the workload and keep things going.
MO00215414
Apr 2022
24 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0568
(Tag F0568)
Could have caused harm · This affected 1 resident
Based on interview and record review, the facility failed to prevent a negative balance for one discharged resident (Resident #266) who was discharged on 3/26/21 and to address that negative balance u...
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Based on interview and record review, the facility failed to prevent a negative balance for one discharged resident (Resident #266) who was discharged on 3/26/21 and to address that negative balance until 4/5/22. This practice potentially affected 14 residents who allowed the facility manage their resident funds. The facility census was 67 residents.
1. Record review of the Trust Fund Yearly Detail Register showed:
-Resident #266's family received $669.01, after the resident was discharged on 3/26/21, instead of $372.01, because $297.00 was spent on an insurance plan on 3/3/21 and not deducted from the resident's ledger.
-Leaving a negative balance of $297.00 outstanding on the resident's account.
During an interview on 4/5/22 at 11:13 A.M., the Business Office Manager (BOM) said the check that was written in March 2021 for $669.01 was written by a person without business office experience and that person forgot to subtract the $297.00 that was already spent on 3/3/21.
.
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 have advanced directives (documents that allow one to communicate t...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to have advanced directives (documents that allow one to communicate their health care preferences when decision-making capacity is lost) and/or a Durable power of Attorney (DPOA- a person previously identified to make decisions for an individual in the event of inability to make wishes known) for one sampled resident (Resident #265) who had an Outside the Hospital Do Not Resuscitate (DNR - an order from a doctor that resuscitation should not be attempted if a person suffers cardiac or respiratory arrest) form signed by a family member; and to ensure physician's orders for a code status change were obtained when OHDNR forms were signed for two sampled residents (Resident #265 and Resident #7) out of 17 sampled residents. The facility census was 67 residents.
Record review of the facility policy Advanced Directives policy revised 9/27/17 showed:
-At the time of admission, each resident, DPOA or responsible party would be given written information regarding resident rights and advanced directives.
-At this time, the resident/responsible party would be asked to furnish existing advanced directives.
-After confirming the accuracy of the provided documents with the resident/responsible party, the documents would be signed.
-Absence of advanced directives of code status for a resident would indicate the resident was a full code status.
-Any advanced directives would be reviewed quarterly with the interdisciplinary team, resident/responsible party.
-The resident's code status should be recorded on the Physician's Orders Sheet (POS).
1. Record review of Resident #265's admission nurses note dated 2/9/22 showed:
-The resident was admitted to the facility via transport van.
-The resident's physician was notified and physician's orders were obtained.
Record review of the resident's Telephone Orders Sheet dated 2/9/22 showed the resident had physician's orders for a full code.
Record review of the resident's baseline care plan dated 2/10/22 showed the resident was cognitively impaired.
Record review of the resident's OHDNR form dated 2/10/22 showed:
-A family member had signed the form and wrote DPOA by his/her name.
-The resident's physician had signed the form.
Record review of the resident's POS dated 2/22, 3/22 and 4/22 showed the resident was a full code status and had a diagnosis of Alzheimer's disease (a slowly progressive disease of the brain that is characterized by impairment of memory and eventually by disturbances in reasoning, planning, language, and perception).
Record review of the resident's medical record on 4/4/22 showed no advanced directives or DPOA on file.
2. Record review of Resident #7's Profile Face Sheet showed he/she:
-Was admitted to the facility on [DATE].
-Had a diagnosis of Dementia (a progressive organic mental disorder characterized by chronic personality disintegration, confusion, disorientation, stupor, deterioration of intellectual capacity and function, and impairment of control of memory, judgment, and impulses).
Record review of the resident's OHDNR form dated 7/24/21 showed:
-The resident's DPOA signed the form.
-The resident's physician signed the form.
Record review of the resident's significant change Minimum Data Set (MDS a federally mandated assessment tool completed by facility staff for care planning) dated 8/2/21 showed the resident was severely cognitively impaired.
Record review of the resident's POS dated 12/21, 1/22 and 2/22 showed the resident was a full code status and had a diagnosis of Frontotemporal lobar degeneration (a group of disorders based on their neuropathology that cause damage and dysfunction of the frontal and temporal lobes of the brain) with behavioral disturbances.
Record review of the resident's care plan last updated 2/22/22 showed the resident was severely cognitively impaired.
Record review of the resident's POS dated 3/22 and 4/22 showed the resident was a full code status and had a diagnosis of Frontotemporal lobar degeneration with behavioral disturbances.
3. During an interview on 4/5/22 at 9:51 A.M. Licensed Practical Nurse (LPN) B said:
-Social services was responsible for obtaining and/or formulating advanced directives and DPOA paperwork and monitoring to ensure residents had the forms completed.
-Social services was responsible for completing the OHDNR forms for the residents and monitoring to ensure the OHDNR and POS matched.
-Social services would notify the nurse to write the DNR order.
-The OHDNR form and physician's orders should match on the POS.
-Social services should verify the residents advanced directive and/or DPOA before having a family member sign the OHDNR form.
-The facility did not have a social services person at this time.
During an interview on 4/5/22 at 2:47 P.M. the Business Office Manager (BOM) said Social Services was responsible for completing advanced directives.
During an interview on 4/6/22 at 1:06 P.M. the Director of Nursing (DON) said:
-If the resident was a DNR, social services would assist with filling out the OHDNR.
-Upon admission, the nurse would complete the code status orders.
-Social services would give the code status changes to the nurses to update the code status.
-The DPOA could sign the OHDNR form.
-The family member should not sign the DNR without a valid DPOA form.
-Social services should verify the DPOA paper for healthcare before signing the OHDNR.
-Social services was responsible for obtaining advanced directives and DPOA directives.
-If the resident was incapacitated the DPOA could sign.
-Social services was responsible for completing audits and monitoring that the code status was correct.
-At this time, the facility did not have a social services person in place.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Comprehensive Assessments
(Tag F0636)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Record review of Resident #265's admission nurses note dated 2/9/22 showed:
-The resident was admitted to the facility via tr...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Record review of Resident #265's admission nurses note dated 2/9/22 showed:
-The resident was admitted to the facility via transport van.
-The resident's physician was notified and physician's orders were obtained.
Record review of the resident's baseline care plan dated 2/10/22 showed:
-The resident was cognitively impaired, a high elopement risk and wandered.
-The resident was independent with walking, bed mobility, and eating.
Record review of the resident's MDS tracking records on 4/4/22 showed:
-The resident had an entry tracking MDS on 2/9/22 upon entry into the facility.
-There was no admission MDS completed for the resident within fourteen days of admission.
During an interview on 4/5/22 at 12:14 P.M. the MDS Coordinator said:
-He/she had been at the facility as the MDS Coordinator since 3/15/21.
-admission assessments were to be completed fourteen days after admission.
-The calendar was off when he/she started in 3/2021.
-There had not been an MDS Coordinator from 12/20/20 until 3/2021.
-He/she had been out due to illness and family issues and the MDS's and care plans were behind.
-The corporate office was aware the MDS's were not completed.
-The corporate office monitored the MDS's quarterly.
-Resident #265 did not have an admission assessment completed upon admission.
3. During an interview on 4/6/22 at 1:06 P.M. the Director of Nursing (DON) said:
-The MDS's were behind.
-When the MDS Coordinator started the MDS's were behind.
-The MDS Coordinator was still behind with completing MDS's and care plans.
-The Administrator was looking at possibly looking at hiring a new MDS Coordinator to help the current MDS Coordinator.
-The MDS Coordinator had a schedule of which MDS's were behind.
-A regional corporate person was working with the MDS Coordinator to monitor and assist with catching up.
-He/she expected the MDS's and care plans to be completed per the required schedule.
-Resident #265's admission MDS should have been completed.
Based on interview and record review, the facility failed to ensure an annual comprehensive assessment was completed for one sampled resident (Resident #47) and to complete a comprehensive admission assessment for one sampled resident (Resident #265) out of of 17 sampled residents. The facility census was 67 residents.
Record review of the Long Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual, Version 1.17.1, October 2019 showed:
-The Minimum Data Set (MDS a federally mandated assessment tool completed by facility staff for care planning) is one of the three components of the RAI process.
-The MDS is a core set of screening, clinical, and functional status elements, including common definitions and coding categories, which forms the foundation of a comprehensive assessment for all residents of nursing homes certified to participate in Medicare or Medicaid.
-The items in the MDS standardize communication about resident problems and conditions within nursing homes, between nursing homes, and between nursing homes and outside agencies.
-An admission MDS is required to be completed by day 14 after the resident's admission.
-An annual MDS is required by day 366 of the resident's previous comprehensive assessment and by day 92 from the resident's previous quarterly MDS assessment reference date (ARD the specific end point of look-back periods in the MDS assessment process; it allows for those who complete the MDS to refer to the same period of time when reporting the condition of the resident).
-Assessments may be scheduled early if a nursing home wants to stagger due dates for assessments; as a result, more than three OBRA Quarterly assessments may be completed on a particular resident in a given year, or the Annual may be completed early to ensure that regulatory time frames between assessments are met.
Record review of the facility Comprehensive Assessment/MDS policy revised 11/1/17 showed:
-The facility would comprehensively assess and periodically reassess each resident.
-The results of the assessment would serve as the basis for determining resident strengths, needs, goals, life history and preferences to develop a comprehensive plan of care for each resident with the goal of attaining or maintaining the resident's highest practicable physical, mental and psychosocial wellbeing.
-Each resident residing in the facility for a full 14 days would have an MDS completed by the 14 day after admission.
-The comprehensive assessment would include completion of the MDS, a review of the Care Area Assessments (CAA - the use of clinical resources to conduct an assessment of potential resident problems triggered on the MDS), and a summary form stating what CAA's triggered, the location and date of the CAA documentation , and the care planning decision.
-The MDS would be reevaluated annually within 366 days of the previous MDS ARD.
1. Record review of Resident #47's Profile Face Sheet showed he/she was admitted to the facility on [DATE].
Record review of the resident's MDS's showed:
-He/she had an admission MDS completed on 3/19/21.
-He/she should have had quarterly MDS assessments completed on 6/19/21, 9/19/21 and 12/20/21 and an annual MDS assessment on 3/20/22.
-He/she had a quarterly MDS completed early on 6/1/21 (based on his/her admission MDS date of 3/19/21).
-He/she had a quarterly MDS completed late on 9/19/21 (based on his/her previous quarterly completion date of 6/1/21).
-He/she had a quarterly MDS completed early on 11/19/21 (based on his/her previous quarterly completion date of 9/19/21.
-He/she had an annual MDS due on 3/18/22 (based on completion of his/her admission MDS completion date or on of 3/19/21) or on 2/19/22 (based on completion of his/her quarterly MDS completed on 11/19/21) which was not completed.
During an interview on 4/5/22 at 12:40 P.M. the MDS Coordinator said:
-The resident had a quarterly MDS completed on 11/19/21.
-He/she stated incorrectly, the resident's annual MDS was due on 4/6/22.
-When he/she came back to work at the facility on March 15, 2021, MDS assessments were already behind due to the facility having been without an MDS coordinator since the previous December.
-He/she discussed the situation with the State RAI Coordinator sometime after he/she returned to the facility and had not recently spoken with the State RAI Coordinator.
-A number of factors had occurred that resulted in MDS assessments being behind including keeping up with Medicare assessments and resident care plans, difficulty communicating with therapy services that were offsite, personal illness of long duration and family illnesses.
-He/she had prioritized getting caught up on quarterly MDS assessments but was not yet current on quarterly MDS's.
-He/she and the corporate MDS coordinator had kept in contact and a scheduled plan for getting caught up had been developed.
-A plan to hire an additional facility MDS staff person was also being worked on; several persons had been contacted but none had committed to a position either full/part time or assisting as available.
-He/she planned to continue to get caught up on MDS assessments.
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 provide the resident and/or their representative with a summary of a baseline care plan that was developed within the first 48 hours of adm...
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Based on interview and record review, the facility failed to provide the resident and/or their representative with a summary of a baseline care plan that was developed within the first 48 hours of admission for one sampled resident (Residents #265) out of 17 sampled residents. The facility census was 67 residents.
Record review of the facility's Baseline Care Planning policy revised 3/16/22 showed:
-The baseline care plan would seek to develop a personal plan of care.
-The baseline care plan should be completed within 48 hours.
-The baseline care plan should be reviewed with the resident and a copy should be provided to the resident and the resident's designated representative.
1. Record review of Resident #265's admission nurses note dated 2/9/22 showed:
-The resident was admitted to the facility via transport van.
-The resident's physician was notified and physician's orders were obtained.
Record review of the resident's baseline care plan dated 2/10/22 showed:
-The resident was cognitively impaired, a high elopement risk and wandered.
-The resident was independent with walking, bed mobility, and eating.
Record review of the resident's Physician's Orders Sheet (POS) dated 2/22 showed the resident had a diagnosis of Alzheimer's disease (a slowly progressive disease of the brain that is characterized by impairment of memory and eventually by disturbances in reasoning, planning, language, and perception).
Record review of the resident's medical record on 4/4/22 showed there were no nurses notes or social services notes that showed staff provided the baseline care plan to the resident's responsible party.
During an interview on 4/5/22 at 9:51 A.M. Licensed Practical Nurse (LPN) B said:
The nurses completed the baseline care plans for the residents upon admission.
-The Minimum Data Set (MDS a federally mandated assessment tool completed for care planning) Coordinator was responsible for providing the baseline care plan to the resident and/or responsible party.
During an interview on 4/5/22 at 12:14 P.M. the MDS Coordinator said:
-The nurses would complete the baseline care plan upon admission.
-Social services was responsible for providing the baseline care plan to the resident and/or responsible party.
-There was no social services designee (SSD) at this time.
During an interview on 4/6/22 at 1:06 P.M. the Director of Nursing (DON) said:
-Baseline care plans were completed by the nurse upon admission with as much information as they knew about the resident.
-This would include care needs, diet orders, and Activity of Daily Living (ADL - dressing, grooming, bathing, eating, and toileting) status, bathing, glasses, communication needs.
-There should be a care plan meeting with the family/resident within 72 hours to go over all the information on the care plan.
-There should be a note somewhere in the medical records.
-The MDS Coordinator along with social services would complete the care plan meeting.
-The MDS Coordinator was responsible for setting up the care plan meetings.
-No one was monitoring the baseline care plan meetings to ensure these were getting completed.
-The resident's responsible party should have been informed of the baseline care plan and the plan of care for the resident.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0657
(Tag F0657)
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 the extent practicable, to include residents and their representati...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to the extent practicable, to include residents and their representatives in the care planning process and failed to conduct care plan conferences to include resident/resident representative participation for two sampled residents (Residents #26 and #57) out of 17 sampled residents. The facility census was 67 residents.
Record review of the facility's Comprehensive Care Planning policy revised 11/1/17 showed:
-The Interdisciplinary team and other staff needed as appropriate should meet to discuss resident care services and needs.
-The resident and/or the resident's representative should participate as possible/appropriate.
-The comprehensive care plan should strive to be person centered.
1. Record review of #26's Profile Face Sheet showed he/she:
-Was admitted to the facility on [DATE].
-Had a diagnosis of multiple sclerosis (MS, a neurological disease that attacks the protective covering of the nerves, leading to impaired sensory and motor nerve function, and in most cases some degree of disability).
Record review of the resident's quarterly Minimum Data Set (MDS-a federally mandated assessment tool required to be completed by facility staff for care planning) dated 11/25/21 showed the resident:
-Was cognitively intact.
-Required the extensive assistance of staff for transfers, dressing, toilet use, and personal hygiene.
Record review of the resident's Care Plan updated 11/25/21 showed the resident required extensive assistance with Activities of Daily Living (ADLs-transfer, bathing, grooming, toilet use).
During an interview on 3/31/22 at 1:01 P.M. the resident said:
-He/she had not been informed of care plan meetings.
-He/she had not had a care plan meeting to go over his/her plan of care.
Record review of the resident's medical record on 4/4/22 showed no information showing care plan meetings had been completed.
2. Record review of Resident #57's Profile Face Sheet showed he/she was admitted to the facility on [DATE] with the following diagnoses:
-Stroke (a blockage in the one or more of the arteries supplying blood to the brain).
-Hemiplegia/hemiparesis (total or partial paralysis of one side of the body that results from disease of or injury to the motor centers of the brain).
Record review of the resident's admission MDS dated [DATE] showed the resident:
-Was cognitively intact.
-Required the extensive assistance of staff for transfers, dressing, toilet use, and personal hygiene.
Record review of the resident's care plan dated 11/1/21 showed the resident had hemiplegia and required the extensive assistance of staff for ADLs.
During an interview on 4/1/22 at 8:41 A.M. the resident said:
-He/she had not been offered a quarterly care plan meeting.
-He/she wanted to be involved and be able to go over his/her plan of care.
Record review of the resident's medical record on 4/4/22 showed no information showing care plan meetings had been completed.
3. During an interview on 4/1/22 at 3:09 P.M. the MDS Coordinator said:
-The Social Services Designee (SSD) was responsible for care plan meetings and sending the letters out to schedule care plan meetings.
-The care plan meetings were usually done by MDS Coordinator but had been moved to social services.
-We did phone care plans meetings for a while.
-Care plan meetings had not been completed by video.
-He/she did not find any documentation for Resident #26 and Resident #57 showing care plan meetings were conducted.
-This was a work in progress.
-The care plan meetings were not getting done for the residents.
-If a care plan meeting was held, this would be documented in the residents' medical record.
During an interview on 4/6/22 at 1:06 P.M. the Director of Nursing (DON) said:
-The MDS Coordinator was responsible for scheduling and setting up care plan meetings.
-The MDS Coordinator was responsible for sending letters for care plan meetings to the resident and/or family.
-The MDS Coordinator should be setting up a care plan meeting with alert and oriented residents even if family did not want to attend.
-There should be a note somewhere in the medical record.
-The MDS Coordinator along with social services would complete the care plan meeting.
-No one was monitoring to ensure care plan meetings were being completed.
-Resident #26 and Resident #57 should have had a care plan meeting quarterly.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0685
(Tag F0685)
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 arrangements were made to replace broken and sc...
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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 arrangements were made to replace broken and scratched glasses for one sampled resident (Resident #41) out of 17 sampled residents. The facility census was 67 residents.
1. Record review of Resident #41's Face Sheet showed he/she was admitted to the facility on [DATE] and readmitted on [DATE].
Record review of the resident's Social Services notes dated November 2020 to December 2020 showed no Social Service notes mentioning the resident's vision needs.
Record review of the facility's Tentative Optometrist List (a list of residents needing to see the optometrist), dated 11/30/21 showed:
-The resident was on the list of residents scheduled to see the optometrist on 12/14/21.
-Beside the resident's name under the heading Visit Reason was written Diluted Fundus Exam (DFE - a diagnostic exam for eye health) and beside that was hand written Needs new glasses.
Record review of the resident's annual Minimum Data Set (MDS - a federally mandated assessment instrument completed by facility staff for care planning), dated 12/13/21 showed:
-The resident's ability to see in light with glasses or visual appliances was adequate.
-The resident wore corrective lenses.
-The resident was severely cognitively impaired.
-It was very important for the resident to take care of personal belongings; have books, newspapers and/or magazines; and to do things with a groups of people.
Record review of the resident's ocular progress note, dated 12/14/21 showed:
-A medically oriented ocular evaluation was performed.
-The resident's chief complaint was blurred vision. He/She has difficulty seeing at a distance and close up.
-He/She was diagnosed with:
--Age-related nuclear cataracts (clouding of the normally clear lens of the eye) which was not visually significant. No treatment indicated.
--Arcus senilis bilateral (a condition in which there is a white or blue ring around the cornea of both eyes) not interfering with vision or affecting eye health. No treatment indicated at this time.
Record review of the optometrist's services list for facility residents, dated 12/14/21 showed a DFE was completed for the resident. No glasses were ordered or delivered for him/her.
Record review of the resident's Social Services notes dated January 2022 through 4/6/22 showed no Social Services notes related to the resident's vision needs or arrangements for the resident to get eyeglasses.
During an interview on 4/1/22 at 11:44 A.M. the resident's Durable Power of Attorney (DPOA - responsible party) for Healthcare said:
-The resident broke his/her glasses two months ago and was supposed to be getting new ones.
-The resident has worn glasses for years and has gone a couple of months without them.
-He/She spoke to the Social Worker who was looking into getting the resident new eyeglasses, but had not heard back about the glasses.
-He/She asked multiple nurses about the resident's glasses, most recently on 3/29/22 and nobody seemed to know anything about them.
-He/She didn't see any glasses in the resident's room when he she visited on 3/29/22.
During an interview on 4/4/22 at 8:58 A.M. Certified Nursing Assistant (CNA) B said:
-The resident wore eyeglasses, but they have been broken for a while, but he/she wasn't sure when they broke.
-CNA's were responsible for notifying the nurse when a resident's eyeglasses or hearing aides were missing.
-He/She thought either the charge nurse or the Social Worker made appointments for glasses and hearing aids.
-The Social Worker had been gone for about a month.
Observation on 4/4/22 at 9:37 A.M. showed the resident was not wearing any glasses and eyeglasses were not in his/her eyeglass case in his/her room.
During an interview on 4/4/22 at 9:52 A.M. CNA D said:
-Months ago he/she took the resident's eyeglasses to the Social Worker to put a screw in them.
-The resident was wearing the glasses for a while, but it had been weeks since he/she had seen the resident's eyeglasses in his/her room.
During an interview on 4/5/22 at 10:08 A.M. Licensed Practical Nurse (LPN) C said:
-The resident's DPOA told him/her a couple of months or more ago he/she gave the resident's eyeglasses to the Social Worker to send out to be fixed.
-The resident's eyeglasses have not come in.
-He/She didn't know where the eyeglasses were sent.
-The information might be in the Social Services notes.
-Months ago the resident's eyeglass lens popped out.
-Then a nose piece broke and they didn't want the broken piece to dig into the resident's nose.
-The resident wore his/her eyeglasses every day when he/she had them.
-If the resident didn't have his/her glasses, he/she would let staff know he/she needed them.
-He/She personally wouldn't want to go around with fuzzy or poor vision.
During an interview on 4/5/22 at 1:44 P.M. Agency CNA F said:
-The resident wore eyeglasses, but it had been weeks since he/she had seen the glasses.
-The resident put them on every day. Sometimes he/she would leave them at the dining room table.
-He/She hadn't heard what happened to the resident's eyeglasses.
During an interview on 4/5/22 at 1:52 P.M. LPN A said:
-He/She heard from other staff the Social Worker mailed the eyeglasses off to get fixed and didn't know where they had been sent. One of the nose rests had came off.
-As far as he/she knew the eyeglasses hadn't come back.
During an interview on 4/5/22 at 1:54 P.M. the MDS Coordinator said:
-He/She put cotton and a Band-Aid where the nose rest piece was missing and reported the condition of the eyeglasses to the Social Worker.
-At one point the Social Worker said he/she had tried to make an eye appointment and nobody would call him/her back. He/She didn't know where the Social Worker tried to make an appointment.
-The resident had been asking for his/her eyeglasses. He/She was able to communicate he/she wanted them.
-He/She told the Social Worker the eyeglasses were scratched and the resident really needed another pair.
During an interview on 4/5/22 at 3:04 P.M. a family member who was visiting the resident said:
-He/She thought the resident was having difficulty with his/her vision because when staff were taking the resident's oxygen saturation levels he/she seemed to have difficulty seeing enough to stick his/her finger in the oximeter.
-He/She remembered the eyeglasses the resident had were very scratched up and thought the resident needed new ones.
During an interview on 4/6/22 at 8:38 A.M. Agency LPN D said:
-The resident normally wore eyeglasses. A couple of weeks or so ago he/she noticed the resident wasn't wearing them.
-The Social Worker usually made vision appointments, although the Assistant Director of Nursing (ADON) had been making appointments since the Social Worker had been gone.
-If the Social Worker had followed up on the resident's eyeglasses there should be a Social Services note indicating that.
During an interview on 4/6/22 at 1:05 P.M. the Director of Nursing (DON) said:
-Normally it was the Social Worker's responsibility to follow up on appointments and arranging for the residents' eyeglasses.
-Nurses would normally let the Social Worker know if there were residents with vision needs, but since the facility had no Social Worker at this time the nurses should let the ADON or DON know of the residents' vision needs.
-The facility had an optometrist who visited the facility regularly. The company would fill prescriptions for eyeglasses and bill the resident's insurance. Eyeglasses were sent through the mail and the turn-around time was normally two weeks.
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 ensure smoking assessments were completed on a quarter...
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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 smoking assessments were completed on a quarterly bases to ensure one sampled resident (Resident #20) was able to smoke safely, out of 17 sampled residents. The facility census was 67 residents.
Record review of the facility's undated Smoking Policy showed:
-Smoking would be permitted by staff and residents in an approved outside location.
-Residents must always be accompanied by a staff member to smoke and may not keep their own smoking materials.
-Note: There was no mention of a resident assessment for ability to smoke safely or to determine what modifications may need to be considered to modify independent smoking so that resident safety was maintained.
Record review of the facility's undated Smoking Assessment form showed:
-Areas for resident's name, the date of the assessment, the resident's physician, and the resident's diagnosis.
-Comprehensive Evaluation Results section with areas to mark for No problem identified as reflected on the resident's Minimum Data Set (MDS - a federally mandate d assessment tool completed by facility staff for care planning) and Care Plan, Unable to follow directions as reflected on the resident's MDS and Care Plan, Poor safety awareness as reflected on the resident's MDS and Care Plan, and Confused and disoriented as reflected on the resident's MDS and Care Plan.
-Behavior Evaluation Results section with areas section with areas to mark for No problem identified as reflected on the resident's MDS and Care Plan, Aggressive and disruptive as reflected on the residents MDS and care plan, Inflicting injuries on self or others as reflected on the resident's MDS and care plan)
-Physical Abilities section with areas section with areas to mark for No problem identified as reflected on the resident's MDS and Care Plan, Weakness, paralysis, hemi-paresis as reflected on the resident's MDS and care plan,: Contractures as reflected on the residents MDS and care plan, Contractures as reflected on the resident's MDS and care plan, Amputations as reflected on the residents MDS and care plan, and Other.
-The Interdisciplinary Team (IDT a group of health care professionals with various areas of expertise who work together toward the goals of their clients) determines the resident may smoke under the following conditions (had a line to hand write specific conditions).
-Area for the resident's signature and date of the signature.
-Areas for names/titles of IDT team members.
-Note: There was no area to include direct observation of the resident while smoking as a part of the smoking assessment.
1. Record review of Resident #20's Profile Face Sheet showed he/she was admitted to the facility on [DATE] with the following diagnoses.
-Hemiplegia (a severe loss of strength in the arm, leg, and sometimes face on one side of the body caused by brain damage or spinal cord injury).
-Seizures (a burst of uncontrolled electrical activity between brain cells that causes temporary stiffness, twitching or limpness, and changes in behaviors/sensations or states of awareness
-Weakness.
-Transient cerebral ischemic attack (TIA a temporary blockage of blood flow to the brain, often called a mini-stroke).
-Atrial fibrillation (A-Fib a quivering or irregular heartbeat that can lead to blood clots/stroke).
-Bradycardia (abnormally slow heart rate below 60 beats per minute).
-Vascular dementia (problems with reasoning, planning, judgment, memory and other thought processes caused by brain damage from impaired blood flow to the brain; it can occur after a stroke, but strokes do not always cause vascular dementia).
Record review of the resident's medical record showed his/her most recent Smoking Safety Risk Assessment was dated 12/22/20 and showed:
-Instruction to evaluate the resident in each of the following categories and to circle the number that most closely reflected the resident's functioning (0 = no problem; 1 - minimal problem; 2 = moderate problem; 3 = severe problem):
-General awareness and orientation including ability to understand the facility safe smoking policy; resident's score = 0.
-Potential for causing injury to self or others from smoking unsupervised or careless use of smoking materials; resident's score = 0.
-History of hazardous behavior (i.e. smoking in unsupervised areas or careless use of smoking materials,); resident's score = 0.
-Potential for safety following the facility safe Smoking policy; residents score = 0.
-Residents total score = zero.
-A comment that the resident must be supervised when smoking.
-Recommendations and Outcome section had an X beside May independently be able to handle smoking material (score 0 - 5).
-The form was signed by the current Social Services staff.
Record review of the resident's medical record showed his/her most recent Resident Smoking Assessment forms were dated 12/22/20 and showed he/she was evaluated with the following physical abilities to be permitted to smoke per facility policies and procedures:
-He/she was able to touch his/her thumb to each finger on each hand.
-He/she was able to grasp small objects with each hand.
-He/she was able to open and close his/her index finger and middle finger to scissor motion with each hand.
-He/she was able to bend his/her arm at his/her elbow, bring his/her hand to his/her mouth and down with each of his/her arms.
-He/she held a cigarette without dropping.
-He/she disposed of ashes and butts appropriately.
-He/she demonstrated safety measures for handling cigarettes.
-He/she exhibited a clear understanding of the smoking policy as explained, and in writing.
-He/she had weakness, paralysis, as reflected on his/her MDS and care plan.
Record review of the resident's care plan with a review date of 11/18/21 showed:
-He/she had chosen to continue smoking.
-He/she would practice safe smoking habits with each cigarette for the next 90 days.
-Staff would inform the resident of the approved smoking location.
-Staff would provide the unit rules regarding smoking and would read and review with the resident at least quarterly and as needed.
-Staff would post smoking times and remind the resident of smoking times as needed.
-Staff members would light the residents smoking materials.
-Smoking materials including lighting materials would be kept in possession of facility staff.
Record review of the resident's quarterly MDS dated [DATE] showed:
-He/she was severely cognitively impaired.
-He/she received supervision and set-up assistance for locomotion in his/her wheelchair.
-He/she had limitations in range of motion on one side of his/her upper and lower body.
Record review of the resident's Physician's Orders Medications and Treatments dated 4/1/22 through 4/30/22 showed his/her physician ordered the following medications:
-Lamotrigine (a medication for seizures that may cause loss of balance or coordination, difficulty thinking or concentrating, drowsiness or dizziness) 100 milligrams (mg) daily.
-Levetiracetam (a medication for seizures that may cause weakness, dizziness, confusion and excessive sleepiness) 500 mg twice daily.
Observation on 4/4/22 at 9:03 A.M. showed:
-He/she was alert, dressed and seated in his/her wheelchair with upright posture.
-He/she propelled himself/herself outside to the smoking area with minimal brief assistance from staff.
-Staff handed him/her a cigarette and lit the cigarette for him/her.
-He/she smoked independently, holding the cigarette in one hand away from his/her clothing while flicking ashes from the cigarette.
-He/she independently deposited his/her cigarette butt into the cigarette receptacle (a product for safe disposal of cigarette butts to reduce the risk caused by lit ends and keep areas clean).
During an interview on 4/6/22 at 11:34 A.M. the resident's Dementia Care Unit charge nurse, Licensed Practical Nurse (LPN) B said:
-The resident smokes independently with staff supervision.
-There were no safety issues with him/her smoking.
-He/she was able to hold and dispose of his/her cigarettes independently.
-He/she was safe with his/her smoking.
-Staff kept all resident's smoking materials, lit all residents' cigarettes and supervised all residents outside during designated smoking times.
-He/she did not complete any smoking assessments for any resident's who smoked.
-He/she did not know who was supposed to complete smoking assessments.
During an interview on 4/6/22 at 1:28 P.M. the Director of Nursing (DON) said:
-Smoking assessments were to be completed on admission for residents who smoked, prior to smoking for a resident who previously had not smoked but decided to smoke, and quarterly or as needed for any change in thee resident's condition.
-Responsibility for completion of smoking assessments had previously been with social services, but in the current absence of the facility having a social service staff, the responsibility may be his/hers until the social services position was filled.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Tube Feeding
(Tag F0693)
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 assess placement of a percutaneous endoscopic gastrost...
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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 assess placement of a percutaneous endoscopic gastrostomy tube (PEG tube - a tube that is placed into a patient's stomach as a means of feeding them when they are unable to eat) using the current standard of practice and to have a policy in place reflecting the standard of practice for one sampled resident (Resident #31) out of 17 sampled residents. The facility census was 67 residents.
Record review of the facility policy titled Enteral Feedings revised 2/08 showed:
-Placement of tube will be confirmed via aspiration.
-If unable to confirm placement via aspiration, air instillation (auscultation) method may be used.
-Placement will be confirmed prior to giving medications.
-Note: The policy did not reflect the current standard of practice for assessing PEG tube placement.
Record review of Center for Clinical Standards and Quality/ Survey & Certification Group (S & C) 12-47 dated 9/27/12 showed facility policies and procedures regarding the technical aspects of feeding tubes must be developed and implemented, which address:
-Monitoring the feeding tube.
--How to verify that the tube is functioning before beginning a feeding and before administering medications.
--Checking gastric residual volume (GRV).
--Observing changes in external length of tubing may indicate a change in position but can only be used if the exit site was marked upon initial placement; this method does not apply to low profile G tubes (tube that sits at skin level).
-NOTE: Auscultation was no longer recommended for checking placement of the feeding tube. Movement of air would likely be heard whether the tube was in the correct or incorrect location. X-ray confirmation is the most accurate method for verification of tube placement when concerns arise regarding dislodgement or placement.
1. Record review of Resident #31's Profile Face Sheet showed he/she was admitted to the facility on [DATE] with the following diagnosis:
-Dysphagia (inability or difficulty swallowing) following cerebral infarction (stroke).
-Abnormal weight loss.
-Adult failure to thrive.
-Esophagitis (inflammation that may damage tissues of the esophagus), unspecified without bleeding.
-Gastro-Esophageal Reflux Disease (GERD back-up of stomach acid/heartburn) with Esophagitis.
Record review of the resident's Care Plan dated 7/20/21 showed:
-Staff would check proper tube placement by aspiration, and auscultation prior to every feeding, every shift, and as needed.
-Staff were to administer tube feeding as ordered by physician.
-Staff were to assess and record for side effects of abdominal pain, distention, constipation, or diarrhea.
-The resident was dependent on staff for administering fluids via his/her feeding tube.
Record review of the resident's Significant Change Minimum Data Set (MDS - a federally mandated assessment instrument completed by facility staff for care planning) dated 12/7/2021 showed:
-He/She had a feeding tube.
-The resident took in more than 51% of total calories through the feeding tube.
-The resident took in more than 501 milliliters (ml) of fluid intake per feeding tube.
Record review of the resident's Physician's Orders Sheet (POS) dated 4/2022 showed:
-Eliquis (used as a prophylaxis against stroke) 2.5 milligram (mg) per tube 1 tablet twice a day.
-Hydrocodone-Acetaminophen (an opioid narcotic pain medication) 10/325 mg 1 tablet as needed every 4 hours per tube.
-Miralax powder (a laxative used to treat constipation) 17 grams daily per tube.
-Prilosec (used to treat GERD) 2 packets daily per tube.
-Valporic acid (an anticonvulsant used to treat seizures) 5 ml three times a day per tube.
-Jevity 1.2 (fiber-fortified therapeutic nutrition that provides complete, balanced nutrition for long- or short-term tube feeding) to be hung at a continuous rate of 50 ml/hr.
-Water bolus 200 ml per tube 3 times daily.
-Check PEG tube residual prior to feedings and every 8 hours; if above 100 ml hold feeding and notify the physician.
-Cleanse PEG tube site with tap water or normal saline, apply A&D ointment (forms a protective barrier to seal out wetness), and then cover with sterile split sponge daily and as needed.
Observation on 4/5/22 at 11:35 A.M., of Licensed Practical Nurse (LPN) C prior to medications being administered showed:
-He/she checked for residual and there was no residual.
-He/she then checked tube placement by auscultation, by injecting 20 ml of air into the PEG tube and listened for the bubbling.
-He/she did not check measurement of the tube prior to administering the above medications.
During an interview on 4/5/22 at 12:13 P.M., LPN C said:
-Placement was checked per facility policy by checking residual and auscultation.
-This was how he/she was taught in nursing school to check placement.
-He/she reviewed the facility policy prior to assessing the site and giving medications.
-The facility had not instructed him/her of any changes to PEG tube site assessment.
-If the resident was cognitively intact, he/she would also ask the resident if he/she felt any discomfort at the PEG tube site.
During an interview on 4/5/22 at 2:03 P.M., the Director of Nursing (DON) said:
-It was the expectation that PEG tube placement would be check per the policy.
-The policy said to check by residual and air insertion (auscultation).
-The policy should have reflected current standards if they had changed.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0740
(Tag F0740)
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 necessary oversight and intervention; and fai...
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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 necessary oversight and intervention; and failed to care plan, fully assess, and thoroughly document the behavioral needs of one sampled resident (Resident #29) who had a known behavior of targeting certain residents and pinching and scratching them. Additionally, the facility failed to fully assess the impact of the resident's behavior on other residents by not comprehensively assessing and documenting injuries (bruises and scratches) that were sustained from the pinching and scratching for one sampled resident (Resident #61) out of 17 sampled residents. The facility census was 67 residents.
Record review of the facility's Behavior Record Guide, Informational dated 9/1/19 showed:
-The monthly Behavior Record form (dated 9/1/19) should be completed to include the resident's name, diagnosis pertinent to the stated behavior (if known), any psychotropic medication pertinent to the stated behavior (if known), and target behavior.
-Instructions for completing the form include:
--Refer to the Care Plan to state the goal that corresponds to the listed target behavior.
--List one to four interventions from the Care Plan that have been found most effective and caregivers will most often use to assist the resident in managing the target behavior.
--Notify the Social Services Designee (SSD)/Psychosocial Director or Minimum Data Set (MDS - a federally mandated assessment instrument completed by facility staff for care planning) Coordinator for inclusion on the Behavior Record and updating of the Care Plan.
--Each shift should document under the appropriate date and shift for the target behavior, the frequency of the behavior, the corresponding number to the intervention used to assist the resident in managing the behavior, and the outcome related to the intervention used.
--A code of C may be used if the frequency is constant or continuous throughout over 50% of the shift.
-Code according to the effectiveness of the intervention as follows:
--1 if the behavior stopped, 2 if the behavior decreased, 3 if the behavior increased and 4 other (see nurse's note).
-The Behavior Record is to be completed daily and includes staff initials at corresponding dates and shifts and signatures with initials at the bottom of the page.
-At the end of the month, a behavioral summary should be done by the SSD/Psychosocial Director in the Social Services (SS) notes or on the Interdisciplinary Progress note.
-Members of the care giving team should communicate behavioral needs to the SSD/Psychosocial Director so the information can be included in the documentation.
-The Behavior Record form included spaces to document according to instruction in the guide.
A resident to resident behavioral policy or behavioral policy that included resident to resident behaviors was requested and not provided.
1. Record review of Resident #29's Face Sheet showed he/she was admitted to the facility on [DATE] with diagnoses that included:
-Cerebral palsy, unspecified (CP -a condition in which parts of the brain that affect movement either do not develop correctly or are damaged before, during or very shortly following birth).
-Aphasia (a language disorder caused by brain damage that affects a person's ability to communicate).
-Neuropathy (a condition in which there is nerve damage causing weakness and pain, usually in the hands and feet).
Record review of the resident's Psychiatric Services Note, dated 7/7/20 showed:
-The resident had been more aggressive towards other residents.
-He/she had been pinching and was yelling, screaming and loudly disruptive.
-His/her Mental Status Exam showed he/she was agitated and restless.
--Staff was to redirect the resident as needed and encourage participation in activities.
Record review of the resident's Psychiatric Services note, dated 2/2/21 showed:
-The resident was treated the past year for impulsivity (acting or tending to act suddenly and without careful thought) and psychosis.
-He/she had CP and intellectual problems.
-The resident was impulsive, delusional (beliefs or impressions that are contradicted by reality or rational argument), and had impaired memory.
-The resident's mental status exam showed he/she was confused, restless and incoherent.
Record review of the resident's Social Services notes from 6/8/21 through 8/3/21 showed:
-Social Service notes were written on 6/8/21 and 7/19/21.
-There was no mention of the resident's behaviors in either note.
Record review of the resident's interdisciplinary progress notes from 6/8/21 through 8/3/21 showed no interdisciplinary notes mentioning the resident's behaviors.
Record review of the resident's Psychiatric Services note, dated 8/3/21 showed:
-The resident had episodes of impulsivity and making deep vocal noises, but was redirectable.
-The resident was confused, a poor historian and had poor memory.
-Recommendations were to redirect the resident when needed, don't force the resident to do things when agitated, and encourage participation in activities.
Record review of the resident's Social Services notes from 8/4/21 through 11/26/21 showed:
-A Social Service note was written on 11/26/21.
-There was no mention of the resident's behaviors in the note.
Record review of the resident's interdisciplinary progress notes from 8/4/21 through 11/26/21 showed no interdisciplinary notes mentioning the resident's behaviors.
Record review of the resident's quarterly Minimum Data Set (MDS a federally mandated assessment tool completed by facility staff for care planning) dated 11/26/21 showed:
-The resident was severely cognitively impaired.
-The resident had no physical or verbal behaviors directed towards others.
-The resident had other behaviors (hitting/scratching self, disruptive sounds, screaming).
-The resident used a wheelchair and was able to move independently from area to area with staff supervision or oversight.
Record review of the resident's Comprehensive Care Plans with the most recent revision dated 12/3/21 showed:
-The resident had no Behavioral Care Plan.
-There were no care plans that described the resident's behaviors or non-pharmacological interventions staff were to implement when the resident displayed behaviors.
Record review of the resident's Nursing notes from 12/26/21 through 2/26/22 showed:
-A note on 12/30/21 showed the resident and another resident (Resident #61) were heard screaming in the dining room.
-The other resident (Resident #61) said this resident (Resident #29) pinched him/her.
-There was a bright red mark on the other resident's (Resident #61's) arm.
-When asked if the resident (Resident #29) pinched the other resident (Resident #61) he/she (Resident #29) screamed No!
-The other residents in the dining room said they saw the resident (Resident #29) pinch the other resident (Resident #61).
-A note dated 2/5/22 showed the resident (Resident #29) had been up screaming at times. He/She was usually easily redirected. Would continue to monitor.
-A note dated 2/26/22 showed the resident's (Resident #29's) responsible party was contacted related to the resident's issues of not sleeping at night.
-The nurse suggested Melatonin (a sleep aid supplement) which the responsible party was in agreement.
Record review of the resident's MDS assessments and care planning showed:
-There was no quarterly MDS completed for the resident in February, 2022.
-No behavioral assessment results were available and no corresponding updates were made to the resident's care plan.
Record review of the resident's Psychiatric Services note, dated 3/1/22 showed:
-The resident was evaluated and treated last year for impulsivity, yelling out, depression, and cognitive impairment.
-He/She was referred for evaluation for not sleeping at night and continued to be calling out.
-The resident was diagnosed with chronic pain. Would increase his/her Gabapentin (an anticonvulsant and nerve pain medication) which might help him/her to sleep at night.
Record review of the resident's Social Services notes dated 3/17/22 showed:
-The resident's assessments were conducted with staff due to the resident's poor cognition.
-The resident required assistance with most Activities of Daily Living (ADLs - eating, dressing, hygiene, toileting) and was dependent on 24 hour care from staff.
-The resident used a wheelchair for locomotion around the facility.
-He/she spent most of his/her leisure time in the lobby watching television or roaming around.
-The resident yelled out at times, especially when he/she wanted or needed something.
-The resident's family member was his/her decision-maker.
-There were no discharge plans at this time. Would continue to monitor.
-The note did not mention the resident's behavior of pinching other residents.
Record review of interdisciplinary progress notes from 3/1/22 through 4/4/22 showed no interdisciplinary notes mentioning the resident's behaviors.
Record review of the resident's Nurse's notes, dated 4/4/22 showed there was no note in the resident's record related to any resident behaviors, including documentation that the psychiatrist, Administrator or Director of Nursing (DON) had been contacted regarding any resident behaviors.
2. Record review of Resident #61's Face Sheet showed he/she was admitted to the facility on [DATE] with diagnoses that included:
-Personal history of traumatic brain injury (TBI - a sudden injury causing damage to the brain).
-Congenital malformations of the eye (problems during embryonic development causing eye malformations).
Record review of the resident's Nurse's note, dated 12/30/21 showed:
-The resident and another resident (Resident #29) were heard yelling in the dining room.
-The resident had a red mark to his/her upper arm.
-The other resident (Resident #29) was removed from the area.
Record review of the resident's Psychiatric Services note, dated 2/1/22 showed:
-The resident had no behavioral problems.
-He/She was pleasantly confused and a poor historian.
-His/Her Mental Status Exam showed the resident was alert and oriented to self, was cooperative, had slow speech and motor activity and was easily distracted.
Record review of the resident's quarterly MDS, dated [DATE] showed the resident:
-Was severely cognitively impaired.
-Had no behaviors towards other residents or any other behaviors.
-Used a wheelchair and required one-person limited assistance for locomotion
Record review of the resident's Comprehensive Care Plans, updated 2/2/22 showed:
-The resident's Long and Short Term Memory Deficit Care Plan, reviewed 2/2/22 showed the resident had head trauma and a TBI from a gunshot wound many years ago resulting in severe cognition problems.
-Staff were to approach the resident in a calm manner and monitor for signs and symptoms of confusion.
-The resident's Impaired Cognition Care Plan, reviewed 2/2/22 showed staff were to maintain personal items in the same place and maintain a consistent routine and schedule.
-The resident's ADL Care Plan, reviewed 2/2/22 showed the resident needed limited assistance with bed mobility, extensive assistance with dressing, grooming, hygiene, toileting and bathing. He/she used a wheelchair which both staff and the resident propelled.
-The resident's Behavior Care Plan, reviewed 2/2/22, showed he/she became easily agitated and annoyed and could become resistive to cares. He/She was to be approached in a calm manner with all procedures explained.
Record review of the resident's Social Service progress note, dated 3/22/22 showed:
-The resident was alert and oriented to self, but not time or place with severe cognitive impairments.
-The resident had a TBI which created difficulty with retaining information.
-Staff reported the resident was dependent on them for all care needs. The resident was also legally blind.
-The resident had an active Durable Power of Attorney (DPOA legal authorization for a designated person to make decisions about another person's property, finances, or medical care) who was his/her decision-maker.
Record review of the resident's Nurse's note dated 4/4/22 showed:
-The resident was sitting in the dining room when another resident (Resident #29) began pinching and scratching the resident's arm.
-The resident's arm was assessed by the nurse with scratches noted and no bleeding noted.
-The resident said he/she was OK and vital signs (body temperature, pulse and respiration rates, and blood pressure) and oxygen saturation levels were obtained.
-The Nurse Practitioner, Director of Nursing (DON), responsible party, and change of shift nurse were notified.
-Note: The note did not show where the scratches were located, the size of the scratches or how many there were and did not mention other skin issues such as redness or bruising.
Any available skin assessments/monitoring sheets for Resident #61 dated 4/4/22 through 4/6/22 were requested, but not provided.
3. Observation on 4/4/22 between 5:20 A.M. through 6:57 A.M. showed:
-At 5:20 A.M. Resident #61 sat in his/her wheelchair at a dining room table facing the other dining room tables.
-At 5:22 A.M. Resident #29 wheeled his/her wheelchair to the left side of Resident #61 and pinched Resident #61's outer upper left arm and then screamed while clenching his/her fists while holding them up.
-Resident #61 placed his/her right hand on his/her upper left arm when Resident #29 pinched him/her.
-Resident #29 continued to intermittently scream and pinch Resident #61 on his/her upper left arm while Resident #61 continued to try to cover his/her upper left arm with his/her right hand. In total Resident #61 was pinched six times by Resident #29.
-At 5:26 A.M. Resident #29 wheeled himself/herself away from the table and frequently moved his/her wheelchair approximately three to six feet behind Resident #61 while Resident #61 continued to hold onto his/her left upper arm.
-There was no staff member in the area.
-At 5:36 A.M. Resident #29 wheeled himself/herself back to Resident #61's left side and continued to intermittently pinch Resident #61 on the outer left upper arm.
-Resident #61 tried to cover his/her upper left arm with his/her right hand. Between pinches Resident #29 would scream loudly.
-At 5:40 A.M. Resident #29 reached with his/her left arm and appeared to scratch Resident #61 on the left outer forearm while Resident #61 tried to cover his/her forearm with his/her right hand.
-Resident #29 continued to scream and tried again to scratch Resident #61 on the left forearm.
-There continued to be no staff member in the area.
-At 5:42 A.M. Registered Nurse (RN) A wheeled Resident #61 out of the dining room area.
-At6:01 A.M. RN A wheeled Resident #61 back into the dining room and parked his/her wheelchair in front of the television.
-At 6:05 A.M. on Resident #61's lateral (outer) upper left arm there were four reddish circles approximately one-half inch in diameter. There were two light purple colored circles on the resident's left anterior (front) lateral upper arm approximately one-half inch in diameter and a light purple coloration approximately one-half inch in diameter three inches above the resident's left elbow on the posterior (back) lateral upper arm.
-There were four scratches on the resident's left outer forearm, approximately one and one-fourth inch long. Two were scabbed over and two were not. The two without scabs were not bleeding.
-At 6:57 A.M. a faint purple coloration was visible around the scratches on the left forearm.
During an interview on 4/4/22 at 8:49 A.M., the Certified Nurse Aide (CNA) B said:
-Resident #29 had behaviors of screaming.
-Resident #29 would raise his/her hands and hit his/her legs.
-Resident #29 had behaviors towards Resident #61 and pinched Resident #61 more than once a month.
-Staff often brought Resident #61 to the front of the building to where the birds were. Resident #29 did not go to that area.
-Resident #29 used to pinch another resident who was at the facility.
-Staff were supposed to redirect Resident #29 because Resident #61 just sat there when Resident #29 pinched him/her.
During an interview on 4/4/22 at 9:27 A.M., Agency CNA C said:
-He/she had worked with Resident #29 four or five times. The resident made noises and was easily frustrated and yelled out.
-He/she had seen Resident #29 clench and shake while holding his/her fists up when agitated.
-He/she never saw Resident #29 act out towards another resident.
During an interview on 4/4/22 at 9:47 A.M., CNA D said:
-Resident #29 screams at Resident #61.
-He/she had caught Resident #29 pinching Resident #61 before.
-Resident #29 did this maybe once every two weeks or so when CNA's were getting people up for breakfast.
-He/she didn't notice the behavior as much throughout the day, probably because there was more for Resident #29 to do later in the day.
-There was usually nobody in the area when Resident #29 had behaviors towards Resident #61.
-He/she had worked at the facility almost a year and Resident #29 had been pinching and screaming at Resident #61 since he/she had worked at the facility.
-Resident #29 did not have behaviors towards any other current resident.
-He/she had seen a red mark before on Resident #61 resembling a pinch mark.
-When Resident #29 was pinching or screaming at Resident #61 CNA's were to report the behavior to the nurse and try to redirect Resident #29's attention to get him/her involved in an activity.
-Resident #29 had lotion in his/her room. It calmed him/her down a lot when staff applied lotion to his/her skin.
During an interview on 4/5/22 at 9:37 A.M. Licensed Practical Nurse (LPN) C said:
-Resident #29's behaviors were mostly yelling out. The screaming seemed to become worse and more frequent over the past couple of years.
-The resident was unable to answer yes or no questions.
-Resident #29 attempts to pinch Resident #61, usually on the upper arms or his/her forearms.
-He/she was informed by Agency Registered Nurse (RN) A during shift change of Resident #29's behaviors earlier in the morning of 4/4/22.
-Resident #61 did nothing when Resident #29 pinched him/her.
-Resident #29 probably pinched Resident #61 because he/she didn't do anything back.
-He/she wasn't sure if Resident #29 ever scratched Resident #61.
-Nurses have an order to monitor Resident #61's arms.
-Staff were to move Resident #29 when he/she pinched and screamed at Resident #61 and then redirect Resident #29's attention.
-He/she was not aware of any injuries inflicted on Resident #61 except for bruises.
-If Resident #29 wanted something someone else had, he/she would throw a fit and scream until he/she got it.
-Resident #29 had stuffed kitties in his/her room. Staff try to get his/her attention on that when he/she was screaming.
-Resident #29 was self-mobile in his/her wheelchair and Resident #61 didn't move around much. -Resident #61 was blind in one eye and visually impaired in the other.
-Resident #61 was capable of wheeling himself/herself, but usually didn't.
During an interview on 4/5/22 at 9:52 A.M., Resident #29's Psychiatrist said:
-The facility called him/her and would let him/her know when Resident #29 had behaviors.
-The resident was childlike and had Intellectual Disabilities (ID).
-Behaviors consisted of screaming and pinching other residents.
-The resident had intrusive behaviors of getting in other people's faces or personal spaces.
-He/she came to the facility monthly and the facility would give him/her a list of residents with recent behaviors that they wanted him/her to see.
-The charge nurse and/or the Social Worker discussed resident behaviors with him/her.
-The resident was seen last month and medications were adjusted and he/she was planning to see the resident again today.
-He/she sees the resident probably five times a year or as needed.
During an interview on 4/5/22 at 10:02 A.M., LPN C said:
-Resident #29 had been having difficulty sleeping recently. He/She would lay down at bedtime and get up every couple of hours.
-He/she had discussed with the psychiatrist it might help the resident's behaviors if he/she slept better at night.
-A PRN order for Melatonin 5 mg daily at HS was added to the resident's medications on 3/1/22. If the resident had difficulty falling asleep they would give him/her the Melatonin.
-The resident's Gabapentin was increased on 3/1/22 from 5 ml BID to 5 ml TID to see if the behaviors were pain-related.
-The physician or Nurse Practitioner came in weekly and Resident #29's behaviors were discussed with them. Behaviors were always discussed with the psychiatrist.
During an interview on 4/5/22 at 12:14 P.M., the MDS Coordinator said:
-He/she got behavioral information from the Social Worker, from the nurses, and from review of the resident's record.
-The previous Social Worker's information had not been updated so he/she wasn't getting all the resident's behavioral information to include in the MDS's and had gotten behind in completing the resident's most recent MDS.
During an interview on 4/5/22 at 12:36 P.M., LPN A said:
-The facility previously used behavioral sheets and charted behaviors in a behavioral book. For the past six to 12 months they had been charting behaviors in the Nurse's notes.
-Resident #29 had behaviors of screaming, screeching when wanting something like coffee, and making loud noises. If there was an activity in the dining room the resident didn't want to participate in he/she made loud noises and disrupted the activity.
-If there was a scab on his/her arm he/she would pick and scratch at it. That is why he/she was wearing protective sleeves. He/She is capable of removing the sleeves, but leaves them on during the day.
-Resident #29 would pinch Resident #61 and make lots of noise. For some reason he/she was fixated on Resident #61. Resident #61 didn't say or do anything.
-Before Resident #29 had behaviors toward Resident #61 he/she targeted another resident and would pinch him/her. That resident would defend himself/herself verbally more.
-Resident #61 might place his/her hand on his/her arm or might say No, but his/her voice was soft. He/She had seen yellowing bruises from the pinch marks on Resident #61 on his/her outer back upper arm.
-He/She had not actually seen Resident #29 pinch Resident #61, but he/she heard Resident #29's loud vocalizations and saw Resident #61 holding onto his/her upper arm.
-Staff were supposed to separate the two. They were both frequently out of their rooms.
-Resident #29 would seek out Resident #61. He/She did the same thing to the previous resident he/she targeted.
-Resident #61 liked to watch the birds in the front of the building. Resident #29 didn't like going over the threshold into the front area where the birds were.
-He/she had seen Resident #29 waiting for Resident #61 to leave the front area.
-They can't put Resident #29 on the dementia unit because those residents aren't capable of communicating what is happening and it could generate behaviors in other residents on the unit. The facility tried Resident #29 on the dementia unit over a year ago.
-Resident #29's behaviors were intentional. He/She didn't know why the resident chose the residents he/she targets. He/She didn't think there was a pattern such as a particular time of day Resident #29 acted out towards other residents, but he/she usually did so when not too many staff or other residents were around.
-Resident #29 liked play dough, coloring, and puzzles. He/She was usually actively involved when he/she has the opportunity to participate in activities. He/She also liked coffee, but coffee didn't seem to calm him/her. It was possible an activity might be enough to distract him/her from pinching.
-Resident #29 probably pinched Resident #61 two or three times a month. He/She hears about it when others have observed the behavior.
During an interview on 4/6/22 at 1:05 P.M., the DON said:
-The facility policy was that every resident on psychotropic medication should have identified target behaviors. The facility should be documenting on those behaviors using behavior sheets.
-There should be approximately three non-pharmacological interventions that are known to help the resident with each target behavior.
-Nurses were now documenting behaviors in Nurse's notes and they write behavioral incidents on 24 hour report sheets.
-If there were behaviors or the resident was agitated the nurse was supposed to contact the DON.
-Behaviors were discussed in morning meetings and staff tried to come up with non-pharmacological interventions to address the behaviors.
-The interventions should be added to the resident's behavior care plan.
-The resident's with behaviors should have a behavior care plan.
-Nurses kept a list of residents needing to be seen by the psychiatrist who came to the facility the first Tuesday of every month.
-Staff should monitor Resident #29 and keep him/her away from Resident #61. When there was a behavior against another resident the nurse should contact him/her or the Administrator.
-The nurse should assess Resident #61's skin if he/she had been pinched or scratched.
-He/She didn't know why Resident #29 liked to pick on Resident #61.
-He/She thought it might be because he/she was an easy target.
-Staff should be monitoring Resident #29 since they know he/she had behaviors against another resident.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0569
(Tag F0569)
Could have caused harm · This affected multiple residents
Based on interview and record review, the facility failed to notify three sampled residents (Residents #61, #50 and #52) who had amounts in their resident trust which exceeded the $4,835.00, which is ...
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Based on interview and record review, the facility failed to notify three sampled residents (Residents #61, #50 and #52) who had amounts in their resident trust which exceeded the $4,835.00, which is within $200 of the limit of $5,035.00 limit for required notification to residents to spend down. This practice affected three residents. The facility census was 67 residents.
1. Record review of Resident #61's trust fund yearly statement dated 1/1/22 through 3/31/22, showed the resident had the following balances:
-A balance of $9,240.42 on 1/31/22.
-A balance of $9,292.56 on 2/28/22.
-A balance of $9,342.56 on 3/31/22.
2. Record review of Resident #50's trust fund yearly statement dated 1/1/22 through 3/31/22, showed the resident had the following balances:
-A balance of $5,421.39 on 2/28/22.
-A balance of $6,987.36 on 3/31/22.
3. Record review of Resident #52's trust fund yearly statement dated 1/1/22 through 3/31/22, showed the resident had the following balances:
-A balance of $5,858.68 on 1/31/22.
-A balance of $5,910.04 on 2/28/22.
-A balance of $5,960.04 on 3/31/22.
During an interview on 4/5/22 at 12:01 P.M., the Business Office Manager (BOM) said he/she:
-Did not find files or copies of the letters that were given to those residents to notify them that their amounts exceeded the limit of $5,035.00.
-Was very new to the position.
-Did marketing and admissions for the facility from 2012 until April 2022.
-Was given less than eight hours of training which covered the following areas of resident trust: how to make deposits, writing checks to the cash box, and writing checks to the facility for room and board.
-Was not given training on the regulations.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0570
(Tag F0570)
Could have caused harm · This affected multiple residents
Based on interview and record review, the facility failed to maintain a surety bond (a promise to be liable for the debt, default, or failure of another; It is a three-party contract by which one part...
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Based on interview and record review, the facility failed to maintain a surety bond (a promise to be liable for the debt, default, or failure of another; It is a three-party contract by which one party (the surety or bond company) guarantees the performance or obligations of a second party (the principal (the nursing home) to a third party (the oblige--the residents who are a part of the resident trust)) that was one and one half times the average of the monthly balance of the reconciled bank statements for the resident trust. This practice potentially affected 14 residents who allowed the facility to manage their resident funds. The facility census was 67 residents.
1. Record review of the instructions for determining what a surety bond amount should be, showed:
-The monthly reconciled bank statements and the monthly ending petty cash (the amount of cash that the facility keeps to be accessible to the residents) are added together for each of the previous (usually 9-12) months since the last survey.
-The total amount of those totals are added together for a grand total.
-That grand total is divide the number of active months for a monthly average.
-That monthly average is rounded up or down to the nearest thousand.
-That new figure is multiplied by 1.5 for the required bond amount.
Record review of the facility's surety bond with a Department of Health and Senior Services (DHSS) approval date of 5/21/13, showed a bond limit of $60, 00.00, which was $10,500.00.
Record review of the average balance of the resident trust showed:
-A balance of $47,365.28 which was rounded down to $47,000.00.
-$47,000.00 was multiplied by 1.5 indicating that the facility's required bond amount should have been $70,500.00.
During an interview on 4/5/22 at 10:44 A.M., the Business Office Manager (BOM) said he/she has only had that position for three days and was unaware that the bond amount was insufficient.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0582
(Tag F0582)
Could have caused harm · This affected multiple residents
Based on interview and record review, the facility failed to provide a Notice of Medicare Non-Coverage (NOMNC) for two sampled residents (Resident #1 and #61) and one supplemental resident (Resident #...
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Based on interview and record review, the facility failed to provide a Notice of Medicare Non-Coverage (NOMNC) for two sampled residents (Resident #1 and #61) and one supplemental resident (Resident #267) and failed to provide a Skilled Nursing Facility Advanced Beneficiary Notice (SNF ABN) for two sampled resident (Resident #1 and #61) who remained in the facility but were discharged from Medicare part A services out of three residents sampled for beneficiary notices. The facility census was 67 residents.
The facility did not have a policy regarding SNF ABNs or NOMNCs.
Record review of the undated Form Instructions for the NOMNC (Centers for Medicare and Medicaid Services Survey and Certification (CMS)-10123 showed the NOMNC must be delivered at least two calendar days before Medicare coverage services end.
Record review of the CMS memo (S&C-09-20), dated 1/9/09, showed:
-The NOMNC, form CMS-10123 is issued when all covered Medicare services end for coverage reasons;
-If the SNF believes on admission or during a resident's stay that Medicare will not pay for skilled nursing or specialized rehabilitative services and the provider believes that an otherwise covered item or service may be denied as not reasonable or necessary, the facility must inform the resident or his/her legal representative in writing why these specific services may not be covered and the beneficiary's potential liability for payment for the non-covered services. The SNF's responsibility to provide notice to the resident can be fulfilled by the use of the SNF ABN (form CMS-10055);
-The SNF ABN provides an estimated cost of items or services in case the beneficiary had to pay for them him/herself or through other insurance they may have; and
-If the SNF provides the beneficiary with either the SNF ABN or a denial letter at the initiation, reduction, or termination of Medicare Part A benefits, the provider has met is obligation to inform the beneficiary of his/her potential liability for payment and related standard claim appeal rights. Issuing the NOMNC to a beneficiary only conveys notice to the beneficiary of his/her right to an expedited review of a service termination.
1. Record review of the facility's undated Beneficiary Notice-Residents discharged in the Last Six Months showed:
-Resident #1 was discharged from Medicare Part A skilled services on 11/3/21 and stayed at the facility.
-Resident #267 was discharged from Medicare Part A skilled services on 1/16/22 and went home.
-Resident #61 was discharged from Medicare Part A skilled services on 3/2/22 and stayed at the facility.
2. Record review of Resident #1's SNF Beneficiary Protection Notification Review form showed:
-The resident had a Medicare part A skilled stay from 10/28/21 to 11/3/21.
-Handwritten by the Business Office Manager (BOM) showed cannot find proof of completion.
-ABNs and NOMNCs were not completed.
3. Record review of Resident #267's SNF Beneficiary Protection Notification Review form showed:
-The resident had a Medicare part A skilled stay from 1/5/22 to 1/16/22.
-Handwritten by the BOM showed cannot find proof of completion.
-The NOMNC was not completed.
4. Record review of Resident #61's SNF Beneficiary Protection Notification Review form showed:
-The resident had a Medicare part A skilled stay from 2/5/22 to 3/2/22.
-Handwritten by the BOM showed cannot find proof of completion.
-ABNs and NOMNCs were not completed.
5. During an interview on 4/5/22 at 2:47 P.M. the BOM said:
-The previous BOM was responsible for completing and monitoring NOMNCs and ABNs.
-The previous BOM was no longer at the facility.
-He/she completed the Beneficiary Protection Notification Review form.
-He/she started in the BOM position on 4/1/22.
-The NOMNC and ABNs were to be given to the resident and/or responsible party two days prior to the last covered day.
-The NOMNCs and ABNs were not found in the resident files in the business office.
-These forms should have been provided to the residents.
During an interview on 4/6/22 at 1:06 P.M. the Director of Nursing (DON) said:
-The BOM was responsible for the NOMNCs and ABNs.
-During the Medicare part A meeting on Friday each week Medicare part A discharges were discussed.
-The BOM attended the meeting and would then give the ABNs and NOMNCs three days prior to the last covered day.
-He/she expected these to be completed for residents.
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 and interview ,the facility failed to maintain the mattresses in resident rooms [ROOM NUMBERS] in an easily...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview ,the facility failed to maintain the mattresses in resident rooms [ROOM NUMBERS] in an easily cleanable condition; to maintain three ceiling fans in the Special Care Unit (SCU) free of a buildup of dust; to maintain the base of two stand-up lifts without cracks; to maintain the ceiling vents in the 300 hall shower room and the restrooms of resident rooms 306, 302, 212, 203, 201, 109, 108, 105, 103, and the north dining room, free of a heavy buildup of dust inside the vents; to maintain the commode seats in the restrooms of resident rooms [ROOM NUMBERS] in an easily cleanable condition; and to maintain the base of two stand-up lifts without cracks. This practice potentially affected at least 40 residents who resided in or used those areas or equipment throughout the facility. The facility census was 67 residents.
1. Observation with the Maintenance Director on 4/4/22 at 10:17 A.M., showed a mattress in resident room [ROOM NUMBER] with an 11 inch (in.) rip which made it not easily cleanable.
During an interview on 4/4/22 at 10:18 A.M., the Maintenance Director said that mattress should have been changed.
Observation with the Maintenance Director on 4/4/22 at 10:56 A.M., showed a mattress in resident room [ROOM NUMBER] with a 22 in. diameter area where the top coating of the mattress was peeling away.
During an interview on 4/4/22 at 10:57 A.M., Certified Nurse's Assistant (CNA) E said he/she did not assist the resident in getting up that morning, and the CNA who assisted the resident in getting up should have written a work order to let the maintenance department know.
During an interview on 4/4/22 at 10:59 A.M. the Maintenance Director said:
- If an employee finds a defective mattress that employee should write a work order.
- He/she checked the work orders daily.
- He/she checked the work orders that morning and did not see anything about the damaged mattress in resident room [ROOM NUMBER].
During an interview on 4/6/22 at 10:41 A.M. the Director of Nursing (DON) said:
- He/she expected the CNAs to examine the mattresses when they change the bed sheets.
- If a mattress needed to be replaced, they should contact her, so he/she could help them find a good mattress.
- If there is not a good mattress in storage, he/she would obtain a quote on a new mattress and have it ordered.
2. Observation with the Maintenance Director on 4/4/22 at 10:26 A.M., showed three ceiling fans with a heavy dust buildup of dust on the blades of the fans with at least 12 residents who used the dining room for recreation at that time.
During an interview on 4/4/422 at 10:31 A.M. the Housekeeping Supervisor said the housekeeping staff missed cleaning a few fans the previous week and the fans should be cleaned once per week.
3. Observation with the Maintenance Director on 4/4/22 at 11:17 A.M., showed Stand-Up Lift A in the 500 Hall shower room with a two in. crack in the base of that stand up lift.
During an interview on 4/4/22 at 11:18 A.M., the Maintenance Director said the crack in the base of the Stand-Up lift A was difficult to notice.
Observation on 4/4/22 at 12:23 P.M., showed Stand-Up Lift B located on the 300 Hall with a two in. crack in the base.
Observation on 4/5/22 at 11:05 A.M., showed Stand up lift B located in a storage room on the 200 Hall had a two in. crack in the base of that stand-up lift.
During an interview on 4/5/22 at 2:46 P.M., Agency CNA C said he/she just used Stand-up lift B to assist a resident in transferring, but he/she did not notice the crack on the base of the lift because that crack was hard to notice.
During an interview on 4/6/22 at 10:49 A.M., the DON said he/she expected the facility staff who used the equipment to inspect that equipment for any kind of damage before they use it.
4. Observation with the Maintenance Director on 4/4/21 at 2:39 P.M., showed the commode seat with areas that were not easily cleanable due the coating peeling away in the restroom of resident room [ROOM NUMBER].
Observation with the Maintenance Director on 4/4/21 at 2:54 P.M., showed the commode seat with areas that were not easily cleanable due the coating peeling away in the restroom of resident room [ROOM NUMBER].
During an interview on 4/4/21 at 2:55 P.M., the Maintenance Director agreed that some of the commode seats needed to be discarded.
5. Observation with the Maintenance Director on 4/4/22, showed the following:
-At 12:19 P.M., a heavy buildup of dust was present inside the three ceiling vents in the 300 Hall shower room.
-At 12:20 P.M., the Maintenance Director said the housekeepers are supposed to keep an eye on those.
- At 1:38 P.M., a heavy buildup of dust was present inside the ceiling vent in the restroom of resident room [ROOM NUMBER].
- At 1:41 P.M., a heavy buildup of dust was present inside the ceiling vent in the restroom of resident room [ROOM NUMBER].
- At 2:20 P.M., a heavy buildup of dust was present inside the ceiling vent in the restroom of resident room [ROOM NUMBER].
- At 2:34 P.M., a heavy buildup of dust was present inside the ceiling vent in the restroom of resident room [ROOM NUMBER].
- At 2:43 P.M., a heavy buildup of dust was present inside the ceiling vent in the restroom of resident room [ROOM NUMBER].
- At 2:54 P.M., a heavy buildup of dust was present inside the ceiling vent in the restroom of resident room [ROOM NUMBER].
- At 2:58 P.M., a heavy buildup of dust was present inside the ceiling vent in the restroom of resident room [ROOM NUMBER].
- At 3:01 P.M., a heavy buildup of dust was present inside the ceiling vent in the restroom of resident room [ROOM NUMBER].
- At 3:03 P.M., a heavy buildup of dust was present inside the ceiling vent in the restroom of resident room [ROOM NUMBER].
During an interview on 4/4/22 at 3:17 P.M., the Maintenance director said dust was present on the other side of the ceiling vents, once we started walking around the North dining room.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0638
(Tag F0638)
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 assess a resident using the quarterly review instrument specified b...
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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 a resident using the quarterly review instrument specified by the State and approved by Centers for Medicare and Medicaid Services (CMS) not less frequently than once every 3 months for nine sampled residents (Resident #31, #9, #34, #32, #27, #47, #45, #7, and #26) out of 17 sampled residents. The facility census was 67 residents.
Record review of the facility policy titled Comprehensive Assessment/MDS (MDS - a federally mandated assessment instrument completed by facility staff for care planning) revised 11/1/2017 showed:
-The facility would comprehensively asses and periodically reassess each resident admitted to the facility.
-The MDS would be re-evaluated quarterly-within 92 days of previous MDS.
-The MDS would be transmitted to the Quality Improvement and Evaluation System (QIES) Assessment Submission and Processing (ASAP) system as required by Federal Regulation and designated in the Resident Assessment Instrument (RAI) Manual.
Record review of the Long Term Care Facility Resident Assessment Instrument 3.0 User's Manual, Version 1.17.1, dated October 2019 showed:
-The MDS was to be completed for all residents in Medicare- or Medicaid-certified nursing homes.
-A quarterly MDS assessment is due 92 calendar days of the previous assessment reference date (ARD - the specific end point of look-back periods in the MDS assessment process; it allows for those who complete the MDS to refer to the same period of time when reporting the condition of the resident).
1. Record review of Resident #31's Face Sheet showed he/she was admitted to the facility on [DATE].
Record review of the resident's MDS's showed he/she:
-Had an admission assessment (required by day 14) dated 7/1/2021
-Had a Quarterly review assessment dated [DATE]
-Had a Significant change in status assessment dated [DATE]
-Did not have a quarterly review assessment dated for March 2022.
2. Record review of Resident #9's Face sheet showed he/she was admitted to the facility on [DATE].
Record review of the resident's MDS's showed he/she:
-Had an admission assessment (required by day 14) dated 8/9/2021.
-Had a Quarterly review assessment dated [DATE].
-Did not have a quarterly review assessment dated for February 2022.
3. Record review of Resident #34's Face sheet showed he/she was admitted to the facility on [DATE].
Record review of the resident's MDS's showed he/she:
-Had an admission assessment (required by day 14) dated 9/18/2021.
-Had a Quarterly review assessment dated [DATE].
-Did not have a quarterly review assessment dated for March 2022.
4. Record review of Resident #32's Face sheet showed he/she was admitted to the facility on [DATE].
Record review of the resident's MDS's showed he/she:
-Had an admission assessment (required by day 14) dated 10/11/2021.
-Had a Significant change in status assessment dated [DATE].
-Did not have a quarterly review assessment dated for March 2022.
5. Record review of Resident #27's Face sheet showed he/she was admitted to the facility on [DATE].
Record review of the resident's MDS's showed he/she:
-Had an admission assessment (required by day 14) dated 11/25/2021.
-Did not have a quarterly review assessment dated for February 2022.
6. During an interview on 4/5/22 at 12:14 P.M., the MDS Coordinator said:
-He/she had been the MDS Coordinator since March 15th 2021
-Quarterly MDS was due every three months.
-The calendar was off when he/she started in March.
-There had been no MDS coordinator since [DATE].
-He/she was a month behind in completing the MDS's and he/she also had to have the MDS's signed by a Registered Nurse (RN).
-He/she was out for illness and other family issues.
-He/she had pulled all assessments due in March up to catch up.
-He/she had notified the corporate office and was told the facility needed two MDS Coordinators.
-The corporate office had a plan in place to hire another MDS Coordinator.
-Residents #31, #9, #34, and #32 did not have assessments completed on time.
-Resident #27's MDS had been completed, but it should have been done sooner.
-The Corporate MDS Coordinator was doing audits quarterly.
-Corporate would send the MDS Coordinator a list of missing assessments based on the audits.
9. Record review of Resident #7' Profile Face Sheet showed he/she:
-Was admitted to the facility on [DATE].
-Had a diagnosis of Dementia (a progressive organic mental disorder characterized by chronic personality disintegration, confusion, disorientation, stupor, deterioration of intellectual capacity and function, and impairment of control of memory, judgment, and impulses).
Record review of the resident's MDS tracking showed:
-Entry into facility 2/9/21.
-admission assessment 2/9/21.
-Quarterly assessment 5/11/21.
-Significant change assessment 8/2/21.
-Quarterly assessment 11/2/21.
-There was no documentation that showed a quarterly assessment was completed in 2/2022.
10. Record review of Resident #26's Profile Face Sheet showed he/she:
-Was admitted to the facility on [DATE].
-Had a diagnosis of multiple sclerosis (MS, a neurological disease that attacks the protective covering of the nerves, leading to impaired sensory and motor nerve function, and in most cases some degree of disability).
Record review of the resident's MDS tracking showed:
-Entry into facility 3/4/21.
-admission assessment 3/4/21.
-Quarterly assessment 6/8/21.
-Quarterly assessment 11/25/21.
-There was no documentation that showed a quarterly assessment was completed in 2/2022.
11. During an interview on 4/5/22 at 12:14 P.M. the MDS Coordinator said:
-He/she had been at the facility as the MDS Coordinator since 3/15/21.
-The calendar was off when he/she started in 3/2021.
-There had not been an MDS Coordinator from 12/20/20 until 3/2021.
-He/she had been out due to illness and family issues and the MDS's were behind.
-Quarterly MDS's were completed every three months.
-The corporate office was aware the MDS's were not completed.
-The corporate office monitors the MDS's quarterly.
-Resident #7 and #26 did not have a quarterly assessment completed in 2/2022 but this should have been completed.
During an interview on 4/6/22 at 1:06 P.M. the Director of Nursing (DON) said:
-The MDS's were behind.
-When the MDS Coordinator started the MDS's were behind.
-The MDS Coordinator was still behind with completing MDS's and care plans.
-The Administrator was looking at possibly looking at hiring a new MDS Coordinator to help the current MDS Coordinator.
-The MDS Coordinator had a schedule of which MDS's that were behind.
-A regional corporate person was working with the MDS Coordinator to monitor and assist him/her with catching up.
-He/she expected the MDS's and care plans to be completed per the required schedule.
-Resident #7's and Resident #26's quarterly MDS should have been completed.
7. Record review of Resident #47's Profile Face Sheet showed he/she was admitted to the facility on [DATE].
Record review of the resident's MDS assessments showed:
-His/her admission MDS was completed on 3/19/21.
-He/she had quarterly MDS's due on 6/17/21, 9/15/21 and 12/14/21 and an annual MDS was due on 3/18/22.
-He/she had two quarterly MDS assessments completed late on 8/24/21 and on 11/19/21.
During an interview on 4/5/22 at 12:40 P.M. the MDS Coordinator said:
-The resident had a quarterly MDS completed on 8/24/21 and on 11/19/22.
-He/she was due for his/her annual MDS in February 2022 and it was not done.
8. Record review of Resident #45's Profile Face Sheet showed he/she was admitted to the facility on [DATE].
Record review of the resident's MDS assessments showed:
-His/her admission MDS was completed on 11/11/21.
-His/her quarterly MDS was due on 2/11/22 and was not completed.
During an interview on 4/6/22 at 12:40 P.M. the MDS Coordinator said:
-The resident's admission MDS was completed on 11/11/21.
-His/her quarterly MDS was due in February 2022 and it was not completed.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
MDS Data Transmission
(Tag F0640)
Could have caused harm · This affected multiple residents
Based on interview and record review,the facility failed to electronically transmit within 14 days of completion 46 out of 100 Minimum Data Set (MDS - a federally mandated assessment instrument comple...
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Based on interview and record review,the facility failed to electronically transmit within 14 days of completion 46 out of 100 Minimum Data Set (MDS - a federally mandated assessment instrument completed by facility staff for care planning) assessment and tracking records (entry/discharge records) electronically transmitted from 1/7/22 through 3/8/22. The facility census was 67 residents.
Record review of the facility Comprehensive Assessment/MDS policy, revised 11/1/20217 showed: The MDS would be transmitted to the Quality Improvement and Evaluation System (QIES) Assessment Submission and Processing (ASAP) system as required by Federal Regulation and designated in the Resident Assessment Instrument (RAI) Manual.
Record review of the Long Term Care Facility RAI 3.0 User's Manual, Version 1.17.1, dated October 2019 showed:
-Nursing homes are required to submit Omnibus Budget Reconciliation Act (OBRA) required MDS records for all residents in Medicare- or Medicaid-certified beds regardless of the pay source to Centers for Medicaid and Medicare Services's (CMS) Quality Improvement and Evaluation System (QIES) Assessment Submission and Processing (ASAP) system.
-Required MDS records include admission/annual/significant change in status/quarterly assessments and tracking records (records of residents' admission/discharge).
-Comprehensive assessments must be transmitted electronically within 14 days of the Care Plan Completion Date (V0200C2 + 14 days).
-All other MDS assessments (quarterly MDS) and tracking records must be submitted within 14 days of the MDS Completion Date.
1. Record review of the facility MDS Electronic transfer record dated 1/7/21 showed eight out of 35 records were submitted greater than 14 days from the completion date.
Record review of the facility MDS Electronic transfer record dated 2/14/22 showed 13 out of 33 records were submitted greater than 14 days from the completion date.
Record review of the facility MDS Electronic transfer record dated 3/8/22 showed 25 out of 32 records were submitted greater than 14 days from the completion date.
During an interview on 4/5/22 at 12:40 P.M. the facility MDS Coordinator said:
-He/she submitted MDS's once a month.
-He/she had submitted MDS's once each month after the fifth of the month.
-He/she had not submitted all comprehensive assessments within 14 days of the residents' care plan dates.
-He/she had not submitted all other MDS's within 14 days of the completion dates.
During an interview on 4/6/22 at 1:06 P.M. the Director of Nursing (DON) said he/she expected all MDS records to be submitted according to instruction in the RAI manual.
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** 3. Record review of Resident #265's admission nurses note dated 2/9/22 showed:
-The resident was admitted to the facility via tr...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Record review of Resident #265's admission nurses note dated 2/9/22 showed:
-The resident was admitted to the facility via transport van.
-The resident's physician was notified and physician's orders were obtained.
Record review of the resident's baseline care plan dated 2/10/22 showed:
-The resident was cognitively impaired, a high elopement risk and wandered.
-The resident was independent with walking, bed mobility, and eating.
Record review of the resident's MDS tracking records on 4/4/22 showed the resident had an entry tracking MDS on 2/9/22 upon entry into the facility.
Record review of the resident's medical record on 4/4/22 showed no comprehensive care plan.
4. During an interview on 4/5/22 at 12:14 P.M. the MDS Coordinator said:
-He/she had been at the facility as the MDS Coordinator since 3/15/21.
-admission assessments were completed fourteen days after admission.
-The calendar was off when he/she started in 3/21.
-There had not been an MDS Coordinator from 12/20/20 until 3/21.
-He/she had been out due to illness and family issues and the MDS's and care plans were behind.
-The corporate office was aware the MDS's and care plans were not completed.
-The corporate office monitors the MDS's quarterly.
-The resident did not have a comprehensive care plan created.
During an interview on 4/6/22 at 1:06 P.M. the DON said:
-The MDS's were behind.
-When the MDS Coordinator started the MDS's were behind.
-The MDS Coordinator was still behind with completing MDS's and care plans.
-The Administrator was looking at possibly hiring a new MDS Coordinator to help the current MDS Coordinator.
-The MDS Coordinator had a schedule of which MDS's were behind.
-A regional corporate person was working with the MDS Coordinator to monitor and assist with catching up.
-He/she expected the MDS's and care plans to be completed per the required schedule.
-Resident #265's should have had a comprehensive care plan created.
Based on interview and record review, the facility failed to develop individualized care plans describing a need or problem and indicating approaches/interventions to assist the resident in relation to the need or problem for two sampled residents (Resident #29 and #41) and to complete a comprehensive care plan addressing all resident needs within 21 days of admission for one sampled resident (Resident #265) out of 17 sampled residents. The facility census was 67 residents.
Record review of the facility's Comprehensive Care Planning policy, revised 11/1/17 showed:
-The facility will comprehensively assess and periodically reassess each resident admitted to the facility. The results of this assessment shall serve as the basis for determining each resident's strengths, needs, goals, and preferences to develop a person-centered, comprehensive plan of care for each resident that will describe the services to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being.
-The following was included in what shall be utilized in the development and maintenance of care plans:
--The comprehensive care plan shall be developed within seven days of the completion of the Resident Assessment Instrument (RAI - utilized for developing all comprehensive assessments, care area assessments and care planning).
--The comprehensive care plan shall be reviewed after each Annual, Significant Change, and Quarterly Minimum Data Set (MDS-a federally mandated assessment tool completed by facility staff for care planning).
--Participants of the Interdisciplinary Team (IDT) in the development and revision of the comprehensive care plan should include the attending physician, Registered Nurse (RN) with responsibility for the resident, Certified Nurse Assistant (CNA) with responsibility for the resident, member of the food service team, and the resident and/or resident representative. Other appropriate staff or professional participation in the IDT shall be based on resident care, services and needs.
--Auxiliary Assessments that serve to further identify or define resident needs and problems.
--Comprehensive care plans shall describe the resident's preferences and goals to assist in attaining or maintaining the resident's highest practicable quality of life; the resident's medical, nursing, physical, mental and psychosocial needs; person-centered measurable objectives and timeframe's for ease of evaluating resident progress toward achieving goals; and specialized services.
1. Record review of Resident #29's Face Sheet showed he/she was admitted to the facility on [DATE] with diagnoses that included:
-Cerebral palsy, unspecified (CP -a condition in which parts of the brain that affect movement either do not develop correctly or are damaged before, during or very shortly following birth).
-Aphasia (a language disorder caused by brain damage that affects a person's ability to communicate).
Record review of the resident's Psychiatric Services Note, dated 7/7/20 showed:
-The resident had been more aggressive towards other residents.
-He/she had been pinching and was yelling, screaming and loudly disruptive.
-His/her Mental Status Exam showed he/she was agitated and restless.
-Staff was to redirect the resident as needed and encourage participation in activities.
Record review of the resident's Psychiatric Services note, dated 2/2/21 showed:
-The resident was treated the past year for impulsivity (acting or tending to act suddenly and without careful thought) and psychosis.
-The resident's mental status exam showed he/she was confused, restless and incoherent.
Record review of the resident's Psychiatric Services note, dated 8/3/21 showed:
-The resident had episodes of impulsivity and making deep vocal noises, but was redirectable.
-The resident was confused, a poor historian and had poor memory.
-Recommendations were to redirect the resident when needed, don't force the resident to do things when agitated, and encourage participation in activities.
Record review of the resident's quarterly MDS dated [DATE] showed:
-The resident was severely cognitively impaired.
-The resident had behaviors (hitting/scratching self, disruptive sounds, screaming).
Record review of the resident's comprehensive care plan with the most recent revision dated 12/3/21 showed:
-The resident had no behavioral care plan.
-There were no care plans that described the resident's behaviors or non-pharmacological interventions staff were to implement when the resident displayed behaviors.
Record review of the resident's Nursing notes dated 12/26/21 to 2/26/22 showed:
-On 12/30/21 the resident pinched and scratched another resident.
-On 2/5/22 the resident had been up throughout the night screaming.
-He/she was usually easily redirected.
Record review of the resident's Psychiatric Services note, dated 3/1/22 showed:
-The resident was evaluated and treated last year for impulsivity, yelling out, depression, and cognitive impairment.
-He/she was referred for evaluation for not sleeping at night and continued to be calling out.
During an interview on 4/4/22 at 8:49 A.M., CNA B said:
-The resident had behaviors of screaming, hitting his/her legs, and pinching others.
-Staff were supposed to redirect the resident.
During an interview on 4/4/22 at 9:27 A.M., Agency CNA C said:
-The resident made noises and was easily frustrated and yelled out.
-The resident would clench and shake his/her fists when agitated.
During an interview on 4/4/22 at 9:47 A.M., CNA D said:
-The resident had behaviors that included screaming and pinching.
-Staff were to report the behavior to the nurse and try to redirect the resident.
During an interview on 4/5/22 at 9:37 A.M. Licensed Practical Nurse (LPN) C said:
-The resident's behaviors were mostly yelling out.
-The resident also attempted to pinch other residents.
-Staff were to move the resident when he/she pinched and screamed and then redirect the resident's attention.
-If the resident wanted something that someone else had, he/she would throw a fit and scream until he/she got it.
-The resident had stuffed kitties in his/her room. Staff tried to get his/her attention on that when he/she was screaming.
During an interview on 4/5/22 at 9:52 A.M., the resident's Psychiatrist said:
-The facility called him/her and would let him/her know when the resident had behaviors.
-The resident was childlike and had Intellectual Disabilities (ID).
-Behaviors consisted of screaming, pinching other residents, and getting in other people's faces or personal spaces.
During an interview on 4/5/22 at 12:14 P.M., the MDS Coordinator said:
-He/she got behavioral information from the Social Worker, from the nurses, and from review of the resident's record.
-All residents with known behaviors should have a behavioral care plan.
-The resident did not have a behavior care plan.
-The resident should have a behavioral care plan.
During an interview on 4/5/22 at 12:36 P.M., LPN A said:
-The resident had behaviors of screaming, screeching when wanting something like coffee, and making loud noises. If there was an activity in the dining room the resident didn't want to participate in he/she made loud noises and disrupted the activity.
-The resident would pinch other residents.
-The resident's behaviors were intentional.
During an interview on 4/6/22 at 1:05 P.M., the Director of Nursing (DON) said:
-The facility policy was that every resident on psychotropic medication should have identified target behaviors. The facility should be documenting on those behaviors using behavior sheets.
-There should be approximately three non-pharmacological interventions that are known to help the resident with each target behavior.
-If there were behaviors or the resident was agitated the nurse was supposed to contact the DON.
-Behaviors were discussed in morning meetings and staff tried to come up with non-pharmacological interventions to address the behaviors and add to the resident's behavior care plan.
-All residents with behaviors should have a behavior care plan.
-The resident should have a behavioral care plan.
2. Record review of Resident #41's Face Sheet showed he/she was admitted to the facility on [DATE] and readmitted on [DATE].
Record review of the resident's annual MDS, dated [DATE] showed:
-The resident's ability to see in light with glasses or visual appliances was adequate.
-The resident wore corrective lenses.
Record review of the resident's ocular progress note, dated 12/14/21 showed:
-A medically oriented ocular evaluation was performed.
-The resident's chief complaint was blurred vision.
-He/she had difficulty seeing at a distance and close up.
Record review of the resident's comprehensive care plan last updated on 3/30/22, showed:
-The resident had no Vision Care Plan.
-The resident's vision was not included in any other of the resident's specialized care plans.
During an interview on 4/1/22 at 11:44 A.M. the resident's Durable Power of Attorney (DPOA - responsible party) for Healthcare said the resident had worn glasses for years.
During an interview on 4/5/22 at 1:54 P.M. the MDS Coordinator said:
-The resident had worn eyeglasses for years and communicated he/she wanted to wear glasses.
-His/Her vision needs and preferences should be reflected in his/her CCP.
During an interview on 4/6/22 at 1:05 P.M. the DON said:
-He/she expected a resident's vision needs and preferences to be care planned within the required schedule.
-If the resident wore eyeglasses that should be reflected in the care plan.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Staffing Information
(Tag F0732)
Could have caused harm · This affected multiple residents
Based on observation and interview, the facility failed to post required nurse staffing information, which included the total and actual hours worked by both licensed and unlicensed staff directly res...
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Based on observation and interview, the facility failed to post required nurse staffing information, which included the total and actual hours worked by both licensed and unlicensed staff directly responsible for resident care, per shift on a daily basis and visible for residents, visitors, and staff to view. The facility census was 67 residents.
A policy was requested but not received by the facility.
1. Observation on 3/31/22 at 11:36 A.M. showed:
-The front lobby area, the front nurses station and area by the administrators office.
-There was no staffing posted.
Observation on 4/1/22 at 10:58 A.M. showed:
-The front lobby area, the front nurses station and area by the administrators office.
-There was no staffing posted.
Observation on 4/4/22 at 5:40 A.M. showed:
-The front lobby area, the front nurses station and area by the administrators office.
-There was no staffing posted.
Observation on 4/5/22 at 8:38 A.M. showed:
-The front lobby area, the front nurses station and area by the administrators office.
-There was no staffing posted.
During an interview on 4/5/22 at 9:20 A.M. Licensed Practical Nurse (LPN) A said:
-Staffing was to be posted by the night nurse in the hallway by the Administrators office.
-This was not being completed.
-He/she observed the area where the staffing should be posted and said it was not posted.
-Staffing should be posted daily to show the daily resident census and how many care staff were in the building to care for the residents.
-This should be posted in an area visible to all residents and visitors.
During an interview on 4/6/22 at 1:06 P.M. the Director of Nursing (DON) said:
-The staffing should be posted by the night charge nurse for the night shift.
-The nurse on the day shift or he/she would complete it.
-The staffing should show the facility census, licensed nurses, Certified Medication Technicians (CMT's), Certified Nursing Assistants (CNA's) and hours worked by shift.
-This should be posted for all residents and visitors by 300 hall.
-The staffing should have been posted daily and this was not being completed.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0804
(Tag F0804)
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 prepare pureed (food that is prepared into a paste or ...
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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 prepare pureed (food that is prepared into a paste or thick liquid suspension usually made from cooked food that was finely ground) eggs in a manner according to the recipe to be flavorful. This practice potentially affected three residents who had physician's orders for pureed diets. The facility also failed to maintain food on breakfast trays delivered to the Special Care Unit (SCU) at or close to 120 ºF (degrees Fahrenheit) of at least seven residents who were served later in the process of serving. The facility census was 67 residents.
1. Record review of the undated recipe for six servings of pureed eggs, showed:
- Six 2 ounce (oz.) servings of scrambled eggs.
- 6 fluid oz. of milk.
- 1 .5 Tablespoons of food thickener (starch or gel-based additives that make fluids and edibles easier to swallow).
Instructions: Remove portions required from the regular prepared recipe and place in a food processor.
- Process until fine in consistency.
- Combine hot milk and commercial thickener and gradually add to eggs while processing.
- Scrape down sides of processor and process for 30 seconds.
- Reheat to 165 ºF.
Observations on 4/1/22 from 7:03 A.M. through 7:34 A.M., showed:
- Dietary [NAME] (DC) C added eggs to the food processor.
- DC C did not open the recipe book during the process.
- DC C added plain water to eggs.
- DC C added a package of food thickener.
- DC C did not taste the pureed eggs and placed the pureed eggs on the steam table.
During an interview on 4/1/22 at 7:11 A.M., DC C said he/she has been working in kitchen since September 2021.
Observation of the taste of the pureed eggs on 4/1/22 at 7:30 A.M. showed the eggs tasted bland.
During an interview on 4/1/22 at 7:34 A.M. DC C said:
- There was a no taste to the pureed eggs after he/she tasted the pureed eggs.
- No one told him/her about using the recipe book for pureed items.
During an interview on 4/1/22 at 8:54 A.M., DC A (a cook with longer tenure), said:
- He/she was not trained in using the recipe book and he/she did not train DC C in using the recipe book.
- They normally use water but they can start following the recipe.
-He/she (DC A) was not trained very well in the beginning of his/her tenure which started in February 2021.
During an interview on 4/6/22 at 10:11 A.M., the Dietary Manager (DM) said said he/she trained the cooks on the using the recipe books in the past.
2. Record review of the Dietary Section of resident Council Meeting minutes dated 12/13/21 showed the residents stated meals are hot when delivered in the dining room, not when they were delivered to the rooms.
Record review of the Dietary Section of resident Council Meeting minutes dated 3/23/22 showed the residents stated the room trays were cold.
Observations on 4/1/22 at 7:53 A.M., showed the cart with food trays for the SCU arrived in the SCU dining room at 7:53 A.M.
Observation with Certified Nurse's Assistant (CNA) A of a test tray on 4/1/22 at 8:17 A.M., showed the temperature of the eggs was 89.3 ºF at 8:17 A.M., after all other trays were delivered to residents in the SCU dining room or in their individual rooms
Observation on 4/1/22 at 8:38 A.M., showed Resident #265 was assisted to the dining room.
Observation on 4/1/22 at 8:40 A.M. showed Agency Certified Medication Technician (CMT) A brought out Resident #265's food tray from the SCU kitchenette. Observation of the food temperature on Resident #265's food tray, showed the temperature of the eggs was 86.3 ºF.
During an interview on 4/1/22 at 8:41 A.M., Agency CMT A said that was a terrible temperature.
During an interview on 4/6/22 at 10:11 A.M., the DM said:
- Before the survey, the dietary staff were not monitoring the food temperatures.
- Dietary staff were not checking the food temperatures on the SCU because they were only checking the temps at the stem table.
During an interview on 4/7/22 at 9:55 A.M., the Activities' Director said:
- After the resident council meetings, he/she gave a copy of the minutes to each department head that was mentioned in the meeting.
- In the meetings when some residents mentioned the food was cold upon delivery, there were times that the hot cart was not being plugged in.
During an interview on 4/7/22 at 10:04 A.M., Resident #300 (a resident who was identified by the admission Minimum Data Set (MDS-- a federally mandated assessment tool required to be completed by facility staff for care planning) dated 2/23/22, as a resident who was able to make himself/herself understood, able to understand others, had no swallowing disorders, and was assessed in a separate Cognitive Assessment (because that section of the MDS was not completed) dated 3/15/22, as a resident who was alert and oriented as evidenced by the resident having a BIMS score of 15 said:
- He/she received room trays back in March 2022.
- Breakfast, lunch, and dinner room trays were cold.
- He/she made his/her complaints known in the resident council meetings and to dietary staff.
- He/she did not like cold food.
During an interview on 4/7/22 at 10:07 A.M., Resident #64 (a resident who was identified by the quarterly MDS dated [DATE], as a resident who was able to make himself/herself understood, able to understand others a resident who was alert and oriented as evidenced by a BIMS score of 15, and had no swallowing disorders, said he/she has discarded food sometimes because it was cold.
During a phone interview on 4/11/22 at 1:28 P.M., the Registered Dietitian (RD) said:
- He/she has not worked with the Dietary Cooks (DC) in the making of the pureed food.
- He/she expected the DCs to use the recipe books that were available.
- He/she expected dietary staff to start monitoring the temperature of test trays of food upon delivery to resident use areas.
- He/she expected the DM to work with with cooks on pureed food.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Food Safety
(Tag F0812)
Could have caused harm · This affected multiple residents
Based on observation, interview and record review, the facility failed to do or maintain the following: keep the package of bacon in the walk-in fridge covered; maintain the floor of the walk-in fridg...
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Based on observation, interview and record review, the facility failed to do or maintain the following: keep the package of bacon in the walk-in fridge covered; maintain the floor of the walk-in fridge free of a buildup of dust and food debris; maintain proper illumination from the light fixtures over the dishwasher area; maintain the top inner part of the ice-machine free of a pink colored slime; maintain the light fixtures in the kitchen free of grease and dust; label a container with the name of what is in the container; and maintain the cutting boards in an easily cleanable condition. This practice potentially affected 65 residents who ate food from the kitchen. The facility census was 67 residents.
1. Observations during the initial kitchen tour on 3/31/22 from 8:56 A.M. through 9:13 A.M., showed:
- Uncovered bacon in the walk-in refrigerator.
- A buildup of debris on the floor of the walk-in refrigerator.
- A buildup of dust in the ceiling vents in the kitchen.
- The presence of a pink slime on the top inner part of the ice machine.
- The lights at the dishwasher area did not illuminated properly.
- A buildup of dust and grease on the light fixtures.
- One container with a white powdery substance that was not labeled with what was in the container.
During an interview on 3/31/22 at 9:11 A.M., the Maintenance Director said he/she was not notified about cleaning the light fixtures because he/she was not the Maintenance Director officially until 4/1/22.
2. Observations during the breakfast meal preparation on 4/1/22 from 6:10 A.M. through 9:38 A.M., showed:
- Uncovered bacon in the walk-in refrigerator.
- A buildup of debris on the floor of the walk-in refrigerator.
- A buildup of dust in the ceiling vents in the kitchen.
- The presence of a pink slime on the top inner part of the ice machine.
- The lights at the dishwasher area not illuminated properly.
- A buildup of dust and grease on the light fixtures.
- One container with a white powdery substance that was not labeled with what was in the container.
- Five cutting boards with stains, numerous nicks, and grooves which made the cutting boards not easily cleanable.
During a interview on 4/1/22 from 8:58 A.M. through 9:21 A.M., Dietary [NAME] (DC) A said:
- He/she could not remember the last time the walk-in fridge was deep cleaned and he/she saw that it needed it again.
- DC A noticed there was a container that was not labeled and said there was flour in the unlabeled container.
- DC A noticed that 5 out of 7 cutting boards needed to be discarded because of the condition of the boards.
During an interview on 4/1/22 at 9:19 A.M., Dietary Aide (DA) A said he/she checked the cutting boards by looking for deep cuts and pieces which stuck out.
Record review of the 1999 and 2009 Food and Drug Administration (FDA) Food Code and Missouri Food Codes, showed:
- In Chapter 3-305.14, During preparation, unpackaged FOOD shall be protected from environmental sources of contamination.
-In Chapter 4-501.12, Surfaces such as cutting blocks and boards that are subject to scratching and scoring shall be resurfaced if they can no longer be effectively cleaned and sanitized, or discarded if they are not capable of being resurfaced. Surfaces such as cutting blocks and boards that are subject to scratching and scoring shall be resurfaced if they can no longer be effectively cleaned and sanitized, or discarded if they are not capable of being resurfaced.
- In Chapter 4-602.13, non-FOOD-CONTACT SURFACES of EQUIPMENT shall be cleaned at a frequency necessary to preclude accumulation of soil residues
- In Chapter 6-501.12, paragraph A, The physical facilities shall be cleaned as often as necessary to keep them clean.
- In Chapter 6-501.14, part A, Intake and exhaust air ducts shall be cleaned and the filters changed so they are not a source of contamination by dust, dirt, and other materials.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0813
(Tag F0813)
Could have caused harm · This affected multiple residents
Based on observation, interview and record review, the facility failed to label and date food that was brought in from outside sources for residents who resided on the Special Care Unit (SCU) and the ...
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Based on observation, interview and record review, the facility failed to label and date food that was brought in from outside sources for residents who resided on the Special Care Unit (SCU) and the Front Halls. This practice potentially affected at least six residents who resided in those areas. The facility census was 67 residents.
Record review of the facility's policy entitled Food from Outside Sources/Personal Food Storage, revised on 6/09, 10/14 and 4/17, showed:
- It is the policy of facility to obtain food for resident consumption from sources approved or considered satisfactory by Federal, State or local authorities.
- All resident have the right to accept food brought to the facility by any visitor(s) and/or food from a facility garden, however the food must be handled in a way to ensure resident safety.
- Food and beverages brought in from outside sources, that are to be stored in the facility refrigerators and freezers, will be checked by a dietary staff member.
- Any suspicious or obviously contaminated food or beverage will be discarded immediately.
- Food and beverages will be labeled with the resident's name food item and date.
- Food and beverages will be placed on a designated tray/shelf.
1. Observation on 4/1/22 at 9:59 A.M., showed the following in the resident food storage refrigerator on the SCU:
- One container of unlabeled food.
- One container of jelly that was unlabeled.
- One container of a cup of ice.
- One can of a carbonated beverage that was unlabeled.
- A dinner plat that was in the fridge that no one knew which resident that plate belonged to.
- The food for residents was not on a separate shelf because those items were mingled with pudding and resident supplemental drinks in that refrigerator.
During an interview on 4/1/22 at 10:09 A.M., Agency Licensed Practical Nurse (LPN) D said the unlabeled and undated items needed to be dated and the items in that fridge needed to be organized into sections for individual residents and items that are for general use such as puddings and supplements.
2. Observation on 4/1/22 at 10:12 A.M., showed the following in the resident food storage refrigerator in the front hall:
- Several bottled drinks that were not labeled with a residents' name.
- Three frozen dinners that were not labeled.
- Five cheese sticks that were unlabeled.
During interviews on 4/1/22 at 10:19 A.M., LPN B said:
- The items should be labeled when they were brought in to the facility.
- He/she believed the cheese sticks belonged to a specific residents but would follow up with that resident for sure.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Garbage Disposal
(Tag F0814)
Could have caused harm · This affected multiple residents
Based on observation, interview and record review, the facility failed to ensure the dumpster lids was closed on two different days of the survey. This practice potentially affected the outdoor premis...
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Based on observation, interview and record review, the facility failed to ensure the dumpster lids was closed on two different days of the survey. This practice potentially affected the outdoor premises of the facility with the potential of pest harborage. The facility census was 67 residents.
1. Observations on 4/1/22 at 9:53 A.M., 10:22 A.M., 11:58 A.M., and 1:08 P.M., showed the lid to one of the outdoor dumpster's open and not closed.
Observations on 4/4/22 at 9:08 A.M., 11:03 A.M., 1:12 P.M., 2:13 P.M., and 3:39 P.M., showed the lid to one of the outdoor dumpster open.
During an interview on 4/4/22 at 2:15 the Assistant Dietary Manager said he/she expected all facility staff to close the lid after dumping trash into the dumpster.
Record review of the 2009 Food and Drug Administration (FDA) Food Code
Chapter 5-501.110 entitled Storing Refuse, Recyclables, and Returnable's, showed: Refuse, recyclables, and returnable's shall be stored in receptacles or waste handling units so that they are inaccessible to insects and rodents.
Chapter 5-501.113 entitled Covering Receptacles, showed: Receptacles and waste handling units for refuse, recyclables, and returnable's shall be kept covered:
(A) Inside the food establishment if the receptacles and units: (1) Contain food residue and are not in continuous use; or
(2) After they are filled; and
(B) With tight-fitting lids or doors if kept outside the food establishment.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0919
(Tag F0919)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, the facility failed to maintain the audible (heard or capable of being heard) function of th...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, the facility failed to maintain the audible (heard or capable of being heard) function of the call lights from the following areas: Resident room [ROOM NUMBER], the 400 Hall shower room and the 500 Hall shower room. This practice potentially affected 26 residents who resided on those halls. The facility census was 67 residents.
1. Observation and interview on 4/4/22 at 11:18 A.M., showed:
- The call light string in the 500 Hall shower room was activated.
- Certified Nurse's Assistants (CNAs) E and G were at the nurse's station.
- CNAs E and G both said the call light from the 500 Hall shower room was not audible at the nurse's station.
2. Observation and interview on 4/4/22 at 11:24 A.M., showed:
- The call light string in the 400 Hall shower room was activated.
- Licensed Practical Nurse (LPN) B and the Maintenance Director were at the nurse's station.
- LPN B and the Maintenance Director both said the call light was not audible at the nurse's station.
3. Observation and interview on 4/5/22 at 9:07 A.M., showed:
- The call light string in resident room [ROOM NUMBER] was activated.
- CNA A was at the nurse's station.
- CNA A said the call light from resident room [ROOM NUMBER] was not audible at the nurse's station.
4. Observation and interview on 4/5/22 at 9:17 A.M., showed:
- Agency CNA H was asked to activate the call light from the 500 Hall shower room.
- CNA A said the call light from the 500 Hall shower room was not audible at the nurse's station.
- Agency CNA H said he/she did not know the call light from the 500 Hall shower room was not audible at the nurse's station.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Safe Environment
(Tag F0921)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, the facility failed to do the following: repair a 13 inch (in.) long by ¼ in. gap bet...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, the facility failed to do the following: repair a 13 inch (in.) long by ¼ in. gap between a climate control unit and the wall where it was installed on resident room [ROOM NUMBER]; maintain the covebase (a type of trim that is installed along the base of an interior wall where the wall meets the floor which is used to protect the base of a wall from damage and to provide a finished look) area in good repair in resident room [ROOM NUMBER] and 301; failed to maintain the tiles in good repair, which exposed the metal studs underneath the layer of tile on the 300 Hall shower room; maintain the ceiling vent in resident room [ROOM NUMBER] in operable condition because the knob to open the vent was absent; maintain the paint on the ceiling of resident room [ROOM NUMBER] in good condition; maintain the ceiling of the kitchen in good repair; maintain the flooring of the dishwasher area in the kitchen in good repair; maintain the window mounted vent, which forced excess heat out of the kitchen in good repair; maintain the thresh hold of the exit door from the service hall, without significant gaps that could let pests in; maintain the floor under the refrigerator in the staff breakroom free of a heavy buildup of food debris and dust; and maintain the ceiling vent in the North Nurse's Station free of a heavy buildup of dust. This practice potentially affected all areas of the facility. The facility census was 67 residents.
1. Observation with the Maintenance Director on 4/4/22 at 9:57 A.M., showed a 13 in. long by ¼ in. wide gap between the climate control unit and the wall that it was mounted into on the window side of resident room [ROOM NUMBER].
During an interview on 4/4/22 at 9:58 A.M., the Maintenance Director said some of the climate control units were too small for the space that it was installed in and sometimes there were spaces between the climate control unit and the wall.
2. Observation with the Maintenance Director on 4/4/22 at 11:07 A.M., an 18 in. long by 33 in. wide section of covebase that was separating from the both the floor and the wall in resident room [ROOM NUMBER].
During an interview on 4/4/22 at 11:09 A.M., the Maintenance Director said he/she was unaware that area in disrepair because he/she had only had the job since 4/1/22.
Observation with the Maintenance Director on 4/4/22 at 12:50 P.M., showed an 18 in. long section of covebase that was damaged in resident room [ROOM NUMBER].
3. Observation with the Maintenance Director on 4/4/22 at 12:18 P.M., showed an 11 in. long by 4 in. wide section of tile missing from part of the wall in the 300 Hall shower room, which exposed the metal studs underneath the wall.
During an interview on 4/4/22 at 12:19 P.M., the Maintenance Director said he/she would like to place a steel bumper in front of that area in the 300 Hall shower hall to protect the floor tiles.
4. Observation with the Maintenance Director on 4/4/22 at 12:28 P.M., the restroom vent could not be opened because the knob to open the ceiling vent, was absent.
During an interview on 4/4/22 at 12:29 P.M., the Maintenance Director said he/she needed to replace the knob which controlled the opening and closing of the restroom ceiling vent.
5. Observations on 3/31/22 at 9:11 A.M., 4/1/22 at 8:35 A.M., and with the Maintenance Director on 4/4/22 at 1:12 P.M., showed buckling (bend (something) out of shape) of the ceiling in a 45 in. long by 18 in. wide section of the ceiling which was over both the serving steam table and the dishwasher area.
During an interview on 4/4/22 at 1:12 P.M., Dietary [NAME] (DC) A said when he/she started working in the kitchen about a year ago, the damaged area on the ceiling was already there.
During an interview on 4/4/22 at 1:13 P.M., the Maintenance Director said that damaged area on the kitchen ceiling has been there for about seven years or more. And there was something in the attic over that area which contributed to the buckling of the ceiling.
During an interview on 4/6/22 at 10:28 A.M., the Dietary Manager (DM) said he/she started working there in June 2021, and he/she saw that crack in the ceiling at that time.
6. Observation with DC A on 4/4/22 at 1:16 P.M., showed a 31 in. long by 18 in. wide section of tile that was damaged or showed missing tile plates in the dishwasher area of the kitchen.
During an interview on 4/4/22 at 1:19 P.M. DC A said the missing tile and the damaged tile made that area of the floor difficult to clean.
7. Observation with DA B on 4/4/22 at 1:31 P.M., showed a broken window mounted exhaust fan in the kitchen.
During an interview on 4/4/22 at 1:32 P.M., DA B said that exhaust fan had not worked in over two years and that was the fan that removed excess heat from the kitchen.
During an interview on 4/4/22 at 1:35 P.M., the Maintenance Director said he/se was unaware of the exhaust fan not working because he/she had only taken the position of Maintenance Director on 4/1/22.
8. Observation with the Maintenance Director on 4/4/22 at 1:29 P.M., showed the thresh hold (a strip of wood, metal, rubber or stone on the floor at the entrance to a building or room) at the exit door from the service hall, was in disrepair as evidenced by a 1 in. gap between the bottom of the door and the flooring underneath the door. That gap was large enough to potentially allow insect pests in.
During an interview on 4/4/22 at 1:30 P.M., the Maintenance Director said he/she was unaware of that area not being in good repair because he/she had only been the Maintenance Director since 4/1/22.
9. Observation with the Maintenance director on 4/4/22 at 2:51 P.M., showed a large buildup of food debris and dust under the staff break room refrigerator.
During an interview on an 4/4/22 at 2:52 P.M., the Maintenance Director said he/she did not know the last time the break room refrigerator was pulled out for cleaning.
10. Observation with the Maintenance Director on 4/4/22 at 3:13 P.M., showed a heavy buildup of dust inside the ceiling vent of the North Nurse's station medication room.
During an interview on 4/4/22 at 3:14 P.M., the Maintenance Director said he/she did not know the ceiling vent of the North Nurse's Station had that much dust in it.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected most or all residents
Based on observation, interview, and record review, the facility failed to establish and maintain a comprehensive, facility-specific infection prevention and control program designed to help prevent t...
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Based on observation, interview, and record review, the facility failed to establish and maintain a comprehensive, facility-specific infection prevention and control program designed to help prevent the development and transmission of waterborne pathogens (a bacterium, virus, or other microorganism that can cause disease), which included the following: a risk assessment to identify where waterborne pathogens could grow and spread, diagrams of which hot water heaters provide hot water to which sections of the facility, testing protocols with acceptable ranges for control measures when control measures in water from the water company were not maintained, how the facility will account for changes in water quality such as water main breaks and construction, and specific actions that would be taken in response to a legionella positive water sample. This deficient practice had the potential to affect all residents and staff who reside in or work in the facility. The facility census was 67 residents with a licensed capacity of 120 residents.
Record review of page 3 of Centers for Disease Control and Prevention (CDC) Legionella Environmental Assessment Form, dated 6/15, showed:
-obtain a written copy of the program policy.
-Page 1 of the assessment noted that requirements for any occupant rooms taken out of service during specific parts of the year.
-Note: It is important to gain an understanding of where and how water flows, starting where it enters the facility and including its distribution to and through buildings to the points of use. Obtain copies of these and/or draw a diagram and include with the completed assessment.
Record review of the Centers for Medicare and Medicaid Services (CMS) QSO dated 6/2/17 and revised on 7/6/18, showed: Facilities must have water management plans and documentation that, at a minimum, ensure each facility: Conducts a facility risk assessment to identify where Legionella and other opportunistic waterborne pathogens (e.g. Pseudomonas, Acinetobacter, Burkholderia, Stenotrophomonas, nontuberculous mycobacteria, and fungi) could grow and spread in the facility water system.
1. The facility's facility specific infection prevention and control program to help prevent the development and transmission of waterborne pathogens documentation was requested, the facility had no such document to provide.
Observation during the survey from 3/31/22 through 4/7/22, showed 14 unoccupied rooms, with two unoccupied rooms on 200 Hall, three unoccupied rooms on 100 Hall and nine empty rooms on 400 Hall.
During an interview on 4/7/22 at 11:01 A.M., the Maintenance director said a risk assessment to identify where opportunistic waterborne pathogens could grow and spread was not done to account for the unoccupied rooms, or other water reservoirs such as oxygen concentrators and humidifiers.
During an interview on 4/7/22 at 11:04 A.M., the Maintenance Director said there were two hot water heaters in the facility; one provided water for the kitchen and the laundry and the other hot water heater provided water for the other areas of the facility such resident rooms and shower rooms.
During an interview on 4/7/22 at 11:15 A.M., the Administrator said the facility did not have a comprehensive plan which addressed waterborne illness at this time.
Understanding Severity Codes (click to expand)
Life-Threatening (Immediate Jeopardy)
J - Isolated
K - Pattern
L - Widespread
Actual Harm
G - Isolated
H - Pattern
I - Widespread
Potential for Harm
D - Isolated
E - Pattern
F - Widespread
No Harm (Minor)
A - Isolated
B - Pattern
C - Widespread
Questions to Ask on Your Visit
- "What changes have you made since the serious inspection findings?"
- "Can I speak with families of current residents?"
- "What's your RN coverage like on weekends and overnight?"
Our Honest Assessment
Strengths
- • Licensed and certified facility. Meets minimum state requirements.
Concerns
- • Multiple safety concerns identified: 2 life-threatening violation(s), $116,230 in fines. Review inspection reports carefully.
- • 66 deficiencies on record, including 2 critical (life-threatening) violations. These warrant careful review before choosing this facility.
- • $116,230 in fines. Extremely high, among the most fined facilities in Missouri. Major compliance failures.
- • Grade F (11/100). Below average facility with significant concerns.
Bottom line: Trust Score of 11/100 indicates significant concerns. Thoroughly evaluate alternatives.
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About This Facility
What is Blue Springs Wellness & Rehabilitation's CMS Rating?
CMS assigns BLUE SPRINGS WELLNESS & REHABILITATION an overall rating of 2 out of 5 stars, which is considered below average nationally. Within Missouri, this rating places the facility higher than 0% of the state's 100 nursing homes. A rating at this level reflects concerns identified through health inspections, staffing assessments, or quality measures that families should carefully consider.
How is Blue Springs Wellness & Rehabilitation Staffed?
CMS rates BLUE SPRINGS WELLNESS & REHABILITATION's staffing level at 1 out of 5 stars, which is much below average compared to other nursing homes.
What Have Inspectors Found at Blue Springs Wellness & Rehabilitation?
State health inspectors documented 66 deficiencies at BLUE SPRINGS WELLNESS & REHABILITATION during 2022 to 2025. These included: 2 Immediate Jeopardy (the most serious level, indicating potential for serious harm or death) and 64 with potential for harm. Immediate Jeopardy findings are rare and represent the most serious regulatory concerns. They require immediate corrective action.
Who Owns and Operates Blue Springs Wellness & Rehabilitation?
BLUE SPRINGS WELLNESS & REHABILITATION 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 120 certified beds and approximately 83 residents (about 69% occupancy), it is a mid-sized facility located in BLUE SPRINGS, Missouri.
How Does Blue Springs Wellness & Rehabilitation Compare to Other Missouri Nursing Homes?
Compared to the 100 nursing homes in Missouri, BLUE SPRINGS WELLNESS & REHABILITATION's overall rating (2 stars) is below the state average of 2.5 and health inspection rating (2 stars) is below the national benchmark.
What Should Families Ask When Visiting Blue Springs Wellness & Rehabilitation?
Based on this facility's data, families visiting should ask: "What changes have been made since the serious inspection findings, and how are you preventing similar issues?" "Can you walk me through typical staffing levels on day, evening, and night shifts?" "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 below-average staffing rating.
Is Blue Springs Wellness & Rehabilitation Safe?
Based on CMS inspection data, BLUE SPRINGS WELLNESS & REHABILITATION has documented safety concerns. Inspectors have issued 2 Immediate Jeopardy citations (the most serious violation level indicating risk of serious injury or death). The facility has a 2-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 Blue Springs Wellness & Rehabilitation Stick Around?
BLUE SPRINGS WELLNESS & REHABILITATION has not reported staff turnover data to CMS. Staff turnover matters because consistent caregivers learn residents' individual needs, medications, and preferences. When staff frequently change, this institutional knowledge is lost. Families should ask the facility directly about their staff retention rates and average employee tenure.
Was Blue Springs Wellness & Rehabilitation Ever Fined?
BLUE SPRINGS WELLNESS & REHABILITATION has been fined $116,230 across 2 penalty actions. This is 3.4x the Missouri average of $34,241. 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 Blue Springs Wellness & Rehabilitation on Any Federal Watch List?
BLUE SPRINGS WELLNESS & REHABILITATION is not on any federal watch list. The most significant is the Special Focus Facility (SFF) program, which identifies the bottom 1% of nursing homes nationally based on persistent, serious quality problems. Not being on this list means the facility has avoided the pattern of deficiencies that triggers enhanced federal oversight. This is a positive indicator, though families should still review the facility's inspection history directly.